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BOX STBEG
1:27:21 PM Monday, April 06, 2009
Page Order # :
5
Page 1 of 368
BOX STBEG
BOX INSTRUCTIONS
( STQ1010 )
IF ((SP WAS COVERED BY A MEDICARE MANAGED CARE PLAN
WITHOUT RX COVERAGE ANYTIME DURING THE CURRENT ROUND) OR
(SP WAS COVERED BY A PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND)) AND ((SP WAS NOT COVEREDY BY A
MEDICARE PRESCRIPTION DRUG PLAN ANYTIME DURING THE
CURRENT ROUND) AND (SP WAS NOT COVERED BY A MEDICARE
PRESCRIPTION DRUG PLAN ANYTIME DURING THE PREVIOUS ROUND))
GO TO ST1 - MHMOSTMT ( STQ1030 ).
ELSE GO TO ST2 - MCSAVAIL ( STQ1080 ).
ASSIGNMENTS
TECHNICAL NOTES
52
DeletedPlans
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
112
PlanIsPrivateHMO
SP is covered by a Private Managed Care Plan during
the current round =
There is a PLAN where PLAN.PLANTYPE=4/PrivatePlan
& PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.PPRVHMO=1/Yes).
Exclude Deleted Plans. See T.N. 52.
351
MPDPAnytimeCurrRnd
SP covered by an MPDP plan anytime during current
round =
There is a PLAN where PLAN.PLANTYPE=7/MPDP &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.COVANYTM=1/Yes).
Exclude Deleted Plans. See T.N. 52.
380
MPDPAnytimePrevRnd
SP covered by an MPDP plan anytime during previous
round =
There is a PLAN where PLAN.PLANTYPE=7/MPDP &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
PLRO.COVANYTM=1/Yes).
Exclude Deleted Plans. See T.N. 52.
381
MHMOAnytimeWithout
Rx
SP covered by MHMO without RX anytime during current
round =
There is a PLAN where PLANTYPE=5/MHMO & PLRO
where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.COVANYTM=1/Yes & PLRO.MHMORX^=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
1:27:22 PM Monday, April 06, 2009
Page 2 of 368
BOX STBEG
362
PrivHMOAnytime
SP covered by Private Managed Care Plan anytime
during current round =
There is a PLAN where PLANTYPE=4/PrivatePlan &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.PPRVHMO=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
DESIGN NOTES
1:27:22 PM Monday, April 06, 2009
Page 3 of 368
ST1
ST1
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
MHMOSTMT
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
30
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
If previous round HRND.MHMOSTMT = DK, RF or EMPTY, then:
Display "[Do you/Does (SP)] usually receive any statements or
papers…"
MANAGED CARE PLAN NAME:
If SP has a Current Medicare Managed Care plan, display name
of current Medicare Managed Care Plan.
Else display name of (one of) SP's Private Managed Care
plan(s).
Else then:
Display "Last time, we recorded that…".
If previous round HRND.MHMOSTMT = 1/Always, display
"always".
Else if previous round HRND.MHMOSTMT = 2/Sometimes,
display "sometimes".
Else display "never".
If previous round HRND.MHMOSTMT ^= empty, display "currently"
Else do not display.
If respondent is SP, display "you always receive statements,
sometimes receive statements, or never receive statements".
Else display "(SP) always receives statements, sometimes receives
statements, or never receives statements".
Multi Field display:
1:27:26 PM Monday, April 06, 2009
Page 4 of 368
ST1
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
Now that we have finished talking about medical visits and
prescribed medicines, let’s talk about [your/(SP’s)] medical costs.
We should start by looking at any paperwork or written explanations
of what was paid by Medicare, any insurance company, or
TRICARE.
[Do you/Does (SP)] usually receive any statements or papers from
Medicare, insurance, such as (MANAGED CARE PLAN NAME), or
TRICARE that show the charges for medical visits or
equipment?/Last time, we recorded that [you/(SP)]
(always/sometimes/never) received statements or papers from
Medicare, insurance, or TRICARE that show the charges for medical
visits or equipment.]
Please tell me if (currently) [you always receive statements,
sometimes receive statements, or never receive statements/(SP)
always receives statements, sometimes receives statements, or
never receives statements].
Int. Instr II:
INPUT FIELDS / ROUTING
1:27:33 PM Monday, April 06, 2009
Page 5 of 368
ST1
MHMOSTMT
Field1:
Cheshire Name:
( STQ1030 )
HRND.MHMOSTMT
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TSt1ahmo
FieldSize:
Min Value:
Max Value:
Mask:
1
No
No
Number Label
1 Always
Route
ST2 - MCSAVAIL ( STQ1080 )
2
English text: ALWAYS
Sometimes
ST2 - MCSAVAIL ( STQ1080 )
3
English text: SOMETIMES
Never
BOX STEND - (STQ3010 )
English text: NEVER
Attribute
Don't know
Route
ST2 - MCSAVAIL ( STQ1080 )
Refusal
ST2 - MCSAVAIL ( STQ1080 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
52
DeletedPlans
1:27:41 PM Monday, April 06, 2009
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
Page 6 of 368
ST1
65
MHMOCurrent
SP has a current Medicare Managed Care plan =
There is a PLAN where PLAN.PLANTYPE=5/MHMO &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.COVCURNT=1/Yes).
Exclude Deleted Plans. See T.N. 52.
112
PlanIsPrivateHMO
SP is covered by a Private Managed Care Plan during
the current round =
There is a PLAN where PLAN.PLANTYPE=4/PrivatePlan
& PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.PPRVHMO=1/Yes).
Exclude Deleted Plans. See T.N. 52.
106
HIPlanName
Health Insurance Plan Roster is stored on PLAN.
Plan name = PLAN.PLNAME.
4
Respondent
On MRES where MRES.MRESRND = current round:
A Proxy interview (respondent is a proxy) =
MRES.SPPROXY=2/Proxy.
MRES.RROSTNUM=ROST.ROSTNUM of respondent.
An SP interview (respondent is the SP) =
MRES.SPPROXY=1/SP.
MRES.RROSTNUM='01'.
DESIGN NOTES
1:27:42 PM Monday, April 06, 2009
Page 7 of 368
ST2
ST2
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
MCSAVAIL
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
80
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
If ST1 - MHMOSTMT = empty, display first paragraph "Now that
we..."
Else do not display.
If this is not SP's first community interview, display "that [you/(SP)]
received since the last interview".
Else do not display.
If SP has a "current" Medicare Prescription Drug plan or there was
a Medicare Prescription Drug plan "current" at the time of the
previous round interview, then display "[PROBE IF NECESSARY:
Please…]".
Else do not display.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
1:27:45 PM Monday, April 06, 2009
Page 8 of 368
ST2
Int. Instr I:
[Now that we have finished talking about medical visits and
prescribed medicines, let’s talk about [your/(SP’s)] medical costs.
We should start by looking at any paperwork or written explanations
of what costs were paid by Medicare, any insurance company, or
TRICARE.]
Question Text:
Do you have any statements or paper from Medicare, insurance, or
TRICARE [that [you/(SP)] received since the last interview]?
[PROBE IF NECESSARY: Please include any statements received
about [your/(SP's)] Medicare prescription drug benefit.]
Int. Instr II:
INPUT FIELDS / ROUTING
Field1:
MCSAVAIL
Cheshire Name:
( STQ1080 )
HRND.MCSAVAIL
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
ST3 - STHIREP ( STQ1107 )
English text: YES
No
BOX STEND - (STQ3010 )
English text: NO
Attribute
Don't know
Route
BOX STEND - (STQ3010 )
Refusal
BOX STEND - (STQ3010 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
1:27:52 PM Monday, April 06, 2009
Page 9 of 368
ST2
HARD EDIT CHECKS
TECHNICAL NOTES
126
FirstCommunity
If this is SP's first community interview =
(MRES.INTTYPE=2/NewFromFacility or
MRES.INTTYPE=3/NewFromSupplement) on MRES
where MRES.MRESRND = current round.
DESIGN NOTES
1:27:52 PM Monday, April 06, 2009
Page 10 of 368
ST3
ST3
Page Order # :
Design Screen Type:
No Entry
Fields:
Field 1:
STHIREP
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
No
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
90
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
Display report below question text.
Display all insurance plans SP reported being covered by in the
current round or in the previous round in the following order:
First line:
If SP was covered by a Medicare Managed care plan, display name
of this Medicare Managed care plan.
Else display "MEDICARE" for the Medicare plan.
Next list Medicaid, Tricare, all Public Plans, all Private Plans and all
Medicare Prescription Drug Plans. If there is more than one plan of
any type, display in order of entry.
Report header: PLANS DISCUSSED AT THIS POINT OF THE
INTERVIEW
Report layout:
Column 1, header="Plan Name", display PLAN.PLNAME.
Column 2, header="Plan Type", display PLAN.PLANTYPE:
1:27:55 PM Monday, April 06, 2009
Page 11 of 368
ST3
If PLANTYPE=1/Medicare, display "(MCAR)".
If PLANTYPE=2/Medicaid, display "(MCAD)".
If PLANTYPE=3/PublicPlan, display "(PUBL)".
If PLANTYPE=4/PrivatePlan, display "(PRIV)".
If PLANTYPE=5/MHMO, display "(MHMO)".
If PLANTYPE=6/Tricare, display "(TRIC)".
If PLANTYPE=7/MPDP, display "(MPDP)".
TEXT:
Context Header:
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
Int. Instr I:
BASED ON THE INFORMATION RECORDED IN THE HEALTH
INSURANCE SECTION FOR RECENT ROUNDS, THE PLAN(S)
LISTED BELOW ARE THE SOURCES OF STATEMENTS YOU
MIGHT EXPECT TO FIND FOR THIS SP.
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING
STHIREP
Field1:
( STQ1107 )
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TContinueEMPTY
1
No
No
Number Label
1 Continue
FieldSize:
Min Value:
Max Value:
Mask:
Route
ST4 - MATCHST ( STQ1110 )
English text: CONTINUE
Attribute
Empty
Route
ST4 - MATCHST ( STQ1110 )
BACKGROUND VARIABLE ASSIGNMENTS
1:28:01 PM Monday, April 06, 2009
Page 12 of 368
ST3
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
144
PlanCurrPrevRnd
Plan was "current" at the time of prev. round interview =
For this PLAN, there is a PLRO where
(PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=previous round &
(COVTIME=1/WholeTime or COVNOW=1/Yes or
COVCURNT=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
145
PlanCoveredPrevRnd
SP covered by PLAN anytime during prev.round =
There is a PLAN where PLAN.PLANTYPE ^= 1/Medicare
& PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=prev. round & (PLRO.COVTIME ^=
empty or PLRO.COVANYTM=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
52
DeletedPlans
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
DESIGN NOTES
1:28:01 PM Monday, April 06, 2009
Page 13 of 368
ST4
ST4
Page Order # :
Design Screen Type:
No Entry
Fields:
Field 1:
MATCHST
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
110
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
If this is the first time ST4 is asked in the current round, display
"MATCH UP MEDICARE INSURANCE, AND TRICARE
STATEMENTS BY PROVIDER AND DATE OF SERVICE."
Else display "PRESS ENTER TO CONTINUE TO THE NEXT
(STATEMENT/BUNDLE)." in interviewer instructions.
Always display "(STATEMENT/BUNDLE)", "(MHMO)", "(MPDP)" in
parenthesis.
If SP had a Medicare Prescription Drug plan or MHMO plan at any
time in the current or previous round, display "SELECT…" for
Interviewer Instruction 2.
Else do not display.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
1:28:04 PM Monday, April 06, 2009
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
Page 14 of 368
ST4
[MATCH UP MEDICARE, INSURANCE, TRICARE, AND
MEDICARE PRESCRIPTION BENEFIT STATEMENTS BY
PROVIDER AND DATE OF SERVICE./PRESS ENTER TO
CONTINUE TO THE NEXT (STATEMENT/BUNDLE).]
Int. Instr I:
Question Text:
[SELECT "MEDICARE PRESCRIPTION DRUG BENEFIT
STATEMENT" AT THE NEXT SCREEN FOR ALL STATEMENTS
FROM THE SP’S "(MHMO)" PLAN OR "(MPDP)" PLAN THAT
REPORT PRESCRIPTION DRUG CLAIMS.]
Int. Instr II:
INPUT FIELDS / ROUTING
Field1:
MATCHST
Cheshire Name:
( STQ1110 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TContinueEMPTY
1
No
No
Number Label
1 Continue
FieldSize:
Min Value:
Max Value:
Mask:
Route
ST5 - ST_CHARGEBUNDLE ( STQ1120 )
English text: CONTINUE
Attribute
Empty
Route
ST5 - ST_CHARGEBUNDLE ( STQ1120 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
1:28:10 PM Monday, April 06, 2009
Page 15 of 368
ST4
DESIGN NOTES
1:28:10 PM Monday, April 06, 2009
Page 16 of 368
ST5
ST5
Page Order # :
Design Screen Type:
Roster
Fields:
Field 1:
ST_CHARGEBUNDLE
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Name:
Statement Charge Bundle
Roster Type:
Single Item Select
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
Yes
Yes
No
No
Grid Functions:
Add Line
Delete Line
No
No
120
Display as ' Add Charge Bundle '
Display as ' Edit Charge Bundle '
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Always display "(S)" in interviewer instructions in parenthesis.
If this is the first time ST5 is asked in the current round, display
"FIRST".
Else display "NEXT" in Interviewer Instructions.
Multi Field display:
Roster/Grid Instructions:
Display all current round Charge Bundles already entered in the
Statement Series.
Display in order of entry.
Display all loaded Charge Bundles as protected rows.
Note: Completed Charge Bundles loaded at ST5 should be
protected and not preselected. The interviewer must add a new
charge bundle at ST5 before being able to continue. The
interviewer should not be able to select an existing charge bundle
and make updates to the charges already collected.
Roster/Grid display:
1:28:11 PM Monday, April 06, 2009
COL #
HEADER
INSTRUCTIONS
1
Bundle #
Display COST.COSTNUM.
2
Statement
Source(s)
Display COST.STATTYPE response text.
Page 17 of 368
ST5
3
MSN Claim Type
Display COST.MCARTYPE response text.
4
Claim Control #
Display "Claim Control #" above
columns 4,5,6.
MSN
If (COSA.MSNCLNUM ^= empty and
COSA MSNCLNUM ^= DK), display first
five digits of COSA.MSNCLNUM.
Else if COSA.MSNCLNUM = DK, display
"DK".
COSA.MSNCLNUM.
Else do not display.
5
INS
If (COST.INSCLNUM ^= empty and
COST.INSCLNUM ^= DK), display first
five digits of COST.INSCLNUM.
Else if COST.INSCLNUM = DK, display
"DK".
Else do not display.
6
TRI
If (COST.TRICLNUM ^= empty and
COST.TRICLNUM ^= DK), display first
five digits of COST.TRICLNUM.
Else if COST.TRICLNUM = DK, display
"DK".
Else do not display.
7
MPD BEGIN
DATE
Display (MPDP SERVICE START DATE)
Report display:
TEXT:
Context Header:
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
Int. Instr I:
ADD THE SOURCE(S) AND TYPE OF STATEMENT(S) FOR THE
(FIRST/NEXT) BUNDLE OF EVENTS.
Question Text:
Int. Instr II:
ADD ONE CHARGE BUNDLE AT THIS ROSTER.
INPUT FIELDS / ROUTING
1:28:12 PM Monday, April 06, 2009
Page 18 of 368
ST5
ST_CHARGEBUNDLE
Field1:
( STQ1120 )
TEMP
Cheshire Name:
Display "AND" in all response options in BOLD.
Item Text display:
Item Text:
Label:
Label Position:
String
TCOSTPICK135
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
135
Route
BOX ST5 - (STQ1125 )
BACKGROUND VARIABLE ASSIGNMENTS
Charge Bundle details will be collected on COST and CORO:
COST key = COST.COSTBASE + COST.COSTNUM
COST.COSTNUM = Number of charge bundle generated at ST5.
For charge bundles added, see STATEMENT CHARGE BUNDLE POP-UP specifications
for pop-up window programming instructions.
Variables populated:
COST.COSTNUM
COST.COSTRNDC
COST.COSTTYPE
COST.MCREDPCT
COST.STATTYPE
COST.MCARTYPE
CORO.COROCOST
CORO.CORORND
CORO.COROTYPE
CORO.TOTALTYP
BASE.LASTCOST
Charge Bundle COST Number
Current Round
1/ST
0
Statement Type
MSN Type
Charge Bundle COST number
Current Round
1/ST
1/TotalCharge, if COST.MCARTYPE ^= 6/MSNPartAInpatient
Highest COST.COSTNUM.
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
52
DeletedPlans
1:28:15 PM Monday, April 06, 2009
Deleted plans that are not valid for displays or checks =
Page 19 of 368
ST5
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
250
CurrentChargeBundles
Current Round Charge Bundles entered in Statement
Series =
There is a COST where COST.COSTRNDC = current
round and COST.COSTTYPE = 1/ST.
261
NeverInsurancePlan
SP never had a health insurance plan other than
Medicare or Tricare =
There is no PLAN where (PLAN.PLANTYPE =
2/Medicaid, 3/PublicPlan, or 4/PrivatePlan).
Exclude Deleted Plans. See T.N. 52.
262
NeverTricare
SP never had a Tricare plan =
There is no PLAN where PLAN.PLANTYPE = 6/Tricare.
Exclude Deleted Plans. See T.N. 52.
DESIGN NOTES
ST5 is called from NS and CPS when SP reports having a statement.
1:28:15 PM Monday, April 06, 2009
Page 20 of 368
BOX ST5
BOX ST5
Page Order # :
125
BOX INSTRUCTIONS
( STQ1125 )
IF ST5 - STATTYPE = 1/Medicare, 3/MedicareAndInsurance,
5/MedicareAndTricare, OR 7/MedicareAndTricareAndInsurance, GO TO ST7 MSNCLNUM ( STQ1190 ).
ELSE IF ST5 - STATTYPE = 2/Insurance OR 6/TricareAndInsurance, GO TO
ST10 - INSCLNUM ( STQ1330 ).
ELSE IF ST5 - STATTYPE = 4/Tricare ST11 - TRICLNUM ( STQ1350 ).
ELSE GO TO ST11B - PDPBEGMM ( STQ1354 ).
ASSIGNMENTS
TECHNICAL NOTES
DESIGN NOTES
1:28:15 PM Monday, April 06, 2009
Page 21 of 368
ST7
ST7
Page Order # :
Design Screen Type:
Text
Fields:
Field 1:
MSNCLNUM
Field 2:
MSNCLNM2
Field 3:
MSNCLNM3
Field 4:
MSNCLNM4
Field 5:
MSNCLNM5
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
Enable Functions:
150
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Always display "(MSN)" and "(S)" in interviewer instructions in
parenthesis.
Multi Field display:
Vertical Alignment
Display all fields at one time.
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
ENTER UP TO FIVE CLAIM CONTROL NUMBERS FROM THE
MEDICARE SUMMARY NOTICE (MSN) ASSOCIATED WITH ONE
CLAIM TOTAL.
IF NO CLAIM CONTROL NUMBER(S) LISTED, ENTER "DON'T
1:28:19 PM Monday, April 06, 2009
Page 22 of 368
ST7
KNOW".
Question Text:
DO NOT ENTER ANY CLAIM CONTROL NUMBERS IN
COMMENTS.
Int. Instr II:
INPUT FIELDS / ROUTING
MSNCLNUM
Field1:
Cheshire Name:
( STQ1190 )
COSA.MSNCLNUM
ST7 claim numbers are stored on one record in SQL and
then transformed to multiple records on COSA in Cheshire.
SQL field = tblCOST.MSNCLNUM
Item Text display:
Item Text:
Label:
Label Position:
MSN CLAIM CONTROL NUMBER:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TMSNCLNUM
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
FieldSize:
Min Value:
Max Value:
Mask:
63
Route
ST7 - MSNCLNM2 ( STQ1200 )
Route
ST7 - MSNCLNM2 ( STQ1200 )
1:28:28 PM Monday, April 06, 2009
Page 23 of 368
ST7
MSNCLNM2
Field2:
Cheshire Name:
( STQ1200 )
COSA.MSNCLNM2
ST7 claim numbers are stored on one record in SQL and
then transformed to multiple records on COSA in Cheshire.
SQL field = tblCOST.MSNCLNM2
Item Text display:
Item Text:
Label:
Label Position:
MSN CLAIM CONTROL NUMBER:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TMSNCLNM2
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Empty
Route
BOX ST7 - (STQ1240 )
Don't know
ST7 - MSNCLNM3 ( STQ1210 )
1:28:37 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
63
Route
ST7 - MSNCLNM3 ( STQ1210 )
Page 24 of 368
ST7
MSNCLNM3
Field3:
Cheshire Name:
( STQ1210 )
COSA.MSNCLNM3
ST7 claim numbers are stored on one record in SQL and
then transformed to multiple records on COSA in Cheshire.
SQL field = tblCOST.MSNCLNM3
Item Text display:
Item Text:
Label:
Label Position:
MSN CLAIM CONTROL NUMBER:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TMSNCLNM2
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Empty
Route
BOX ST7 - (STQ1240 )
Don't know
ST7 - MSNCLNM4 ( STQ1220 )
1:28:47 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
63
Route
ST7 - MSNCLNM4 ( STQ1220 )
Page 25 of 368
ST7
MSNCLNM4
Field4:
Cheshire Name:
( STQ1220 )
COSA.MSNCLNM4
ST7 claim numbers are stored on one record in SQL and
then transformed to multiple records on COSA in Cheshire.
SQL field = tblCOST.MSNCLNM4
Item Text display:
Item Text:
Label:
Label Position:
MSN CLAIM CONTROL NUMBER:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TMSNCLNM2
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Empty
Route
BOX ST7 - (STQ1240 )
Don't know
ST7 - MSNCLNM5 ( STQ1230 )
1:28:56 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
63
Route
ST7 - MSNCLNM5 ( STQ1230 )
Page 26 of 368
ST7
MSNCLNM5
Field5:
Cheshire Name:
( STQ1230 )
COSA.MSNCLNM5
ST7 claim numbers are stored on one record in SQL and
then transformed to multiple records on COSA in Cheshire.
SQL field = tblCOST.MSNCLNM5
Item Text display:
Item Text:
Label:
Label Position:
MSN CLAIM CONTROL NUMBER:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TMSNCLNM2
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Empty
Route
BOX ST7 - (STQ1240 )
Don't know
BOX ST7 - (STQ1240 )
FieldSize:
Min Value:
Max Value:
Mask:
63
Route
BOX ST7 - (STQ1240 )
BACKGROUND VARIABLE ASSIGNMENTS
COSARNDC
COST.COSARNDC = current round. This is set in
SQL only in order to flag data transformation to
generate new COSA records.
SOFT EDIT CHECKS
HARD EDIT CHECKS
Edit #1:
For each MSN CLAIM NUMBER entered at ST7, if (CLAIM
NUMBER ^= DK and ^= RF), CLAIM NUMBER entered should ^=
any other CLAIM NUMBER already entered at ST7.
If not true, display message "NUMBER HAS ALREADY BEEN
ENTERED. PLEASE REENTER CLAIM CONTROL NUMBER."
Edit #2:
For each MSN CLAIM NUMBER entered at ST7, if (CLAIM
NUMBER ^= DK and ^= RF), CLAIM NUMBER entered should be a
minimum of twelve characters in length.
1:29:00 PM Monday, April 06, 2009
Page 27 of 368
ST7
If not true, display message "INVALID RESPONSE. ENTRY NOT
IN RANGE. PLEASE REENTER."
TECHNICAL NOTES
DESIGN NOTES
MSNCLNUM is the only required field. The remaining fields are specified
to allow EMPTY and are not required.
1:29:00 PM Monday, April 06, 2009
Page 28 of 368
BOX ST7
BOX ST7
Page Order # :
160
BOX INSTRUCTIONS
( STQ1240 )
IF ST7 - MSNCLNUM = DK, GO TO BOX ST9 - (STQ1320 ).
ELSE GO TO ST8 - MSCLVER1 ( STQ1270 ).
ASSIGNMENTS
TECHNICAL NOTES
DESIGN NOTES
1:29:01 PM Monday, April 06, 2009
Page 29 of 368
ST8
ST8
Page Order # :
Design Screen Type:
Text
Fields:
Field 1:
MSCLVER1
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
180
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Always display "(MSN)" in interviewer instructions in parenthesis.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
PLEASE ENTER THE FIRST CLAIM CONTROL NUMBER FROM
THE MEDICARE SUMMARY NOTICE (MSN) AGAIN.
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING
1:29:02 PM Monday, April 06, 2009
Page 30 of 368
ST8
Field1:
Cheshire Name:
MSCLVER1
( STQ1270 )
COSA.MSCLVER1
ST7 claim numbers are stored on one record in SQL and
then transformed to multiple records on COSA in Cheshire.
SQL field = tblCOST.MSCLVER1
Item Text display:
Item Text:
Label:
Label Position:
MSN CLAIM CONTROL NUMBER:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TTEMPCLNUM
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
63
Route
BOX ST8 - (STQ1290 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
Edit #1
IF (ST8 - MSCLVERR1 ^= DK and ^= RF), ST8 - MSCLVER1
should ^= any other CLAIM NUMBER already entered at ST7.
If not true, display message "NUMBER HAS ALREADY BEEN
ENTERED. PLEASE REENTER CLAIM CONTROL NUMBER."
Edit #2:
If (ST8 - MSCLVER1 ^= DK and ^= RF), ST8 - MSCLVER1 should
be a minimum of twelve characters in length.
If not true, display message "INVALID RESPONSE. ENTRY NOT
IN RANGE. PLEASE REENTER."
TECHNICAL NOTES
DESIGN NOTES
1:29:05 PM Monday, April 06, 2009
Page 31 of 368
BOX ST8
BOX ST8
Page Order # :
190
BOX INSTRUCTIONS
( STQ1290 )
IF ST8 - MSCLVER1 MATCHES ST7 - MSNCLNUM, GO TO BOX ST9 (STQ1320 ).
ELSE GO TO ST9 - WHICHNUM ( STQ1310 ).
ASSIGNMENTS
TECHNICAL NOTES
DESIGN NOTES
1:29:05 PM Monday, April 06, 2009
Page 32 of 368
ST9
ST9
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
WHICHNUM
Field 2:
NEWCLNUM
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
Enable Functions:
210
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
FIRST MSN CLAIM CONTROL NUMBER: Display ST7 MSNCLNUM.
SECOND MSN CLAIM CONTROL NUMBER: Display ST8 MSCLVER1.
Always display "(MSN)" in interviewer instructions in parenthesis.
Multi Field display:
Vertical Alignment
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
YOU HAVE ENTERED THE CLAIM CONTROL NUMBERS FROM
THE MEDICARE SUMMARY NOTICE (MSN) DIFFERENTLY.
Question Text:
FIRST TIME: (FIRST MSN CLAIM CONTROL NUMBER)
1:29:10 PM Monday, April 06, 2009
Page 33 of 368
ST9
SECOND TIME: (SECOND MSN CLAIM CONTROL NUMBER)
WHICH IS CORRECT?
Int. Instr II:
INPUT FIELDS / ROUTING
WHICHNUM
Field1:
Cheshire Name:
( STQ1310 )
COST.WHICHNUM
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TWhichnum
1
No
No
Number Label
1 First
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX ST9 - (STQ1320 )
2
English text: FIRST
Second
BOX ST9 - (STQ1320 )
3
English text: SECOND
Neither
ST9 - NEWCLNUM ( STQ1312 )
English text: NEITHER
1:29:20 PM Monday, April 06, 2009
Page 34 of 368
ST9
NEWCLNUM
Field2:
Cheshire Name:
( STQ1312 )
TEMP
Item Text display:
ENTER CORRECT MSN CLAIM CONTROL NUMBER:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TMSNCLNUM
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
FieldSize:
Min Value:
Max Value:
Mask:
63
Route
BOX ST9 - (STQ1320 )
Route
BOX ST9 - (STQ1320 )
BACKGROUND VARIABLE ASSIGNMENTS
MSCLVER2
If ST9 - WHICHNUM = 2/Second or 3/Neither, set
COSA.MSCLVER2 = ST7 - MSNCLNUM.
SQL field = tblCOST.MSCLVER2. This field is
transformed to COSA.MSCLVER2 in Cheshire.
MSNCLNUM
If ST9 - WHICHNUM = 2/Second, set
COSA.MSNCLNUM = ST8 - MSCLVER1.
Else if ST9 - WHICHNUM = 3/Neither, set
COSA.MSNCLNUM = ST9 - NEWCLNUM.
SOFT EDIT CHECKS
HARD EDIT CHECKS
Edit # 1
IF (ST9 - NEWCLNUM ^= DK and ^= RF), ST9 - NEWCLNUM
should ^= any other CLAIM NUMBER already entered at ST7.
If not true, display message "NUMBER HAS ALREADY BEEN
ENTERED. PLEASE REENTER CLAIM CONTROL NUMBER."
Edit #2:
If (ST9 - NEWCLNUM ^= DK and ^= RF), ST9 - NEWCLNUM should
be a minimum of twelve characters in length.
If not true, display message "INVALID RESPONSE. ENTRY NOT
IN RANGE. PLEASE REENTER."
TECHNICAL NOTES
1:29:25 PM Monday, April 06, 2009
Page 35 of 368
ST9
DESIGN NOTES
1:29:25 PM Monday, April 06, 2009
Page 36 of 368
BOX ST9
BOX ST9
Page Order # :
220
BOX INSTRUCTIONS
( STQ1320 )
IF ST5 - STATTYPE = 3/MedicareAndInsurance OR
7/MedicareAndTricareAndInsurance, GO TO ST10 - INSCLNUM ( STQ1330 ).
ELSE IF ST5 - STATTYPE = 5/MedicareAndTricare, GO TO ST11 TRICLNUM ( STQ1350 ).
ELSE GO TO ST12 - INCTYPE ( STQ1390 ).
ASSIGNMENTS
TECHNICAL NOTES
DESIGN NOTES
1:29:25 PM Monday, April 06, 2009
Page 37 of 368
ST10
ST10
Page Order # :
Design Screen Type:
Text
Fields:
Field 1:
INSCLNUM
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
230
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
ENTER THE CLAIM CONTROL NUMBER FROM THE INSURANCE
STATEMENT. IF NO CLAIM CONTROL NUMBER LISTED, ENTER
"DON'T KNOW".
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING
1:29:28 PM Monday, April 06, 2009
Page 38 of 368
ST10
INSCLNUM
Field1:
Cheshire Name:
( STQ1330 )
COST.INSCLNUM
Item Text display:
Item Text:
Label:
Label Position:
INSURANCE CLAIM CONTROL NUMBER:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TINSCLNUM
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
FieldSize:
Min Value:
Max Value:
Mask:
15
Route
BOX ST10 - (STQ1340 )
Route
BOX ST10 - (STQ1340 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:29:31 PM Monday, April 06, 2009
Page 39 of 368
BOX ST10
BOX ST10
Page Order # :
240
BOX INSTRUCTIONS
( STQ1340 )
IF ST5 - STATTYPE = 6/TricareAndInsurance OR
7/MedicareAndTricareAndInsurance, GO TO ST11 - TRICLNUM ( STQ1350 ).
ELSE GO TO ST12 - INCTYPE ( STQ1390 ).
ASSIGNMENTS
TECHNICAL NOTES
DESIGN NOTES
1:29:31 PM Monday, April 06, 2009
Page 40 of 368
ST11
ST11
Page Order # :
Design Screen Type:
Text
Fields:
Field 1:
TRICLNUM
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
250
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
ENTER THE CLAIM CONTROL NUMBER FROM THE TRICARE
STATEMENT. IF NO CLAIM CONTROL NUMBER LISTED, ENTER
"DON'T KNOW".
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING
1:29:34 PM Monday, April 06, 2009
Page 41 of 368
ST11
TRICLNUM
Field1:
Cheshire Name:
( STQ1350 )
COST.TRICLNUM
Item Text display:
Item Text:
Label:
Label Position:
TRICARE CLAIM CONTROL NUMBER:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TTRICLNUM
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
FieldSize:
Min Value:
Max Value:
Mask:
15
Route
ST12 - INCTYPE ( STQ1390 )
Route
ST12 - INCTYPE ( STQ1390 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:29:37 PM Monday, April 06, 2009
Page 42 of 368
ST11B
ST11B
Page Order # :
Design Screen Type:
Date
Fields:
Field 1:
PDPBEGMM
Field 2:
PDPBEGDD
Field 3:
PDPBEGYY
Field 4:
PDPENDMM
Field 5:
PDPENDDD
Field 6:
PDPENDYY
HELP
COMMENTS
JUMPBACK
No
Yes
No
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
Enable Functions:
270
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Vertical Alignment
Display begin date input fields, COST.PDPBEGMM,
COST.PDPBEGDD, COST.PDPBEGYY, on 1st line.
Display end date input fields, COST.PDPENDMM, COST.
PDPENDDD, COST.PDPENDYY on 2nd line.
Display all fields at one time.
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
1:29:42 PM Monday, April 06, 2009
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
Page 43 of 368
ST11B
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
ENTER THE BEGINNING AND ENDING DATES OF SERVICE
FROM THE MEDICARE PRESCRIPTION DRUG BENEFIT
STATEMENT.
Int. Instr I:
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING
Field1:
PDPBEGMM
Cheshire Name:
( STQ1354 )
COST.PDPBEGMM
Item Text display:
Item Text:
BEGINNING DATE:
Label:
Label Position:
MM
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TMonthInt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST11B - PDPBEGDD ( STQ1356 )
Refusal
ST11B - PDPBEGDD ( STQ1356 )
1:29:51 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
01
12
Route
ST11B - PDPBEGDD ( STQ1356 )
Page 44 of 368
ST11B
PDPBEGDD
Field2:
Cheshire Name:
( STQ1356 )
COST.PDPBEGDD
Item Text display:
Item Text:
Label:
Label Position:
DD
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TDayIntDKRF
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST11B - PDPBEGYY ( STQ1358 )
Refusal
ST11B - PDPBEGYY ( STQ1358 )
1:30:00 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
2
1
31
Route
ST11B - PDPBEGYY ( STQ1358 )
Page 45 of 368
ST11B
PDPBEGYY
Field3:
Cheshire Name:
( STQ1358 )
COST.DPDBEGYY
Item Text display:
Item Text:
Label:
Label Position:
YY
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TYearDKRF
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST11B - PDPENDMM ( STQ1362 )
Refusal
ST11B - PDPENDMM ( STQ1362 )
1:30:09 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
0
99
Route
ST11B - PDPENDMM ( STQ1362 )
Page 46 of 368
ST11B
PDPENDMM
Field4:
Cheshire Name:
( STQ1362 )
COST.PDPENDMM
Item Text display:
Item Text:
ENDING DATE:
Label:
Label Position:
MM
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TMonthInt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST11B - PDPENDDD ( STQ1364 )
Refusal
ST11B - PDPENDDD ( STQ1364 )
1:30:19 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
01
12
Route
ST11B - PDPENDDD ( STQ1364 )
Page 47 of 368
ST11B
PDPENDDD
Field5:
Cheshire Name:
( STQ1364 )
COST.PDPENDDD
Item Text display:
Item Text:
Label:
Label Position:
DD
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TDayDKRF
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST11B - PDPENDYY ( STQ1366 )
Refusal
ST11B - PDPENDYY ( STQ1366 )
1:30:28 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
2
1
31
Route
ST11B - PDPENDYY ( STQ1366 )
Page 48 of 368
ST11B
PDPENDYY
Field6:
Cheshire Name:
( STQ1366 )
COST.PDPENDYY
Item Text display:
Item Text:
Label:
Label Position:
YY
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TYearDKRF
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST12 - INCTYPE ( STQ1390 )
Refusal
ST12 - INCTYPE ( STQ1390 )
FieldSize:
Min Value:
Max Value:
Mask:
0
99
Route
ST12 - INCTYPE ( STQ1390 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
Edit #1
If SP is deceased, Stop Date,
PDPENDMM/PDPENDDD/PDPENDYY, should be on or before
(DATE OF DEATH).
If not true, display message "VERIFY THAT THE STOP DATE WAS
AFTER SP'S DATE OF DEATH, (DATE OF DEATH)."
Edit #2
If SP is institutionalized, Stop Date,
PDPENDMM/PDPENDDD/PDPENDYY, should be on or before
(DATE OF INSTITUTIONALIZATION).
If not true, display message "VERIFY THAT THE STOP DATE WAS
AFTER SP'S DATE OF INSTITUTIONALIZATION, (DATE OF
INSTITUTIONALIZATION)."
Edit #3
Stop Date, PDPENDMM/PDPENDDD/PDPENDYY, must be after
the Start Date, PDPBEGMM/PDPBEGDD/PDPBEGYY.
If not true, display message: "VERIFY THAT THE BEGIN DATE
AND END DATE ARE THE SAME DATE."
HARD EDIT CHECKS
1:30:32 PM Monday, April 06, 2009
Page 49 of 368
ST11B
Edit #1
Month and Year of Start Date, PDPBEGMM/PDPBEGYY, should be
on or after (SURVEY REFERENCE MONTH AND YEAR).
If not true, display message "INVALID DATE. START DATE MUST
BE ON OR AFTER (SURVEY REFERENCE MONTH AND YEAR).
PLEASE REENTER."
Edit #2
Start Date, PDPBEGMM/PDPBEGDD/PDPBEGYY, should be on or
before (TODAY).
If not true, display message "INVALID DATE. START DATE MUST
BE ON OR BEFORE (TODAY). PLEASE REENTER."
Edit #3
Stop Date, PDPENDMM/PDPENDDD/PDPENDYY, should be on or
before (TODAY).
If not true, display message "INVALID DATE. STOP DATE MUST
BE ON OR BEFORE (TODAY). PLEASE REENTER."
Edit #4
Stop Date, PDPENDMM/PDPENDDD/PDPENDYY, must be on or
after the Start Date, PDPBEGMM/PDPBEGDD/PDPBEGYY.
If not true, display message: "INVALID DATE. STOP DATE MUST
BE ON OR AFTER (MPDP SERVCE START DATE). PLEASE
REENTER."
Edit #5
If SP is deceased, Start Date,
PDPBEGMM/PDPBEGDD/PDPBEGYY, must be on or before
(DATE OF DEATH).
If not true, display message "INVALID DATE. START DATE MUST
BE ON OR BEFORE SP'S DATE OF DEATH, (DATE OF DEATH).
PLEASE REENTER."
Edit #6
If SP is institutionalized, Start Date,
PDPBEGMM/PDPBEGDD/PDPBEGYY, must be on or before
(DATE OF INSTITUTIONALIZATION).
If not true, display message "INVALID DATE. START DATE MUST
BE ON OR BEFORE SP'S DATE OF INSTITUTIONALIZATION,
(DATE OF INSTITUTIONALIZATION). PLEASE REENTER."
TECHNICAL NOTES
DESIGN NOTES
1:30:32 PM Monday, April 06, 2009
Page 50 of 368
ST12
ST12
Page Order # :
Design Screen Type:
Code All
Fields:
Field 1:
INCTYPE
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
290
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Always display "(S)" in interviewer instructions in parenthesis.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
Int. Instr I:
WHAT TYPE(S) OF EVENT(S) ARE INCLUDED IN THIS CHARGE
BUNDLE ON THE (TYPE OF STATEMENT)?
Question Text:
Int. Instr II:
CHECK ALL THAT APPLY.
INPUT FIELDS / ROUTING
1:30:36 PM Monday, April 06, 2009
Page 51 of 368
ST12
INCTYPE
Field1:
Cheshire Name:
( STQ1390 )
NONE
REPLACES THE FOLLOWING CHESHIRE VARIABLES:
1=COST.INCDATES
2=COST.INCHHS - NEED TO ADD TO CHESHIRE
DATABASE
3=COST.INCOMS
4=COST.INCPMS
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TIncTypes
4
No
No
Number Label
1 ProvDates
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX ST12 - (STQ1400 )
2
English text: PROVIDER SERVICE DATES
HHVisits
BOX ST12 - (STQ1400 )
3
English text: HOME HEALTH VISITS
OMExpenses
BOX ST12 - (STQ1400 )
4
English text: OTHER MEDICAL EXPENSES
Pmed
BOX ST12 - (STQ1400 )
English text: PRESCRIBED MEDICINES
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
Edit # 1:
If ST5 - STATTYPE = 8/MPDPBenefit, response to ST12 - INCTYPE
should not include 1/ProvDates.
If not true, display message "PLEASE VERIFY THAT PROVIDER
SERVICE DATES ARE INCLUDED IN CHARGE BUNDLE."
Edit # 2:
If ST5 - STATTYPE = 8/MPDPBenefit, response to ST12 - INCTYPE
should not include 2/HHVisits.
If not true, display message "PLEASE VERIFY THAT HOME
1:30:43 PM Monday, April 06, 2009
Page 52 of 368
ST12
HEALTH VISITS ARE INCLUDED IN CHARGE BUNDLE."
Edit # 3:
If ST5 - STATTYPE = 8/MPDPBenefit, response to ST12 - INCTYPE
should not include 3/OMExpenses.
If not true, display message "PLEASE VERIFY THAT OTHER
MEDICAL EXPENSES ARE INCLUDED IN CHARGE BUNDLE."
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:30:43 PM Monday, April 06, 2009
Page 53 of 368
BOX ST12
BOX ST12
Page Order # :
300
BOX INSTRUCTIONS
( STQ1400 )
IF THE RESPONSE TO ST12 - INCTYPE INCLUDES 1/ProvDates, GO TO
ST13 - PROVIDER_STDATE ( STQ1410 ).
ELSE GO TO BOX ST26 - (STQ1720 ).
ASSIGNMENTS
TECHNICAL NOTES
DESIGN NOTES
1:30:43 PM Monday, April 06, 2009
Page 54 of 368
ST13
ST13
Page Order # :
Design Screen Type:
Roster
Fields:
Field 1:
PROVIDER_STDATE
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Name:
Provider Roster
Roster Type:
Single Item Select
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
Yes
Yes
No
No
Grid Functions:
Add Line
Delete Line
No
No
310
Display as ' Add a Provider '
Display as ' Edit a Provider '
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Display all Providers except for Providers where
PROV.PROVNUM=01 and 02, which are reserved for PM and OM
events.
Display in order of entry.
Roster/Grid display:
COL #
HEADER
1
Provider Name
INSTRUCTIONS
Display PROV.PROVNAME.
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
Int. Instr I:
WHICH MEDICAL PROVIDER IS IN THIS CHARGE BUNDLE?
Question Text:
Int. Instr II:
1:30:44 PM Monday, April 06, 2009
SELECT OR ADD ONLY ONE PROVIDER.
Page 55 of 368
ST13
INPUT FIELDS / ROUTING
Field1:
PROVIDER_STDATE
( STQ1410 )
TEMP
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
String
TProvPick135
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
135
Route
ST14 - STDATEUPD ( STQ1412 )
BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on PROV:
PROV key = PROV.PROVBASE + PROV.PROVNUM
PROV.PROVNUM = Number of Provider selected at ST13.
If Provider added at Provider Roster, see PROVIDER ROSTER POP-UP specifications for
pop-up window programming instructions.
Variables populated in Provider Roster Pop-Up Window:
PROV.PROVNUM
PROV.PROVRNDC
PROV.PROVNAME
Provider number
Round number
Provider name
If Provider added, set additional fields as instructed below:
COSTPROV
COST.COSTPROV = PROV.PROVNUM of provider
selected at ST13.
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:30:47 PM Monday, April 06, 2009
Page 56 of 368
ST13
Interviewer can add or select Provider at this roster.
1:30:47 PM Monday, April 06, 2009
Page 57 of 368
ST14
ST14
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
STDATEUPD
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
No
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
312
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display name of Provider, PROV.PROVNAME, selected at ST13.
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
Display report below Question Text.
Display all events for this provider where:
EVNT.EVNTTYPE = 'DU', 'ER', 'IP', 'IU', 'OP', 'MP', 'SD', or 'SL', and
EVNT.EVNTPROV = the PROV.PROVNUM selected at ST13, and
EVNT.EVNTDFLG ^= 1/Yes
Display in order of entry.
Report Header: PROVIDER SERVICE EVENTS
Column 1, Header = "Type".
Column 1, Display =
Display EVNT.EVNTTYPE
Column 2, Header = "Start Date".
Column 2, Display =
Display EVENT DATE in "Mon DD YYYY" format.
1:30:50 PM Monday, April 06, 2009
Page 58 of 368
ST14
Column 3, Header = "Stop Date".
Column 3, Display =
If (EVNT.EVNTTYPE = 'IU') or (EVNT.EVNTTYPE = 'IP' and
EVNT.IPSTATUS ^= 1/StillInHospital), display EVENT END DATE in
"Mon DD YYYY" format.
Else do not display.
Column 4, Header = "Status".
Column 4, Display =
If EVNT.EVNTTYPE = 'IP' and EVNT.IPSTATUS = 1/StillInHospital,
display "ON".
Else if EVNT.VISTTYPE = 2/RepeatVisit, display "RV".
Else do not display.
Column 5, Header = "# Visits".
Column 5, Display =
If EVNT.VISTTYPE = 2/RepeatVisit, display EVNT.RVTIMES.
Else do not display.
Column 6, Header = "Round".
Column 6, Display =
Display "R" + EVNT.EVNTRNDC. EX: R45
Column 7, Display =
If Event Date is out of the Survey Reference Period, display "ORP".
Else do not display.
TEXT:
Context Header:
(ST CLAIM HEADER)
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
PROVIDER: (PROVIDER NAME)
Int. Instr I:
THE FOLLOWING EVENT DATES HAVE BEEN ENTERED FOR
THIS PROVIDER.
Question Text:
Int. Instr II:
DO YOU NEED TO ADD OR EDIT AN EVENT DATE FOR THIS
CHARGE BUNDLE?
INPUT FIELDS / ROUTING
1:30:52 PM Monday, April 06, 2009
Page 59 of 368
ST14
STDATEUPD
Field1:
Cheshire Name:
( STQ1412 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TSTDateUpd
1
No
No
Number Label
1 No
FieldSize:
Min Value:
Max Value:
Mask:
Route
ST24 - EVENT_STDATE ( STQ1705 )
2
English text: NO, DO NOT NEED TO ADD OR EDIT EVENT DATES
YesAddEvent
ST16 - EVENT_STDATEADD ( STQ1430 )
3
English text: YES, NEED TO ADD EVENT DATE
YesEditEvent
ST15 - EVENT_STDATEDIT ( STQ1414 )
English text: YES, NEED TO EDIT EVENT DATE
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
246
ORPEvent
Existing Event Date is outside survery reference period =
EVNT.EVORPFLAG = 1/ORP.
New event is Out of the Survey Reference Period =
See general specifications for Date check logic for
determing ORP events.
DESIGN NOTES
1:30:57 PM Monday, April 06, 2009
Page 60 of 368
ST15
ST15
Page Order # :
Design Screen Type:
Roster
Fields:
Field 1:
EVENT_STDATEDIT
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Name:
Statement Event Edit Roster
Roster Type:
Multiple Item Select
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
Yes
No
No
Add Line
Delete Line
No
No
Grid Functions:
314
Display as ' Edit Event Date '
DISPLAY INSTRUCTIONS:
Context header display:
Display name of Provider, PROV.PROVNAME, selected at ST13.
Question display:
Multi Field display:
Roster/Grid Instructions:
Display all events for this provider where:
EVNT.EVNTTYPE = 'DU', 'ER', 'IP', 'IU', 'OP', 'MP', 'SD', or 'SL', and
EVNT.EVNTPROV = the PROV.PROVNUM selected at ST13, and
EVNT.EVNTDFLG ^= 1/Yes
If EVNT.EVNTTYPE = 'IP' and EVNT.IPSTATUS = 1/StillInHospital,
display as a protected row.
Display in order of entry.
Roster/Grid display:
1:30:58 PM Monday, April 06, 2009
COL #
HEADER
INSTRUCTIONS
1
Type
Display EVNT.EVNTTYPE.
2
Start Date
Display EVENT DATE in "Mon DD YYYY"
format.
3
Stop Date
If (EVNT.EVNTTYPE = 'IU') or
(EVNT.EVNTTYPE = 'IP' and
EVNT.IPSTATUS ^=1/StillInHospital),
display EVENT END DATE in "Mon DD
YYYY" format.
Else do not display.
Page 61 of 368
ST15
4
Status
If EVNT.EVNTTYPE = 'IP' and
EVNT.IPSTATUS = 1/StillInHospital,
display "ON".
Else if EVNT.VISTTYPE = 2/RepeatVisit,
display "RV".
Else do not display.
5
# Visits
If EVNT.VISTTYPE = 2/RepeatVisit,
display EVNT.RVTIMES.
Else do not display.
6
Round
Display 'R' + EVNT.EVNTRNDC. EX:
R45
7
If Event Date is out of the Survey
Reference Period, display "ORP".
Else do not display.
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
PROVIDER: (PROVIDER NAME)
Int. Instr I:
Question Text:
Int. Instr II:
SELECT AND EDIT THE EVENT DATE THAT NEEDS
CORRECTION.
INPUT FIELDS / ROUTING
1:31:01 PM Monday, April 06, 2009
Page 62 of 368
ST15
Field1:
Cheshire Name:
EVENT_STDATEDIT
( STQ1414 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TEvntPick135
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
135
Route
ST14 - STDATEUPD ( STQ1412 )
BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on EVNT:
EVNT key = EVNT.EVNTBASE + EVNT.EVNTNUM
EVNT.EVNTNUM = Number of event selected at ST15.
If event selected for editing, see STATEMENT EVENT EDIT ROSTER POP-UP
specifications for pop-up window programming specifications.
Variables updated in STATEMENT EVENT EDIT ROSTER Pop-Up Window:
EVNT.VISTTYPE
SingleVisit or RepeatVisit
EVNT.RVTIMES
# of visits
EVNT.EVBEGMM
Event Month
EVNT.EVBEGDD
Event Day
EVNT.EVBEGYY
Event Year
EVNT.EVENDMM
Event End Month
EVNT.EVENDDD
Event End Day
EVNT.EVENDYY
Event End Year
NOTE: EVNT.IPSTATUS cannot be updated in Pop-Up Window.
EVORPFLG
If Event date edited is outside the Survey Reference
Period, set EVNT.EVORPFLG = 1/ORP. See
General Specifications for setting this ORP flag.
SOFT EDIT CHECKS
HARD EDIT CHECKS
Edit #1
Date of event, EVBEGMM/EVBEGDD/EVBEGYY, should be on or
before (TODAY).
If not true, display message "INVALID DATE. DATE MUST BE ON
1:31:04 PM Monday, April 06, 2009
Page 63 of 368
ST15
OR BEFORE (TODAY). PLEASE REENTER."
Edit #2
If (EVNTTYPE = 'IP' or 'IU'), then Discharge date,
EVENDMM/EVENDDD/EVENDYY, should be on or before (TODAY).
If not true, display message "INVALID DATE. DISCHARGE DATE
MUST BE ON OR BEFORE (TODAY). PLEASE REENTER."
Edit #3
If (EVNTTYPE = 'IP' or 'IU'), then Discharge date,
EVENDMM/EVENDDD/EVENDYY, must be on or
after the Admission date, EVBEGMM/EVBEGDD/EVBEGYY.
If not true, display message: "INVALID DATE. DISCHARGE DATE
MUST BE ON OR AFTER (ADMISSION DATE). PLEASE
REENTER."
Edit #4
If EVNTTYPE = 'IP', then the IP Admission and Discharge Date
cannot overlap an existing IP stay.
If not true, display message "INVALID DATE. THIS DATE
OVERLAPS AN EXISTING IP STAY FROM (ADMISSION DATE) TO
[(DISCHARGE DATE)/SP STILL IN HOSPITAL]. PLEASE
REENTER."
Display instructions:
Display (ADMISSION DATE) of existing IP stay that the IP stay
added overlaps.
If existing IP stay IPSTATUS=1/StillInHosptial, display "SP STILL IN
HOSPITAL".
Else display (DISCHARGE DATE) of existing IP stay that the IP stay
added overlaps.
See General specifcations for overlapping date logic.
Edit #5
If EVNTTYPE = 'IU' and SPALIVE=2/AliveAndInstitute and Date of
Institutionalization colllected at INS2 does not have any missing
data, SPINSTMM, SPINSTDD, SPINSTYY ^= DK and SPINSTMM,
SPINSTDD, SPINSTYY ^= RF, then admission date,
EVBEGMM/EVBEGDD/EVBEGYY, and discharge date,
EVENDMM/EVENDDD/EVENDYY, cannot match date of
institutionalization collected at INS2,
SPINSTMM/SPINSTDD/SPINSTYY.
If not true, display message "INVALID DATE. THIS DATE
MATCHES THE CURRENT INSTITUTIONALIZATION DATE, (DATE
OF INSTITUTIONALIZATION). PLEASE REENTER."
Edit #6
If EVNT.EVNTTYPE = 'DU', 'ER', 'OP', 'MP', 'SL' or 'SD', then Date of
event, EVBEGMM/EVBEGDD/EVBEGYY, cannot match an existing
event date for the same provider.
The following must be true for the event added to be a duplicate of
an existing event:
Both event's EVNTDFLG ^= 1/Yes,
Both event's EVNTTYPE match.
Both event's EVNTPROV match.
Both event's EVENT DATE match. See general specifications for
matching date logic.
The date of the event added should not match any event date for
the same provider.
If not true, display message "INVALID DATE. THIS DATE HAS
1:31:04 PM Monday, April 06, 2009
Page 64 of 368
ST15
ALREADY BEEN ENTERED. PLEASE REENTER. PLEASE
REENTER."
TECHNICAL NOTES
59
SPStatus
SP is Alive and not institutionalized =
MRES.SPALIVE=1/Alive or empty
SP is Alive =
MRES.SPALIVE=1/Alive, 2/AliveAndInstitute, or EMPTY
SP is Institutionalized =
MRES.SPALIVE=2/AliveAndInstitute
SP is Deceased =
MRES.SPALIVE=3/Deceased.
246
ORPEvent
Existing Event Date is outside survery reference period =
EVNT.EVORPFLAG = 1/ORP.
New event is Out of the Survey Reference Period =
See general specifications for Date check logic for
determing ORP events.
DESIGN NOTES
Interviewer can select events to be edited at this roster.
1:31:04 PM Monday, April 06, 2009
Page 65 of 368
ST16
ST16
Page Order # :
Design Screen Type:
Roster
Fields:
Field 1:
EVENT_STDATEADD
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Name:
Statement Event Roster
Roster Type:
Multiple Item Select
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
Yes
Yes
No
No
Grid Functions:
Add Line
Delete Line
No
No
320
Display as ' Add Event Date '
Display as ' Edit Event Date '
DISPLAY INSTRUCTIONS:
Context header display:
Display name of Provider, PROV.PROVNAME, selected at ST13.
Question display:
Always display "(S)" in interviewer instructions in parenthesis.
Multi Field display:
Roster/Grid Instructions:
Display all events for this provider where:
EVNT.EVNTTYPE = 'DU', 'ER', 'IP', 'IU', 'OP', 'MP', 'SD', or 'SL', and
EVNT.EVNTPROV = the PROV.PROVNUM selected at ST13, and
EVNT.EVNTDFLG ^= 1/Yes
Display in order of entry.
Display all loaded events as protected rows.
Roster/Grid display:
1:31:05 PM Monday, April 06, 2009
COL #
HEADER
INSTRUCTIONS
1
Type
Display EVNT.EVNTTYPE.
2
Start Date
Display EVENT DATE in "Mon DD YYYY"
format.
3
Stop Date
If (EVNT.EVNTTYPE = 'IU') or
(EVNT.EVNTTYPE = 'IP' and
EVNT.IPSTATUS ^=1/StillInHospital),
display EVENT END DATE in "Mon DD
YYYY" format.
Else do not display.
Page 66 of 368
ST16
4
Status
If EVNT.EVNTTYPE = 'IP' and
EVNT.IPSTATUS = 1/StillInHospital,
display "ON".
Else if EVNT.VISTTYPE = 2/RepeatVisit,
display "RV".
Else do not display.
5
# Visits
If EVNT.VISTTYPE = 2/RepeatVisit,
display EVNT.RVTIMES.
Else do not display.
6
Round
Display 'R' + EVNT.EVNTRNDC. EX:
R45
If Event Date is out of the Survey
Reference Period, display "ORP".
Else do not display.
7
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
PROVIDER: (PROVIDER NAME)
Int. Instr I:
ADD THE MISSING EVENT DATE(S) IN THIS CHARGE BUNDLE.
Question Text:
ADD ALL EVENT DATES FOR THIS PROVIDER.
Int. Instr II:
INPUT FIELDS / ROUTING
Field1:
Cheshire Name:
EVENT_STDATEADD
( STQ1430 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TSTEventPick135
1
No
No
Number Label
1 [Continuous answer.]
1:31:08 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
135
Route
BOX ST16A - (STQ1550 )
Page 67 of 368
ST16
BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on EVNT:
EVNT key = EVNT.EVNTBASE + EVNT.EVNTNUM
EVNT.EVNTNUM = Number of event selected at ST16.
See STATEMENT EVENT ROSTER POP-UP specifications for pop-up window
programming instructions:
Variables populated in Statement Event Roster Pop-Up Window:
EVNT.EVNTNUM
EVNT.EVNTRNDC
EVNT.EVNTTYPE
EVNT.VISTTYPE
EVNT.RVTIMES
EVNT.EVBEGMM
EVNT.EVBEGDD
EVNT.EVBEGYY
EVNT.EVENDMM
EVNT.EVENDDD
EVNT.EVENDYY
EVNT.STEVTYPE
BASE.LASTEVNT
EVCHGFLG
If Event added, set EVNT.EVCHGFLG = 1/Yes.
EVORPFLG
If Event date added is outside the Survey Reference
Period, set EVNT.EVORPFLG = 1/ORP. See
General Specifications for setting this ORP flag.
SOFT EDIT CHECKS
HARD EDIT CHECKS
Edit #1
Date of event, EVBEGMM/EVBEGDD/EVBEGYY, should be on or
before (TODAY).
If not true, display message "INVALID DATE. DATE MUST BE ON
OR BEFORE (TODAY). PLEASE REENTER."
Edit #2
If (EVNTTYPE = 'IP' or 'IU'), then Discharge date,
EVENDMM/EVENDDD/EVENDYY, should be on or before (TODAY).
If not true, display message "INVALID DATE. DISCHARGE DATE
MUST BE ON OR BEFORE (TODAY). PLEASE REENTER."
Edit #3
If (EVNTTYPE = 'IP' or 'IU'), then Discharge date,
EVENDMM/EVENDDD/EVENDYY, must be on or
after the Admission date, EVBEGMM/EVBEGDD/EVBEGYY.
If not true, display message: "INVALID DATE. DISCHARGE DATE
MUST BE ON OR AFTER (ADMISSION DATE). PLEASE
REENTER."
Edit #4
If EVNTTYPE = 'IP', then the IP Admission and Discharge Date
cannot overlap an existing IP stay.
If not true, display message "INVALID DATE. THIS DATE
OVERLAPS AN EXISTING IP STAY FROM (ADMISSION DATE) TO
[(DISCHARGE DATE)/SP STILL IN HOSPITAL]. PLEASE
1:31:08 PM Monday, April 06, 2009
Page 68 of 368
ST16
REENTER."
Display instructions:
Display (ADMISSION DATE) of existing IP stay that the IP stay
added overlaps.
If existing IP stay IPSTATUS=1/StillInHosptial, display "SP STILL IN
HOSPITAL".
Else display (DISCHARGE DATE) of existing IP stay that the IP stay
added overlaps.
See General specifcations for overlapping date logic.
Edit #5
If EVNTTYPE = 'IU' and SPALIVE=2/AliveAndInstitute and Date of
Institutionalization colllected at INS2 does not have any missing
data, SPINSTMM, SPINSTDD, SPINSTYY ^= DK and SPINSTMM,
SPINSTDD, SPINSTYY ^= RF, then admission date,
EVBEGMM/EVBEGDD/EVBEGYY, and discharge date,
EVENDMM/EVENDDD/EVENDYY, cannot match date of
institutionalization collected at INS2,
SPINSTMM/SPINSTDD/SPINSTYY.
If not true, display message "INVALID DATE. THIS DATE
MATCHES THE CURRENT INSTITUTIONALIZATION DATE, (DATE
OF INSTITUTIONALIZATION). PLEASE REENTER."
Edit #6
If EVNT.EVNTTYPE = 'DU', 'ER', 'OP', 'MP', 'SL' or 'SD', then Date of
event, EVBEGMM/EVBEGDD/EVBEGYY, cannot match an existing
event date for the same provider.
The following must be true for the event added to be a duplicate of
an existing event:
Both event's EVNTDFLG ^= 1/Yes,
Both event's EVNTTYPE match.
Both event's EVNTPROV match.
Both event's EVENT DATE match. See general specifications for
matching date logic.
The date of the event added should not match any event date for
the same provider.
If not true, display message "INVALID DATE. THIS DATE HAS
ALREADY BEEN ENTERED. PLEASE REENTER. PLEASE
REENTER."
TECHNICAL NOTES
59
SPStatus
SP is Alive and not institutionalized =
MRES.SPALIVE=1/Alive or empty
SP is Alive =
MRES.SPALIVE=1/Alive, 2/AliveAndInstitute, or EMPTY
SP is Institutionalized =
MRES.SPALIVE=2/AliveAndInstitute
SP is Deceased =
MRES.SPALIVE=3/Deceased.
246
ORPEvent
Existing Event Date is outside survery reference period =
EVNT.EVORPFLAG = 1/ORP.
New event is Out of the Survey Reference Period =
See general specifications for Date check logic for
determing ORP events.
1:31:08 PM Monday, April 06, 2009
Page 69 of 368
ST16
DESIGN NOTES
Interviewer can only add events at this roster.
1:31:08 PM Monday, April 06, 2009
Page 70 of 368
BOX ST16A
BOX ST16A
Page Order # :
370
BOX INSTRUCTIONS
( STQ1550 )
IF AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU', 'ER', 'IP', 'IU', 'OP', OR
'MP' EVENT TYPE AND THE EVENT DATE WAS NOT OUTSIDE THE
SURVEY REFERENCE PERIOD, GO TO BOX ST16B - (STQ1555 ).
ELSE GO TO ST14 - STDATEUPD ( STQ1412 ).
ASSIGNMENTS
TECHNICAL NOTES
246
ORPEvent
Existing Event Date is outside survery reference period =
EVNT.EVORPFLAG = 1/ORP.
New event is Out of the Survey Reference Period =
See general specifications for Date check logic for
determing ORP events.
241
TypeOfEvent
Type of Event =
EVNT.EVNTTYPE.
DESIGN NOTES
We do not collect event details for EVNT.EVNTTYPE = 'SD' or 'SL'.
1:31:08 PM Monday, April 06, 2009
Page 71 of 368
BOX ST16B
BOX ST16B
Page Order # :
375
BOX INSTRUCTIONS
( STQ1555 )
IF AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU', 'ER', 'IP', 'OP', OR
'MP' EVENT TYPE, GO TO ST17 - STDATEINTRO ( STQ1560 ).
ELSE GO TO BOX ST18 - (STQ1620 ).
ASSIGNMENTS
TECHNICAL NOTES
241
TypeOfEvent
Type of Event =
EVNT.EVNTTYPE.
DESIGN NOTES
We do not display ST17 Introduction if EVNT.EVNTTYPE = 'IU'.
1:31:08 PM Monday, April 06, 2009
Page 72 of 368
ST17
ST17
Page Order # :
Design Screen Type:
No Entry
Fields:
Field 1:
STDATEINTRO
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
380
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Always display "(s)" in parenthesis.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
Before we continue with this statement, I would like to ask you a few
questions about the visit(s) I just added.
Int. Instr II:
INPUT FIELDS / ROUTING
1:31:11 PM Monday, April 06, 2009
Page 73 of 368
ST17
STDATEINTRO
Field1:
Cheshire Name:
( STQ1560 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TContinueEMPTY
1
No
No
Number Label
1 Continue
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX ST17 - (STQ1570 )
English text: CONTINUE
Attribute
Empty
Route
BOX ST17 - (STQ1570 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:31:16 PM Monday, April 06, 2009
Page 74 of 368
BOX ST17
BOX ST17
Page Order # :
390
BOX INSTRUCTIONS
( STQ1570 )
IF AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU' OR 'MP' EVENT TYPE
AND THE PROVIDER SPECIALTY HAS NOT BEEN COLLECTED, GO TO
ST18 - PROVSPEC ( STQ1600 ).
ELSE GO TO BOX ST18 - (STQ1620 ).
ASSIGNMENTS
TECHNICAL NOTES
170
ProviderSpecCollected
Provider Specialty has already been collected =
PROV.PROVSPEC ^= EMPTY.
Provider Specialty has not been collected =
PROV.PROVSPEC = EMPTY.
241
TypeOfEvent
Type of Event =
EVNT.EVNTTYPE.
DESIGN NOTES
1:31:16 PM Monday, April 06, 2009
Page 75 of 368
ST18
ST18
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
PROVSPEC
Field 2:
PROVSPOS
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
Enable Functions:
420
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Display name of Provider, PROV.PROVNAME, selected at ST13.
Multi Field display:
Vertical Alignment
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
What kind of medical person is (PROVIDER NAME)?
Int. Instr II:
INPUT FIELDS / ROUTING
1:31:28 PM Monday, April 06, 2009
Page 76 of 368
ST18
1:31:52 PM Monday, April 06, 2009
Page 77 of 368
ST18
PROVSPEC
Field1:
Cheshire Name:
( STQ1600 )
PROV.PROVSPEC
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TProvspec
1
No
No
Number Label
1 Dentist
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX ST18 - (STQ1620 )
2
English text: DENTIST/DENTAL PROVIDER
MedicalDoctor
BOX ST18 - (STQ1620 )
3
English text: MEDICAL DOCTOR
Audiologist
BOX ST18 - (STQ1620 )
4
English text: AUDIOLOGIST
Chiropractor
BOX ST18 - (STQ1620 )
5
English text: CHIROPRACTOR
ClinicalSocialWorker
BOX ST18 - (STQ1620 )
6
English text: CLINICAL SOCIAL WORKER
Dietitian
BOX ST18 - (STQ1620 )
7
English text: DIETITIAN-NUTRITIONIST
HearingTherapist
BOX ST18 - (STQ1620 )
8
English text: HEARING THERAPIST
HomeHealthAide
BOX ST18 - (STQ1620 )
9
English text: HOME HEALTH/HEALTH AIDE
Homemaker
BOX ST18 - (STQ1620 )
10
English text: HOMEMAKER
HospiceWorker
BOX ST18 - (STQ1620 )
11
English text: HOSPICE WORKER
IvTherapist
BOX ST18 - (STQ1620 )
12
English text: I.V. THERAPIST
Nurse
BOX ST18 - (STQ1620 )
13
English text: NURSE (RN)
NursePractitioner
BOX ST18 - (STQ1620 )
English text: NURSE PRACTITIONER
1:32:32 PM Monday, April 06, 2009
Page 78 of 368
ST18
14
NursesAide
BOX ST18 - (STQ1620 )
15
English text: NURSE'S AIDE
OccupationalTherapist
BOX ST18 - (STQ1620 )
16
English text: OCCUPATIONAL THERAPIST (OT)
Optometrist
BOX ST18 - (STQ1620 )
17
English text: OPTOMETRIST (OD)
Osteopath
BOX ST18 - (STQ1620 )
18
English text: OSTEOPATH (DO)
Paramedic
BOX ST18 - (STQ1620 )
19
English text: PARAMEDIC
PhysicalTherapist
BOX ST18 - (STQ1620 )
20
English text: PHYSICAL THERAPIST (PT)
PhysiciansAssistant
BOX ST18 - (STQ1620 )
21
English text: PHYSICIAN'S ASSISTANT
Podiatrist
BOX ST18 - (STQ1620 )
22
English text: PODIATRIST (FOOT DOCTOR)
Psychologist
BOX ST18 - (STQ1620 )
23
English text: PSYCHOLOGIST
RespiratoryTherapist
BOX ST18 - (STQ1620 )
24
English text: RESPIRATORY THERAPIST
SocialWorker
BOX ST18 - (STQ1620 )
25
English text: SOCIAL/CASE WORKER
SpeechTherapist
BOX ST18 - (STQ1620 )
26
English text: SPEECH THERAPIST
MentalHealth
BOX ST18 - (STQ1620 )
27
English text: THERAPIST (MENTAL HEALTH)
XrayTechnician
BOX ST18 - (STQ1620 )
28
English text: X-RAY TECHNICIAN
LicensedPracticalNurse
29
English text: LICENSED PRACTICAL NURSE (LPN)
Acupuncturist
BOX ST18 - (STQ1620 )
30
English text: ACUPUNCTURIST
Homeopath
BOX ST18 - (STQ1620 )
31
English text: HOMEOPATH
MassageTherapist
BOX ST18 - (STQ1620 )
32
English text: MASSAGE THERAPIST
Naturopath
BOX ST18 - (STQ1620 )
33
English text: NATUROPATH
LicensedCounselor
BOX ST18 - (STQ1620 )
34
English text: LICENSED PROFESSIONAL COUNSELOR [LPC]
LabTechnician
BOX ST18 - (STQ1620 )
BOX ST18 - (STQ1620 )
English text: LAB TECHNICIAN
1:33:19 PM Monday, April 06, 2009
Page 79 of 368
ST18
91
Other
ST18 - PROVSPOS ( STQ1610 )
English text: OTHER MEDICAL PROVIDER SPECIALTY
Attribute
Don't know
Route
BOX ST18 - (STQ1620 )
Refusal
BOX ST18 - (STQ1620 )
Field2:
Cheshire Name:
PROVSPOS
( STQ1610 )
PROV.PROVSPOS
Item Text display:
Display "(SPECIFY)" in the same blue font used for
interviewer instructions.
Item Text:
OTHER MEDICAL PROVIDER (SPECIFY)
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TOthrspec
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
30
Route
BOX ST18 - (STQ1620 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:33:25 PM Monday, April 06, 2009
Page 80 of 368
BOX ST18
BOX ST18
Page Order # :
430
BOX INSTRUCTIONS
( STQ1620 )
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A.
IN THE CURRENT ROUND OR ANY PREVIOUS ROUND) AND (IF THIS
PROVIDER IS ASSOCIATED WITH V.A. IS UNKNOWN), GO TO ST19 VAPLACE ( STQ1630 ).
ELSE GO TO BOX ST19 - (STQ1650 ).
ASSIGNMENTS
TECHNICAL NOTES
423
SPReceivedCaretThruV
A
SP reported receiving health care services through
V.A.in the current or any previous round =
There is an HRND where HRND.HRNDRND = current
round and HRND.VACOVER = 1/Yes.
HRND.VACOVER is set at BOX HI20 or collected at
HI36.
127
ProviderVAUnknown
If Provider is associated with V.A. is unknown =
PROV.VAPLACE = empty.
DESIGN NOTES
1:33:25 PM Monday, April 06, 2009
Page 81 of 368
ST19
ST19
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
VAPLACE
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
440
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Display name of Provider, PROV.PROVNAME, selected at ST13.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
Is (PROVIDER NAME) associated with a Department of Veterans
Affairs, or V.A. facility?
Int. Instr II:
INPUT FIELDS / ROUTING
1:33:28 PM Monday, April 06, 2009
Page 82 of 368
ST19
VAPLACE
Field1:
Cheshire Name:
( STQ1630 )
PROV.VAPLACE
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX ST19 - (STQ1650 )
English text: YES
No
BOX ST19 - (STQ1650 )
English text: NO
Attribute
Don't know
Route
BOX ST19 - (STQ1650 )
Refusal
BOX ST19 - (STQ1650 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:33:34 PM Monday, April 06, 2009
Page 83 of 368
BOX ST19
BOX ST19
Page Order # :
460
BOX INSTRUCTIONS
( STQ1650 )
IF ALL EVENTS ADDED AT ST16 ARE 'IU' EVENT TYPE, GO TO ST14 STDATEUPD ( STQ1412 ).
ELSE IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING
THE CURRENT ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH
A MANAGED CARE PLAN IS UNKNOWN), GO TO ST20 - HMOASSOC (
STQ1660 ).
ELSE IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING
THE CURRENT ROUND) AND (THIS PROVIDER IS NOT ASSOCIATED
WITH A MANAGED CARE PLAN), GO TO ST21 - HMOREFER ( STQ1670 ).
ELSE GO TO ST22A_IN - NAVIGATOR ( STQ1675 ).
ASSIGNMENTS
TECHNICAL NOTES
52
DeletedPlans
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
2
ManagedCarePlan
SP covered by a Managed Care Plan anytime during
current round =
There is a PLRO.PLROPLAN=PLAN.PLANUM &
PLRO.PLRORND=current round &
((PLRO.PPRVHMO=1/Yes) or (PLAN.PLANTYPE =
5/MHMO & PLRO.COVANYTM=1/Yes) or
(PLRO.MCAIDHMO=1/Yes)). See T.N. 52.
128
ProviderHMOUnknown
If Provider is associated with a Managed Care plan is
unknown =
PROV.HMOASSOC=empty.
130
ProviderNotHMO
Provider is not associated with a Managed Care plan =
PROV.HMOASSOC=2/No, DK, or RF.
129
ProviderAssocHMO
Provider is associated with a Managed Care plan =
PROV.HMOASSOC=1/Yes.
241
TypeOfEvent
Type of Event =
EVNT.EVNTTYPE.
DESIGN NOTES
We do not collect event details for 'IU' events.
1:33:34 PM Monday, April 06, 2009
Page 84 of 368
ST20
ST20
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
HMOASSOC
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
470
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Display name of Provider, PROV.PROVNAME, selected at ST13.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
Display all managed care plans SP was covered by anytime during
the current round.
Display managed care plan name(s) below question text.
Display plans in the following order: Medicare Managed Care plans,
Medicaid Managed Care plans, and Private Managed Care plans. If
there is more than one plan for any specific plan type, display in
order of entry.
Column 1, header = "MANAGED CARE PLANS".
Column 1, display= If Medicaid Managed Care Plan, display
"Medicaid Managed Care Plan".
Else display health insurance plan name "(PLAN NAME) Managed
Care Plan".
TEXT:
Context Header:
1:33:37 PM Monday, April 06, 2009
Page 85 of 368
ST20
Int. Instr I:
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ
MANAGED CARE PLAN NAME(S) BELOW] plan?
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING
HMOASSOC
Field1:
Cheshire Name:
( STQ1660 )
PROV.HMOASSOC
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
ST22A_IN - NAVIGATOR ( STQ1675 )
English text: YES
No
ST21 - HMOREFER ( STQ1670 )
English text: NO
Attribute
Don't know
Route
ST21 - HMOREFER ( STQ1670 )
Refusal
ST21 - HMOREFER ( STQ1670 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
52
DeletedPlans
1:33:45 PM Monday, April 06, 2009
Deleted plans that are not valid for displays or checks =
Page 86 of 368
ST20
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
2
ManagedCarePlan
SP covered by a Managed Care Plan anytime during
current round =
There is a PLRO.PLROPLAN=PLAN.PLANUM &
PLRO.PLRORND=current round &
((PLRO.PPRVHMO=1/Yes) or (PLAN.PLANTYPE =
5/MHMO & PLRO.COVANYTM=1/Yes) or
(PLRO.MCAIDHMO=1/Yes)). See T.N. 52.
107
PlanIsMCaidHMO
SP is covered by a Medicaid Managed Care Plan during
the current round =
There is a PLAN where PLAN.PLANTYPE=2/Medicaid &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.MCAIDHMO=1/Yes).
Exclude Deleted Plans. See T.N. 52.
111
PlanIsMCareHMO
SP is covered by a Medicare Managed Care Plan during
the current round =
There is a PLAN where PLAN.PLANTYPE=5/MHMO &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.COVANYTM=1/Yes).
Exclude Deleted Plans. See T.N. 52.
112
PlanIsPrivateHMO
SP is covered by a Private Managed Care Plan during
the current round =
There is a PLAN where PLAN.PLANTYPE=4/PrivatePlan
& PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.PPRVHMO=1/Yes).
Exclude Deleted Plans. See T.N. 52.
106
HIPlanName
Health Insurance Plan Roster is stored on PLAN.
Plan name = PLAN.PLNAME.
DESIGN NOTES
1:33:45 PM Monday, April 06, 2009
Page 87 of 368
ST21
ST21
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
HMOREFER
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
480
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Display name of Provider, PROV.PROVNAME, selected at ST13.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
Display all managed care plans SP was covered by anytime during
the current round.
Display managed care plan name(s) below question text.
Display plans in the following order: Medicare Managed Care plans,
Medicaid Managed Care plans, and Private Managed Care plans. If
there is more than one plan for any specific plan type, display in
order of entry.
Column 1, header = "MANAGED CARE PLANS".
Column 1, display= If Medicaid Managed Care Plan, display
"Medicaid Managed Care Plan".
Else display health insurance plan name "(PLAN NAME) Managed
Care Plan".
TEXT:
Context Header:
1:33:48 PM Monday, April 06, 2009
Page 88 of 368
ST21
Int. Instr I:
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ
MANAGED CARE PLAN NAME(S) BELOW]?
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING
HMOREFER
Field1:
Cheshire Name:
( STQ1670 )
EVNT.HMOREFER
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
ST22A_IN - NAVIGATOR ( STQ1675 )
English text: YES
No
ST22A - NOGOHMO ( STQ1672 )
English text: NO
Attribute
Don't know
Route
ST22A_IN - NAVIGATOR ( STQ1675 )
Refusal
ST22A_IN - NAVIGATOR ( STQ1675 )
BACKGROUND VARIABLE ASSIGNMENTS
HMOREFER is an EVENT level detail. The response to HMOREFER needs to be copied
to EVNT.HMOREFER for event added at ST16.
HMOREFER
Set EVNT.HMOREFER = ST21 - HMOREFER on
each event added at ST16.
SOFT EDIT CHECKS
HARD EDIT CHECKS
1:33:56 PM Monday, April 06, 2009
Page 89 of 368
ST21
TECHNICAL NOTES
52
DeletedPlans
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
2
ManagedCarePlan
SP covered by a Managed Care Plan anytime during
current round =
There is a PLRO.PLROPLAN=PLAN.PLANUM &
PLRO.PLRORND=current round &
((PLRO.PPRVHMO=1/Yes) or (PLAN.PLANTYPE =
5/MHMO & PLRO.COVANYTM=1/Yes) or
(PLRO.MCAIDHMO=1/Yes)). See T.N. 52.
107
PlanIsMCaidHMO
SP is covered by a Medicaid Managed Care Plan during
the current round =
There is a PLAN where PLAN.PLANTYPE=2/Medicaid &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.MCAIDHMO=1/Yes).
Exclude Deleted Plans. See T.N. 52.
111
PlanIsMCareHMO
SP is covered by a Medicare Managed Care Plan during
the current round =
There is a PLAN where PLAN.PLANTYPE=5/MHMO &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.COVANYTM=1/Yes).
Exclude Deleted Plans. See T.N. 52.
112
PlanIsPrivateHMO
SP is covered by a Private Managed Care Plan during
the current round =
There is a PLAN where PLAN.PLANTYPE=4/PrivatePlan
& PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.PPRVHMO=1/Yes).
Exclude Deleted Plans. See T.N. 52.
106
HIPlanName
Health Insurance Plan Roster is stored on PLAN.
Plan name = PLAN.PLNAME.
DESIGN NOTES
1:33:56 PM Monday, April 06, 2009
Page 90 of 368
ST22A
ST22A
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
NOGOHMO
Field 2:
NOGOHMOS
HELP
COMMENTS
JUMPBACK
No
No
No
Enable Functions:
485
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Vertical Alignment
Roster/Grid Instructions:
Roster/Grid display:
Report display:
Display managed care plan name(s) below question text.
Display plans in the following order: Medicare Managed Care plans,
Medicaid Managed Care plans, and Private Managed Care plans. If
there is more than one plan for any specific plan type, display in
order of entry.
Column 1, header = "MANAGED CARE PLANS".
Column 1, display= If Medicaid Managed Care Plan, display
"Medicaid Managed Care Plan".
Else display health insurance plan name "(PLAN NAME) Managed
Care Plan".
TEXT:
Context Header:
Int. Instr I:
1:34:03 PM Monday, April 06, 2009
Page 91 of 368
ST22A
Question Text:
What is the most important reason [you/(SP)] did not see a doctor
associated with [READ MANAGED CARE PLAN NAME(S) BELOW]
or a doctor that [READ MANAGED CARE PLAN NAME(S) BELOW]
would refer [you/(SP)] to?
Int. Instr II:
INPUT FIELDS / ROUTING
1:34:15 PM Monday, April 06, 2009
Page 92 of 368
ST22A
NOGOHMO
Field1:
Cheshire Name:
( STQ1672 )
EVNT.NOGOHMO
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
Tnogohmo
1
No
No
Number Label
1 PlanNotCoverService
FieldSize:
Min Value:
Max Value:
Mask:
Route
ST22A_IN - NAVIGATOR ( STQ1675 )
2
English text: PLAN DOES NOT COVER THE SERVICE SP WANTED
DifficultyDelayGettingService
ST22A_IN - NAVIGATOR ( STQ1675 )
3
English text: DIFFICULTY OR DELAY IN GETTING SERVICES
SPProviderPreference
ST22A_IN - NAVIGATOR ( STQ1675 )
4
English text: SP PROVIDER PREFERENCE
ServiceCoverdbyOtherInsurance
5
English text: THIS SERVICE WAS COVERED BY OTHER INSURANCE SP HAS
NotinManagedCareTimeofEvent
ST22A_IN - NAVIGATOR ( STQ1675 )
6
English text: NOT IN A MANAGED CARE PLAN AT TIME OF EVENT
NoChoiceMedEmergency
ST22A_IN - NAVIGATOR ( STQ1675 )
91
ST22A_IN - NAVIGATOR ( STQ1675 )
English text: NO CHOICE - MEDICAL EMERGENCY OR OUT OF SERVICE AREA
Other
ST22A - NOGOHMOS ( STQ1674 )
English text: OTHER
Attribute
Don't know
Route
ST22A_IN - NAVIGATOR ( STQ1675 )
Refusal
ST22A_IN - NAVIGATOR ( STQ1675 )
1:34:31 PM Monday, April 06, 2009
Page 93 of 368
ST22A
Field2:
Cheshire Name:
NOGOHMOS
( STQ1674 )
EVNT.NOHMOMOS
Item Text display:
Display "(SPECIFY)" in the same blue font used for
interviewer instructions.
Item Text:
OTHER (SPECIFY)
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TOthrspec
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
30
Route
ST22A_IN - NAVIGATOR ( STQ1675 )
BACKGROUND VARIABLE ASSIGNMENTS
NOGOHMO and NOGOHMOS are EVENT level details.
The response to NOGOHMO needs to be copied to EVNT.NOGOHMO for each event
added at ST16.
The response to NOGOHMOS needs to be copied to EVNT.NOGOHMOS for each event
added at ST16.
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:34:33 PM Monday, April 06, 2009
Page 94 of 368
ST22A_IN
ST22A_IN
Page Order # :
Design Screen Type:
Instance Navigator
Fields:
Field 1:
NAVIGATOR
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
489
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Display all DU, ER, IP, OP, MP events added at ST16.
Display all IU, SD, SL events as "DONE". Do not allow event
details to be collected for these events.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING
1:34:35 PM Monday, April 06, 2009
Page 95 of 368
ST22A_IN
NAVIGATOR
Field1:
Cheshire Name:
( STQ1675 )
N/A
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TInstanceNavigator
1
No
No
Number Label
1 SelectItemInList
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX ST22A - (STQ1680 )
English text: ITEM SELECTED IN INSTANCE NAVIGATOR
SelectContinueInterview
ST14 - STDATEUPD ( STQ1412 )
English text: CONTINUE INTERVIEW SELECTED
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:34:39 PM Monday, April 06, 2009
Page 96 of 368
BOX ST22A
BOX ST22A
Page Order # :
490
BOX INSTRUCTIONS
( STQ1680 )
FOR THIS EVENT ADDED AT ST16,
IF TYPE OF EVENT = 'DU', GO TO DU7 - DVPROCDR ( DUQ1170 ).
ELSE IF TYPE OF EVENT = 'ER', GO TO ER5 - CONDTION_ER ( ERQ1160
).
ELSE IF TYPE OF EVENT = 'IP', GO TO IP7 - ANYOPERS ( IPQ1240 ).
ELSE IF TYPE OF EVENT = 'OP', GO TO OP5 - ANYOPERS ( OPQ1160 ).
ELSE IF TYPE OF EVENT = 'MP', GO TO BOX ST22B - (STQ1685 ).
ELSE GO TO BOX ST23B - (STQ1700 ).
ASSIGNMENTS
TECHNICAL NOTES
241
TypeOfEvent
Type of Event =
EVNT.EVNTTYPE.
DESIGN NOTES
BOX ST22A calls the DU, ER, IP, OP Utilization sections, depending on
EVNTTYPE of event added at ST16.
MP events are handled by BOX ST23A.
IU, SD, SL events do not get event details.
DU, ER, IP and OP returns to ST at BOX ST23B.
1:34:39 PM Monday, April 06, 2009
Page 97 of 368
BOX ST22B
BOX ST22B
Page Order # :
495
BOX INSTRUCTIONS
( STQ1685 )
IF (PROVIDER SPECIALTY IS A MEDICAL DOCTOR) AND ((EVENT DATE
OVERLAPS AN EXISTING IP EVENT) OR (EVENT DATE MATCHES AN
EXISTING ER OR OP EVENT) GO TO ST23 - MPSDVIS ( STQ1691 ).
ELSE GO TO BOX ST23A - (STQ1695 ).
ASSIGNMENTS
TECHNICAL NOTES
171
ProviderMedicalDoctor
Provider Specialty is a Medical Doctor =
PROV.PROVSPEC=2/MedicalDoctor
350
OverlapERIPOPStay
Event date overlaps an existing IP stay or Event date
matches an existing ER or OP event date =
See general specifications for detailed date logic check.
DESIGN NOTES
1:34:39 PM Monday, April 06, 2009
Page 98 of 368
ST23
ST23
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
MPSDVIS
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
500
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Display name of medical provider, PROV.PROVNAME, for MP event
added at ST16, where PROV.PROVNUM = EVNT.EVNTPROV.
Display date of event for the for MP event added at ST16.
Question display:
EVENT MONTH = Display Month of the MP event added at ST16.
Display name of medical provider, PROV.PROVNAME, for MP
event added at ST16, where PROV.PROVNUM =
EVNT.EVNTPROV.
Display "in" in the second sentence in BOLD.
If event overlaps more than one existing ER, IP, or OP event,
display "any of these places".
Else display "the [READ EVENT LISTED BELOW]".
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
1:34:43 PM Monday, April 06, 2009
Display report below question text.
Display ER, IP, and OP events that overlap or match the MP event
added at ST16.
Report Header: OVERLAPPING EVENT DATES
Column 1, header = "EVENT TYPE".
Column 1, display =
Page 99 of 368
ST23
If EVNT.EVNTTYPE = 2/ER, display "Emergency Room".
Else if EVNT.EVNTTYPE = 5/IP, display "Hospital as an Inpatient".
Else if EVNT.EVNTTYPE = 9/OP, display "Outpatient Department".
Column 2, header = "EVENT DATE".
Column 2, display EVENT BEGIN DATE
Column 3, header = "EVENT END DATE".
Column 3, display EVENT END DATE
TEXT:
Context Header:
PROVIDER: (PROVIDER NAME)
EVENT: (EVENT DATE)
Int. Instr I:
Question Text:
We have recorded that in (EVENT MONTH) [you were/(SP) was]
also in [READ EVENT(S) LISTED BELOW]. Was this visit with
(PROVIDER NAME) a visit while [you were/(SP) was] in [the [READ
EVENT LISTED BELOW]/any of these places]?
Int. Instr II:
INPUT FIELDS / ROUTING
1:34:50 PM Monday, April 06, 2009
Page 100 of 368
ST23
( STQ1691 )
MPSDVIS
Field1:
Cheshire Name:
EVNT.MPSDVIS
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX ST23A - (STQ1695 )
English text: YES
No
BOX ST23A - (STQ1695 )
English text: NO
Attribute
Don't know
Route
BOX ST23A - (STQ1695 )
Refusal
BOX ST23A - (STQ1695 )
BACKGROUND VARIABLE ASSIGNMENTS
EVNTTYPE
If ST23 - MPSDVIS = 1/Yes, update MP event type
to Separately Billing Doctor, EVNT.EVNTTYPE =
'SD'.
STEVTYPE
If ST23 - MPSDVIS = 1/Yes, update MP Statement
event type to Separately Billing Doctor,
EVNT.STEVTYPE = 2/SD.
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
350
OverlapERIPOPStay
Event date overlaps an existing IP stay or Event date
matches an existing ER or OP event date =
See general specifications for detailed date logic check.
DESIGN NOTES
1:34:56 PM Monday, April 06, 2009
Page 101 of 368
BOX ST23A
BOX ST23A
Page Order # :
505
BOX INSTRUCTIONS
( STQ1695 )
IF ST23 ASKED AND ST23 - MPSDVIS = 1/Yes, GO TO BOX ST23B (STQ1700 ).
ELSE GO TO BOX MP2C - (MPQ1220 ).
ASSIGNMENTS
TECHNICAL NOTES
DESIGN NOTES
BOX ST23A calls the MP Utilization section.
MP returns to ST at BOX ST23B.
1:34:56 PM Monday, April 06, 2009
Page 102 of 368
BOX ST23B
BOX ST23B
Page Order # :
510
BOX INSTRUCTIONS
( STQ1700 )
GO TO ST22A_IN - NAVIGATOR ( STQ1675 ).
ASSIGNMENTS
TECHNICAL NOTES
DESIGN NOTES
Return from Utilzation sections at BOX ST23B.
1:34:56 PM Monday, April 06, 2009
Page 103 of 368
ST24
ST24
Page Order # :
Design Screen Type:
Roster
Fields:
Field 1:
EVENT_STDATE
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
Roster Name:
Statement Event Roster
Roster Type:
Multiple Item Select
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
515
DISPLAY INSTRUCTIONS:
Context header display:
Display name of Provider, PROV.PROVNAME, selected at ST13.
Question display:
Always display "(S)" in interviewer instructions in parenthesis.
Multi Field display:
Roster/Grid Instructions:
Display all events for this provider where:
EVNT.EVNTTYPE = 'DU', 'ER', 'IP', 'IU', 'OP', 'MP', 'SD', or 'SL', and
EVNT.EVNTPROV = the PROV.PROVNUM selected at ST13, and
EVNT.EVNTDFLG ^= 1/Yes
Display in order of entry.
Roster/Grid display:
1:34:57 PM Monday, April 06, 2009
COL #
HEADER
INSTRUCTIONS
1
Type
Display EVNT.EVNTTYPE.
2
Start Date
Display EVENT DATE in "Mon DD YYYY"
format.
3
Stop Date
If (EVNT.EVNTTYPE = 'IU') or
(EVNT.EVNTTYPE = 'IP' and
EVNT.IPSTATUS ^=1/StillInHospital),
display EVENT END DATE in "Mon DD
YYYY" format..
Else do not display.
Page 104 of 368
ST24
4
Status
If EVNT.EVNTTYPE = 'IP' and
EVNT.IPSTATUS = 1/StillInHospital,
display "ON".
Else if EVNT.VISTTYPE = 2/RepeatVisit,
display "RV".
Else do not display.
5
# Visits
If EVNT.VISTTYPE = 2/RepeatVisit,
display EVNT.RVTIMES.
Else do not display.
6
Round
Display 'R' + EVNT.EVNTRNDC. EX:
R45
7
If Event Date is out of the Survey
Reference Period, display "ORP".
Else do not display.
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
PROVIDER: (PROVIDER NAME)
Int. Instr I:
Question Text:
Int. Instr II:
SELECT THE EVENT DATE(S) THAT ARE INCLUDED IN THIS
CHARGE BUNDLE.
INPUT FIELDS / ROUTING
1:35:00 PM Monday, April 06, 2009
Page 105 of 368
ST24
Field1:
Cheshire Name:
EVENT_STDATE
( STQ1705 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TEvntPick135
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
135
Route
BOX ST24 - (STQ1707 )
BACKGROUND VARIABLE ASSIGNMENTS
Create an XCEV record for each event selected at ST24 to link the event to the charge
bundle being asked about. XCEV record may already exist.
If XCEV record does not exist, create XCEV record:
XCEV key = XCEV.XCEVBASE + XCEV.XCEVCOST + XCEV.XCEVBAS2 +
XCEV.XCEVEVNT
XCEV.XCEVBASE and XCEV.XCEVBAS2 = BASE.BASEID.
XCEV.XCEVCOST = COST.COSTNUM of charge bundle being asked about.
XCEV.XCEVEVNT = EVNT.EVNTNUM of event selected at ST24.
Set fields as specified below:
XCEVCOST
Create XCEV where XCEV.XCEVCOST = this
COST.COSTNUM.
XCEVEVNT
Create XCEV where XCEV.XCEVEVNT =
EVNT.EVNTNUM of EVNT selected.
XCEVRNDC
Set XCEV.XCEVRNDC = current round.
DELLINK
If XCEV exists and XCEV.DELLINK = 1/Yes, update
XCEV.DELLINK = empty.
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
1:35:03 PM Monday, April 06, 2009
Page 106 of 368
ST24
246
ORPEvent
Existing Event Date is outside survery reference period =
EVNT.EVORPFLAG = 1/ORP.
New event is Out of the Survey Reference Period =
See general specifications for Date check logic for
determing ORP events.
DESIGN NOTES
Interviewer can only select events at this roster.
1:35:03 PM Monday, April 06, 2009
Page 107 of 368
BOX ST24
BOX ST24
Page Order # :
517
BOX INSTRUCTIONS
( STQ1707 )
IF AT LEAST ONE EVENT SELECTED AT ST24 IS A REPEAT VISIT, GO TO
ST24A - RVLINKS ( STQ1708 ).
ELSE GO TO ST25 - STDATEMTCH ( STQ1710 ).
ASSIGNMENTS
TECHNICAL NOTES
135
RepeatVisitEvent
If Event entered as a Repeat Visit =
EVNT.VISTTYPE=2/RepeatVisit.
DESIGN NOTES
1:35:03 PM Monday, April 06, 2009
Page 108 of 368
ST24A
ST24A
Page Order # :
Design Screen Type:
Numeric
Fields:
Field 1:
RVLINKS
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
518
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Display name of Provider, PROV.PROVNAME, selected at ST13.
Question display:
Display type of event, EVNT.EVNTTYPE, for the ST24 Repeat Visit
being asked about.
Display the date of the ST24 Repeat Visit event being asked
about. Display in "Month, YYYY" format.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
PROVIDER: (PROVIDER NAME)
Int. Instr I:
Question Text:
Int. Instr II:
1:35:05 PM Monday, April 06, 2009
ENTER THE NUMBER OF (EVENT TYPE) VISITS IN (EVENT
MONTH, YEAR) THAT ARE COVERED BY THIS CHARGE.
Page 109 of 368
ST24A
INPUT FIELDS / ROUTING
Field1:
RVLINKS
( STQ1708 )
XCEV.RVLINKS
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
NUMBER OF VISITS:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TRvtimes
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
BOX ST24A - (STQ1709 )
Refusal
BOX ST24A - (STQ1709 )
FieldSize:
Min Value:
Max Value:
Mask:
1
90
Route
BOX ST24A - (STQ1709 )
BACKGROUND VARIABLE ASSIGNMENTS
Collect # of visits on XCEV:
XCEV key = XCEV.XCEVBASE + XCEV.XCEVCOST + XCEV.XCEVBAS2 +
XCEV.XCEVEVNT
XCEV.XCEVCOST = COST.COSTNUM of charge bundle being asked about.
XCEV.XCEVEVNT = EVNT.EVNTNUM of Repeat Visit event currently being asked about.
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:35:09 PM Monday, April 06, 2009
Page 110 of 368
BOX ST24A
BOX ST24A
Page Order # :
519
BOX INSTRUCTIONS
( STQ1709 )
IF ANOTHER EVENT SELECTED AT ST24 IS A REPEAT VISIT, GO TO
ST24A - RVLINKS ( STQ1708 ).
ELSE GO TO ST25 - STDATEMTCH ( STQ1710 ).
ASSIGNMENTS
TECHNICAL NOTES
135
RepeatVisitEvent
If Event entered as a Repeat Visit =
EVNT.VISTTYPE=2/RepeatVisit.
DESIGN NOTES
1:35:09 PM Monday, April 06, 2009
Page 111 of 368
ST25
ST25
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
STDATEMTCH
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
520
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
Display report below question text.
Display all Events linked to this charge bundle where
XCEV.XCEVEVNT = the EVNT.EVNTNUM and XCEV.XCEVCOST
= the COST.COSTNUM for the Charge Bundle and XCEV.DELLINK
^=1/Yes. Display PMs followed by OM events, HH events and then
other provider service events.
NOTE: This report is shared by other questions. Not all Event types
will be applicable at each screen.
Report header: EVENTS IN CHARGE BUNDLE
Report layout:
Column 1, header =Type
Display EVNT.EVNTTYPE
Column 2, NO HEADER.
If EVNT.RENTPROB=2/Rent and ((EVNT.RENT2BUY ^=
2/PurchasedRentToBuy) or (EVNT.RENT2BUY = EMPTY)), display
1:35:12 PM Monday, April 06, 2009
Page 112 of 368
ST25
"R".
Else do not display.
Column 3, header = Description
If EVNT.EVNTTYPE = OM then
If EVNT.STOMTYPE = 91, display EVOS.EVOSTEXT on EVOS
where EVOS.EVOSEVNT = this EVNT.EVNTNUM.
Else display EVNT.STOMTYPE response text.
Else if EVNT.EVNTTYPE = PM, display EVNT.PMEDNAME.
Else display PROV.PROVNAME on PROV where PROV.PROVNUM
= this EVNT.EVNTPROV.
Column 4, header = Start Date
If EVNT.EVNTTYPE = HF or HP,
display COST START DATE in "Mon DD YYYY" format.
Else if (EVNT.EVNTTYPE = DU, ER, IP, IU, OP, MP, SD or SL) or
(EVNT.EVNTTYPE = OM and
((EVNT.OTHRTYPE ^= 5/OstomySupplies and
^= 6/IncontinenceSupplies and ^= 7/Bandages) or
(EVNT.OTHRTYPE = EMPTY)) and
((EVNT.OMSTATUS ^= 1/AlterationNotComplete) or
(EVNT.OMSTATUS = EMPTY))),
display EVENT DATE in "Mon DD YYYY" format.
Else do not display.
Column 5, header = Stop Date
If EVNT.EVNTTYPE = HF or HP,
display COST STOP DATE in "Mon DD YYYY" format.
Else if (EVNT.EVNTTYPE = IU) or
(EVNT.EVNTTYPE = IP and
EVNT.IPSTATUS ^= 1/StillInHospital) or
(EVNT.EVNTTYPE = OM and EVNT.RENTPROB = 2/Rent and
(EVNT.RENTSTIL = 2/No, DK, or RF) and
((EVNT.RENT2BUY ^= 2/PurchasedRentToBuy) or
(EVNT.RENT2BUY = EMPTY))),
display EVNT END DATE in "Mon DD YYYY" format.
Else do not display.
Column 6, header = Status
If EVNT.VISTTYPE = 2/RepeatVisit, display “RV”.
Else if
(EVNT.EVNTTYPE = OM and
EVNT.OMSTATUS = 1/AlterationNotComplete) or
(EVNT.EVNTTYPE = IP and EVNT.IPSTATUS =
1/StillInHospital),
1:35:14 PM Monday, April 06, 2009
Page 113 of 368
ST25
display "ON".
Else if EVNT.RENTSTIL = 1/Yes, display "RR".
Else if EVNT.RENT2BUY=2/PurchasedRentToBuy, display "OW".
Else do not display.
Column 7, header = # Visits
If EVNT.VISTTYPE = 2/RepeatVisit, display XCEV.RVLINKS on
XCEV where XCEV.XCEVEVNT = this EVNT.EVNTNUM and
XCEV.XCEVCOST = the COST.COSTNUM for this charge bundle.
Else do not display.
Column 8, header = # Purchases
If (EVNT.EVNTYPE = PM) or
(EVNT.EVNTTYPE = OM and
(EVNT.OTHRTYPE = 5/OstomySupplies,
6/IncontinenceSupplies, or 7/Bandages)),
display XCEV.NUMLINKS on XCEV where
XCEV.XCEVEVNT = this EVNT.EVNTNUM and
XCEV.XCEVCOST = the COST.COSTNUM for this charge
bundle.
Else do not display.
Column 9,
If Event Date is out of Survey Reference Period, display “ORP”.
Else do not display.
TEXT:
Context Header:
(ST CLAIM HEADER)
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
PROVIDER: (PROVIDER NAME)
Int. Instr I:
ARE ALL THE PROVIDER EVENTS FROM THE CHARGE BUNDLE
ON (TYPE OF STATEMENT) SHOWN BELOW?
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING
1:35:17 PM Monday, April 06, 2009
Page 114 of 368
ST25
STDATEMTCH
Field1:
Cheshire Name:
( STQ1710 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TSTDateMtch
1
No
No
Number Label
1 Yes
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX ST26 - (STQ1720 )
2
English text: YES
NoAddDate
3
English text: NO, NEED TO ADD A PROVIDER EVENT
NoDeleteDate
ST26 - EVENT_STDATEDEL ( STQ1715 )
ST13 - PROVIDER_STDATE ( STQ1410 )
English text: NO, NEED TO REMOVE A PROVIDER EVENT
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
246
ORPEvent
Existing Event Date is outside survery reference period =
EVNT.EVORPFLAG = 1/ORP.
New event is Out of the Survey Reference Period =
See general specifications for Date check logic for
determing ORP events.
DESIGN NOTES
1:35:22 PM Monday, April 06, 2009
Page 115 of 368
ST26
ST26
Page Order # :
Design Screen Type:
Roster
Fields:
Field 1:
EVENT_STDATEDEL
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
Roster Name:
Statement Event Roster
Roster Type:
Multiple Item Select
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
525
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Always display "(S)" in interviewer instructions in parenthesis.
Multi Field display:
Roster/Grid Instructions:
Display all Provider Service events linked to this charge bundle:
There is an EVNT where:
EVNT.EVNTTYPE = 'DU', 'ER', 'IP', 'IU', 'OP', 'MP', 'SD', or 'SL', and
There is an XCEV where:
XCEV,XCEVEVNT = this EVNT.EVNTNUM, and
XCEV.XCEVCOST = COST.COSTNUM for this charge bundle, and
XCEV.DELLINK ^= 1/Yes.
Display in order of entry.
Roster/Grid display:
1:35:23 PM Monday, April 06, 2009
COL #
HEADER
INSTRUCTIONS
1
Type
Display EVNT.EVNTTYPE.
2
Start Date
Display EVENT DATE in "Mon DD YYYY"
format.
3
Stop Date
If (EVNT.EVNTTYPE = 'IU') or
(EVNT.EVNTTYPE = 'IP' and
EVNT.IPSTATUS ^=1/StillInHospital),
display EVENT END DATE in "Mon DD
YYYY" format.
Else do not display.
Page 116 of 368
ST26
4
Status
If EVNT.EVNTTYPE = 'IP' and
EVNT.IPSTATUS = 1/StillInHospital,
display "ON".
Else if EVNT.VISTTYPE = 2/RepeatVisit,
display "RV".
Else do not display.
5
# Visits
If EVNT.VISTTYPE = 2/RepeatVisit,
display XCEV.RVLINKS on XCEV where
XCEV.XCEVEVNT=this
EVNT.EVNTNUM and
XCEV.XCEVCOST=COST.COSTNUM
for this charge bundle.
Else do not display.
6
Round
Display 'R' + EVNT.EVNTRNDC. EX:
R45
7
If Event Date is out of the Survey
Reference Period, display "ORP".
Else do not display.
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
PROVIDER: (PROVIDER NAME)
Int. Instr I:
Question Text:
Int. Instr II:
SELECT THE EVENT(S) THAT YOU WOULD LIKE TO REMOVE
FROM THE CHARGE BUNDLE.
INPUT FIELDS / ROUTING
1:35:26 PM Monday, April 06, 2009
Page 117 of 368
ST26
EVENT_STDATEDEL
Field1:
Cheshire Name:
( STQ1715 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TEvntPick135
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
135
Route
ST25 - STDATEMTCH ( STQ1710 )
BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on XCEV:
XCEV key = XCEV.XCEVBASE + XCEV.XCEVCOST + XCEV.XCEVBAS2 +
XCEV.XCEVEVNT
XCEV.XCEVBASE and XCEV.XCEVBAS2 = BASE.BASEID.
XCEV.XCEVCOST = COST.COSTNUM of charge bundle being asked about.
XCEV.XCEVEVNT = EVNT.EVNTNUM of event selected at ST26
Each Event selected at ST26 will be flagged as "deleted" on XCEV. The event will no
longer being "linked" to the charge bundle being asked about. See detailed instructions
below.
Set XCEV.DELLINK = 1/Yes on XCEV where
XCEV.XCEVCOST = this COST.COSTNUM and
XCEV.XCEVEVNT = EVNT.EVNTNUM of event
selected.
DELLINK
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
246
ORPEvent
Existing Event Date is outside survery reference period =
EVNT.EVORPFLAG = 1/ORP.
New event is Out of the Survey Reference Period =
See general specifications for Date check logic for
determing ORP events.
DESIGN NOTES
1:35:28 PM Monday, April 06, 2009
Page 118 of 368
ST26
Interviewer can only select events at this roster.
1:35:28 PM Monday, April 06, 2009
Page 119 of 368
BOX ST26
BOX ST26
Page Order # :
530
BOX INSTRUCTIONS
( STQ1720 )
IF ST12 – INCTYPE INCLUDES 2/HHVisits, GO TO ST27 PROVIDER_STHH ( STQ1725 ).
ELSE GO TO BOX ST33 - (STQ1785 ).
ASSIGNMENTS
TECHNICAL NOTES
DESIGN NOTES
1:35:28 PM Monday, April 06, 2009
Page 120 of 368
ST27
ST27
Page Order # :
Design Screen Type:
Roster
Fields:
Field 1:
PROVIDER_STHH
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Name:
Provider Roster
Roster Type:
Single Item Select
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
Yes
Yes
No
No
Grid Functions:
Add Line
Delete Line
No
No
535
Display as ' Add a Provider '
Display as ' Edit a Provider '
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Display all Providers except for Providers where
PROV.PROVNUM=01 and 02, which are reserved for PM and OM
events.
Display in order of entry.
Roster/Grid display:
COL #
HEADER
1
Provider Name
INSTRUCTIONS
Display PROV.PROVNAME.
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
Int. Instr I:
WHICH HOME HEALTH PROVIDER IS IN THIS CHARGE
BUNDLE?
Question Text:
1:35:30 PM Monday, April 06, 2009
Page 121 of 368
ST27
SELECT OR ADD ONLY ONE PROVIDER.
Int. Instr II:
INPUT FIELDS / ROUTING
Field1:
PROVIDER_STHH
( STQ1725 )
TEMP
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
String
TProvPick135
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
135
Route
ST28 - COSTBEGM ( STQ1730 )
BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on PROV:
PROV key = PROV.PROVBASE + PROV.PROVNUM
PROV.PROVNUM = Number of Provider selected at ST27.
If Provider added at Provider Roster, see PROVIDER ROSTER POP-UP specifications for
pop-up window programming instructions.
Variables populated in Provider Roster Pop-Up Window:
PROV.PROVNUM
PROV.PROVRNDC
PROV.PROVNAME
Provider number
Round number
Provider name
If Provider added, set additional fields as instructed below:
COSTPROV
COST.COSTPROV = PROV.PROVNUM of provider
selected at ST27.
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
1:35:32 PM Monday, April 06, 2009
Page 122 of 368
ST27
DESIGN NOTES
Interviewer can add or select Provider at this roster.
1:35:32 PM Monday, April 06, 2009
Page 123 of 368
ST28
ST28
Page Order # :
Design Screen Type:
Numeric
Fields:
Field 1:
COSTBEGM
Field 2:
COSTBEGD
Field 3:
COSTBEGY
Field 4:
COSTENDM
Field 5:
COSTENDD
Field 6:
COSTENDY
HELP
COMMENTS
JUMPBACK
No
No
No
Enable Functions:
538
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Display name of Provider, PROV.PROVNAME, selected at ST27.
Question display:
Multi Field display:
Vertical Alignment
Display start date input fields, COST.COSTBEGM,
COST.COSTBEGD, COST.COSTBEGY, on 1st line.
Display stop date input fields, COST.COSTENDM,
COST.COSTENDD, COST.COSTENDY, on 2nd line.
Display all fields at one time.
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
1:35:37 PM Monday, April 06, 2009
(ST CLAIM HEADER)
Page 124 of 368
ST28
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
PROVIDER: (PROVIDER NAME)
Int. Instr I:
Question Text:
ENTER THE START DATE AND STOP DATE COVERED BY THE
CHARGE BUNDLE.
Int. Instr II:
INPUT FIELDS / ROUTING
Field1:
COSTBEGM
Cheshire Name:
( STQ1730 )
COST.COSTBEGM
Item Text display:
Item Text:
START DATE:
Label:
Label Position:
MM
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TMonthInt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST28 - COSTBEGD ( STQ1731 )
Refusal
ST28 - COSTBEGD ( STQ1731 )
1:35:47 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
2
01
12
Route
ST28 - COSTBEGD ( STQ1731 )
Page 125 of 368
ST28
COSTBEGD
Field2:
Cheshire Name:
( STQ1731 )
COST.COSTBEGD
Item Text display:
Item Text:
Label:
Label Position:
DD
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TDayDKRF
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST28 - COSTBEGY ( STQ1732 )
Refusal
ST28 - COSTBEGY ( STQ1732 )
1:35:56 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
2
1
31
Route
ST28 - COSTBEGY ( STQ1732 )
Page 126 of 368
ST28
COSTBEGY
Field3:
Cheshire Name:
( STQ1732 )
COST.COSTBEGY
Item Text display:
Item Text:
Label:
Label Position:
YY
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TYear2DKRF
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST28 - COSTENDM ( STQ1733 )
Refusal
ST28 - COSTENDM ( STQ1733 )
1:36:05 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
2
00
99
Route
ST28 - COSTENDM ( STQ1733 )
Page 127 of 368
ST28
COSTENDM
Field4:
Cheshire Name:
( STQ1733 )
COST.COSTENDM
Item Text display:
Item Text:
STOP DATE:
Label:
Label Position:
MM
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TMonthInt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST28 - COSTENDD ( STQ1734 )
Refusal
ST28 - COSTENDD ( STQ1734 )
1:36:14 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
2
01
12
Route
ST28 - COSTENDD ( STQ1734 )
Page 128 of 368
ST28
COSTENDD
Field5:
Cheshire Name:
( STQ1734 )
COST.COSTENDD
Item Text display:
Item Text:
Label:
Label Position:
DD
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TDayDKRF
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST28 - COSTENDY ( STQ1735 )
Refusal
ST28 - COSTENDY ( STQ1735 )
1:36:23 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
2
1
31
Route
ST28 - COSTENDY ( STQ1735 )
Page 129 of 368
ST28
COSTENDY
Field6:
Cheshire Name:
( STQ1735 )
COST.COSTENDY
Item Text display:
Item Text:
Label:
Label Position:
YY
Under
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TYear2DKRF
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
BOX ST28A - (STQ1740 )
Refusal
BOX ST28A - (STQ1740 )
FieldSize:
Min Value:
Max Value:
Mask:
2
00
99
Route
BOX ST28A - (STQ1740 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
Edit #1
If SP is deceased, Start Date,
COSTBEGM/COSTBEGD/COSTBEGY, should be on or before
(DATE OF DEATH).
If not true, display message "VERIFY THAT THE START DATE
WAS AFTER SP'S DATE OF DEATH, (DATE OF DEATH)."
Edit #2
If SP is deceased, Stop Date,
COSTENDM/COSTENDD/COSTENDY, should be on or before
(DATE OF DEATH).
If not true, display message "VERIFY THAT THE STOP DATE WAS
AFTER SP'S DATE OF DEATH, (DATE OF DEATH)."
Edit #3
If SP is institutionalized, Start Date,
COSTBEGM/COSTBEGD/COSTBEGY, should be on or before
(DATE OF INSTITUTIONALIZATION).
If not true, display message "VERIFY THAT THE START DATE
WAS AFTER SP'S DATE OF INSTITUTIONALIZATION, (DATE OF
INSTITUTIONALIZATION)."
1:36:28 PM Monday, April 06, 2009
Page 130 of 368
ST28
Edit #4
If SP is institutionalized, Stop Date,
COSTENDM/COSTENDD/COSTENDY, should be on or before
(DATE OF INSTITUTIONALIZATION).
If not true, display message "VERIFY THAT THE STOP DATE WAS
AFTER SP'S DATE OF INSTITUTIONALIZATION, (DATE OF
INSTITUTIONALIZATION)."
Edit #5
Start Date, COSTBEGM/COSTBEGD/COSTBEGY, should not be
Out of the Survey Reference period.
If not true, display message "VERIFY THAT THE START DATE IS
OUTSIDE OF THE SURVEY REFERENCE PERIOD."
Edit #6
Stop Date, COSTENDM/COSTENDD/COSTENDY, should not be
Out of the Survey Reference period.
If not true, display message "VERIFY THAT THE STOP DATE IS
OUTSIDE OF THE SURVEY REFERENCE PERIOD."
HARD EDIT CHECKS
Edit #1
Start Date, COSTBEGM/COSTBEGD/COSTBEGY, should be on or
before (TODAY).
If not true, display message "INVALID DATE. START DATE MUST
BE ON OR BEFORE (TODAY). PLEASE REENTER."
Edit #2
Stop Date, COSTENDM/COSTENDD/COSTENDY, should be on or
before (TODAY).
If not true, display message "INVALID DATE. STOP DATE MUST
BE ON OR BEFORE (TODAY). PLEASE REENTER."
Edit #3
Stop Date, COSTENDM/COSTENDD/COSTENDY, must be on or
after the Start Date, COSTBEGM/COSTBEGD/COSTBEGY.
If not true, display message: "INVALID DATE. STOP DATE MUST
BE ON OR AFTER (COST START DATE). PLEASE REENTER."
TECHNICAL NOTES
59
SPStatus
SP is Alive and not institutionalized =
MRES.SPALIVE=1/Alive or empty
SP is Alive =
MRES.SPALIVE=1/Alive, 2/AliveAndInstitute, or EMPTY
SP is Institutionalized =
MRES.SPALIVE=2/AliveAndInstitute
SP is Deceased =
MRES.SPALIVE=3/Deceased.
246
ORPEvent
Existing Event Date is outside survery reference period =
EVNT.EVORPFLAG = 1/ORP.
New event is Out of the Survey Reference Period =
See general specifications for Date check logic for
determing ORP events.
1:36:28 PM Monday, April 06, 2009
Page 131 of 368
ST28
DESIGN NOTES
1:36:28 PM Monday, April 06, 2009
Page 132 of 368
BOX ST28A
BOX ST28A
540
Page Order # :
BOX INSTRUCTIONS
( STQ1740 )
IF (HOME HEALTH PROVIDER WAS ADDED AT ST27) OR (AN EXISTING
PROVIDER WAS SELECTED AT ST27 THAT WAS NOT ASSOCIATED
WITH A HOME HEALTH EVENT), GO TO ST30 - HHEVNTTYPE ( STQ1755
).
ELSE GO TO BOX ST31B - (STQ1770 ).
ASSIGNMENTS
TECHNICAL NOTES
245
ProviderNotHHEvent
Provider not associated with Home Health Event =
For this PROV, there is no EVNT where
(EVNT.EVNTPROV=PROV.PROVNUM &
(EVNT.EVNTTYPE = 'HP' or 'HF') & EVNT.EVNTDFLG
^= 1/Yes).
DESIGN NOTES
1:36:28 PM Monday, April 06, 2009
Page 133 of 368
ST30
ST30
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
HHEVNTTYPE
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
555
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Display name of Provider, PROV.PROVNAME, selected at ST27.
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
PROVIDER: (PROVIDER NAME)
Int. Instr I:
Question Text:
Int. Instr II:
IS THE PROVIDER A HOME HEALTH PROFESSIONAL OR SOME
OTHER TYPE OF HOME HEALTH PROVIDER (HOME HEALTH
AIDE, HOMEMAKER, ETC.)?
INPUT FIELDS / ROUTING
1:36:30 PM Monday, April 06, 2009
Page 134 of 368
ST30
HHEVNTTYPE
Field1:
Cheshire Name:
( STQ1755 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
THHEVNTTYPE
1
No
No
Number Label
1 HP
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
ST31 - STHHINTRO ( STQ1760 )
English text: HOME HEALTH PROFESSIONAL
HF
ST31 - STHHINTRO ( STQ1760 )
English text: OTHER HOME HEALTH PROVIDER
BACKGROUND VARIABLE ASSIGNMENTS
Set Provider Type based on ST30 - HHEVNTTYPE:
PROVTYPE
If ST30 - HHEVNTTYPE = 1/HP, set
PROV.PROVTYPE = 6/HomeHealthProfessionals.
Else set PROV.PROVTYPE =
7/HomeHealthNotHHMembers.
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:36:34 PM Monday, April 06, 2009
Page 135 of 368
ST31
ST31
Page Order # :
Design Screen Type:
No Entry
Fields:
Field 1:
STHHINTRO
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
560
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
Before we continue with this statement, I would like to ask you a few
questions about the home health provider I just added.
Int. Instr II:
INPUT FIELDS / ROUTING
1:36:37 PM Monday, April 06, 2009
Page 136 of 368
ST31
STHHINTRO
Field1:
Cheshire Name:
( STQ1760 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TContinueEMPTY
1
No
No
Number Label
1 Continue
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX ST31A - (STQ1765 )
English text: CONTINUE
Attribute
Empty
Route
BOX ST31A - (STQ1765 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:36:41 PM Monday, April 06, 2009
Page 137 of 368
BOX ST31A
BOX ST31A
Page Order # :
565
BOX INSTRUCTIONS
( STQ1765 )
IF ST30 - HHEVNTTYPE = 1/HP, GO TO HH3 - PROVSPEC ( HHQ1030 ).
ELSE GO TO HH20 - HHFTYPE ( HHQ1330 ).
ASSIGNMENTS
TECHNICAL NOTES
DESIGN NOTES
BOX ST31A calls the Home Health Utilization Section.
Event details will be collected on EVNT where EVNT.EVNTPROV =
PROV.PROVNUM of Provider selected at ST27 and EVNT.EVNTTYPE =
HP or HF. The EVNT record will be identified or created while
administering the HH questions.
Home Health returns to ST at BOX ST31B.
1:36:41 PM Monday, April 06, 2009
Page 138 of 368
BOX ST31B
BOX ST31B
Page Order # :
570
BOX INSTRUCTIONS
( STQ1770 )
LINK HOME HEALTH PROVIDER TO CHARGE BUNDLE .
GO TO ST32 - STHHMTCH ( STQ1775 ).
ASSIGNMENTS
Create an XCEV record to link Home Health event to the charge bundle being asked
about. XCEV record may already exist.
If XCEV record does not exist, create XCEV record:
XCEV key = XCEV.XCEVBASE + XCEV.XCEVCOST + XCEV.XCEVBAS2 +
XCEV.XCEVEVNT
XCEV.XCEVBASE and XCEV.XCEVBAS2 = BASE.BASEID.
XCEV.XCEVCOST = COST.COSTNUM of charge bundle being asked about.
XCEV.XCEVEVNT = EVNT.EVNTNUM of Home Health event currently being asked about.
Set fields as specified below:
XCEVCOST
Create XCEV where XCEV.XCEVCOST = this
COST.COSTNUM.
XCEVEVNT
Create XCEV where XCEV.XCEVEVNT =
EVNT.EVNTNUM where EVNT.EVNTPROV =
PROV.PROVNUM for Home Health Provider
currently being asked about.
XCEVRNDC
Set XCEV.XCEVRNDC = current round.
DELLINK
If XCEV exists and XCEV.DELLINK = 1/Yes, update
XCEV.DELLINK = empty.
TECHNICAL NOTES
DESIGN NOTES
Return from Home Section Section at BOX ST31B.
1:36:41 PM Monday, April 06, 2009
Page 139 of 368
ST32
ST32
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
STHHMTCH
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
575
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
Display report below question text.
Display all Events linked to this charge bundle where
XCEV.XCEVEVNT = the EVNT.EVNTNUM and XCEV.XCEVCOST
= the COST.COSTNUM for the Charge Bundle and XCEV.DELLINK
^=1/Yes. Display PMs followed by OM events, HH events and then
other provider service events.
NOTE: This report is shared by other questions. Not all Event types
will be applicable at each screen.
Report header: EVENTS IN CHARGE BUNDLE
Report layout:
Column 1, header =Type
Display EVNT.EVNTTYPE
Column 2, NO HEADER.
If EVNT.RENTPROB=2/Rent and EVNT.RENT2BUY ^=
2/PurchasedRentToBuy, display "R".
1:36:44 PM Monday, April 06, 2009
Page 140 of 368
ST32
Else do not display.
Column 3, header = Description
If EVNT.EVNTTYPE = OM then
If EVNT.STOMTYPE = 91, display EVOS.EVOSTEXT on EVOS
where EVOS.EVOSEVNT = this EVNT.EVNTNUM.
Else display EVNT.STOMTYPE response text.
Else if EVNT.EVNTTYPE = PM, display EVNT.PMEDNAME.
Else display PROV.PROVNAME on PROV where PROV.PROVNUM
= this EVNT.EVNTPROV.
Column 4, header = Start Date
If EVNT.EVNTTYPE = HF or HP, display COST START DATE in
"Mon DD YYYY" format.
Else if (EVNT.EVNTTYPE = DU, ER, IP, IU, OP, MP, SD or SL) or
(EVNT.EVNTTYPE = OM and
(EVNT.OTHRTYPE ^= 5/OstomySupplies and EVNT.OTHRTYPE
^= 6/IncontinenceSupplies, and
EVNT.OTHRTYPE ^= 7/Bandages) and
(EVNT.OMSTATUS ^=1/AlterationNotComplete)),
display EVENT DATE in "Mon DD YYYY" format.
Else do not display.
Column 5, header = Stop Date
If EVNT.EVNTTYPE = HF or HP,
display COST STOP DATE in "Mon DD YYYY" format.
Else if (EVNT.EVNTTYPE = IU) or
(EVNT.EVNTTYPE = IP and EVNT.IPSTATUS ^=
1/StillInHospital) or
(EVNT.EVNTTYPE = OM and (EVNT.RENTSTIL = 2/No,
DK, or RF) and
(EVNT.RENT2BUY ^= 2/PurchasedRentToBuy)),
display EVNT END DATE in "Mon DD YYYY" format.
Else do not display.
Column 6, header = Status
If EVNT.VISTTYPE = 2/RepeatVisit, display “RV”.
Else if (EVNT.EVNTTYPE = OM and EVNT.OMSTATUS =
1/AlterationNotComplete) or
(EVNT.EVNTTYPE = IP and EVNT.IPSTATUS =
1/StillInHospital),
display "ON".
Else if EVNT.RENTSTIL = 1/Yes, display "RR".
1:36:47 PM Monday, April 06, 2009
Page 141 of 368
ST32
Else if EVNT.RENT2BUY=2/PurchasedRentToBuy, display "OW".
Else do not display.
Column 7, header = # Visits
If EVNT.VISTTYPE = 2/RepeatVisit, display XCEV.RVLINKS on
XCEV where XCEV.XCEVEVNT = this EVNT.EVNTNUM and
XCEV.XCEVCOST = the COST.COSTNUM for this charge bundle.
Else do not display.
Column 8, header = # Purchases
If (EVNT.EVNTYPE = PM) or
(EVNT.EVNTTYPE = OM and (EVNT.OTHRTYPE =
5/OstomySupplies, 6/IncontinenceSupplies, or 7/Bandages)),
display XCEV.NUMLINKS on XCEV where XCEV.XCEVEVNT =
this EVNT.EVNTNUM and XCEV.XCEVCOST = the
COST.COSTNUM for this charge bundle.
Else do not display.
Column 9,
If Event Date is out of Survey Reference Period, display “ORP”.
Else do not display.
TEXT:
Context Header:
(ST CLAIM HEADER)
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
PROVIDER: (PROVIDER NAME)
Int. Instr I:
THE FOLLOWING HOME HEALTH PROVIDER EVENT HAS BEEN
ADDED TO THIS CHARGE BUNDLE.
PLEASE ENTER A COMMENT IF THIS EVENT WAS ENTERED IN
ERROR OR IF ANOTHER HOME HEALTH EVENT SHOULD BE
INCLUDED IN THIS CHARGE BUNDLE.
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING
1:36:50 PM Monday, April 06, 2009
Page 142 of 368
ST32
( STQ1775 )
STHHMTCH
Field1:
Cheshire Name:
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TContinueEMPTY
1
No
No
Number Label
1 Continue
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX ST33 - (STQ1785 )
English text: CONTINUE
Attribute
Empty
Route
BOX ST33 - (STQ1785 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
246
ORPEvent
Existing Event Date is outside survery reference period =
EVNT.EVORPFLAG = 1/ORP.
New event is Out of the Survey Reference Period =
See general specifications for Date check logic for
determing ORP events.
DESIGN NOTES
1:36:54 PM Monday, April 06, 2009
Page 143 of 368
BOX ST33
BOX ST33
585
Page Order # :
BOX INSTRUCTIONS
( STQ1785 )
IF ST12 – INCTYPE INCLUDES 3/OMExpenses, GO TO ST34 - STOMUPD
( STQ1790 ).
ELSE GO TO BOX ST40 - (STQ1840 ).
ASSIGNMENTS
TECHNICAL NOTES
DESIGN NOTES
1:36:54 PM Monday, April 06, 2009
Page 144 of 368
ST34
ST34
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
STOMUPD
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
590
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
Display Report below Question Text.
Display all other medical expense items where:
EVNT.EVNTDFLG^=1/Yes, and
EVNT.EVNTTYPE = OM.
Display in order of entry.
Report Header = OTHER MEDICAL EXPENSE EVENTS
Column 1, Display =
If EVNT.RENTPROB=2/Rent and ((EVNT.RENT2BUY ^=
2/PurchasedRentToBuy) or (EVNT.RENT2BUY = EMPTY)), display
"R".
Column 2, Header = "OME Type".
Column 2, Display =
1:36:57 PM Monday, April 06, 2009
Page 145 of 368
ST34
If EVNT.STOMTYPE = 91/Other, display Other Specify Text,
EVOS.EVOSTEXT, on EVOS where EVOS.EVOSEVNT = this
EVNT.EVNTNUM.
Else display EVNT.STOMTYPE response text.
Column 3, Header =
"Purchase or Repair/Rental Date".
Column 3, Display =
If ((EVNT.OTHRTYPE ^= 5/OstomySupplies and ^=
6/IncontinenceSupplies and ^= 7/Bandages) or
(EVNT.OTHRTYPE = EMPTY)) and ((EVNT.OMSTATUS ^=
1/AlterationNotComplete) or (EVNT.OMSTATUS = EMPTY)), display
EVNT DATE in "Mon DD YYYY" format.
Else do not display.
Column 4, Header =
"Rental Stop Date".
Column 4, Display =
If EVNT.RENTPROB = 2/Rent and (EVNT.RENTSTIL = 2/No, DK, or
RF) and ((EVNT.RENT2BUY ^= 2/PurchasedRentToBuy) or
(EVNT.RENT2BUY = EMPTY)), display EVNT END DATE in "Mon
DD YYYY" format.
Else do not display.
Column 5, Header = "Status".
Column 5, Display =
If EVNT.OMSTATUS = 1/AlterationNotComplete, display "ON".
Else if EVNT.RENTSTIL = 1/Yes, display "RR".
Else if EVNT.RENT2BUY = 2/PurchasedRentToBuy, display "OW".
Else do not display.
Column 6, Header = "Round".
Column 6, Display =
If ((EVNT.OTHRTYPE ^= 5/OstomySupplies and EVNT.OTHRTYPE
^= 6/IncontinenceSupplies and EVNT.OTHRTYPE ^= 7/Bandages)
or (EVNT.OTHRTYPE = EMPTY)), display 'R' + EVNT.EVNTRNDC.
EX: R45
Else do not display.
Column 7, Display =
If Event Date is out of the Survey Reference Period, display "ORP".
Else do not display.
TEXT:
Context Header:
(ST CLAIM HEADER)
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
Int. Instr I:
THE FOLLOWING OME EVENTS HAVE BEEN ENTERED.
DO YOU NEED TO ADD OR EDIT AN OME EVENT FOR THIS
CHARGE BUNDLE?
Question Text:
Int. Instr II:
1:37:00 PM Monday, April 06, 2009
Page 146 of 368
ST34
INPUT FIELDS / ROUTING
Field1:
STOMUPD
Cheshire Name:
( STQ1790 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TSTOMUpd
1
No
No
Number Label
1 No
FieldSize:
Min Value:
Max Value:
Mask:
Route
ST37 - EVENT_STOM ( STQ1812 )
2
English text: NO, DO NOT NEED TO ADD OR EDIT OM EVENT
YesAddEvent
ST36 - STOMADD ( STQ1800 )
3
English text: YES, NEED TO ADD AN OME EVENT
YesEditEvent
ST35 - EVENT_STOMEDIT ( STQ1795 )
English text: YES, NEED TO EDIT AN OME EVENT
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:37:04 PM Monday, April 06, 2009
Page 147 of 368
ST35
ST35
Page Order # :
Design Screen Type:
Roster
Fields:
Field 1:
EVENT_STOMEDIT
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
Roster Name:
Statement OM Edit Roster
Roster Type:
Multiple Item Select
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
Yes
No
No
Add Line
Delete Line
No
No
Grid Functions:
595
Display as ' Edit OME Event '
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Display all other medical expense items where:
EVNT.EVNTDFLG^=1/Yes, and
EVNT.EVNTTYPE = OM.
If (EVNT.OTHRTYPE=5/Ostomy Supplies, 6/Incontinence Supplies,
or 7/Bandages) or (EVNT.OMSTATUS=1/Alteration NotComplete),
display as protected row.
Display in order of entry.
Roster/Grid display:
COL #
1
1:37:06 PM Monday, April 06, 2009
HEADER
INSTRUCTIONS
If EVNT.RENTPROB=2/Rent and
((EVNT.RENT2BUY ^=
2/PurchasedRentToBuy) or
(EVNT.RENT2BUY = EMPTY)), display
"R".
Else do not display.
Page 148 of 368
ST35
2
OME Type
If EVNT.STOMTYPE = 91/Other, display
Other Specify Text, EVOS.EVOSTEXT,
on EVOS where EVOS.EVOSEVNT =
this EVNT.EVNTNUM.
Else display EVNT.STOMTYPE response
text.
3
Purchase or
Repair/Rental
Date
If ((EVNT.OTHRTYPE ^=
5/OstomySupplies and ^=
6/IncontinenceSupplies & ^=
7/Bandages) or (EVNT.OTHRTYPE =
EMPTY)) & ((EVNT.OMSTATUS ^=
1/AlterationNotComplete) or
(EVNT.OMSTATUS = EMPTY)), display
EVENT DATE in "Mon DD YYYY" format.
Else do not display.
4
Rental Stop Date
If EVNT.RENTPROB = 2/Rent and
(EVNT.RENTSTIL = 2/No, DK, or RF)
and ((EVNT.RENT2BUY ^=
2/PurchasedRentToBuy) or
(EVNT.RENT2BUY = EMPTY)), display
EVENT END DATE in "Mon DD YYYY"
format.
Else do not display.
5
Status
If EVNT.OMSTATUS =
1/AlterationNotComplete, display "ON".
Else if EVNT.RENTSTIL = 1/Yes, display
"RR".
Else if EVNT.RENT2BUY =
2/PurchasedRentToBuy, display "OW".
Else do not display.
6
Round
If ((EVNT.OTHRTYPE ^=
5/OstomySupplies and ^=
6/IncontinenceSupplies and ^=
7/Bandages) or (EVNT.OTHRTYPE =
EMPTY)), display 'R' +
EVNT.EVNTRNDC. EX: R45
Else do not display.
7
If Event Date is out of the Survey
Reference Period, display "ORP".
Else do not display.
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
Int. Instr I:
Question Text:
Int. Instr II:
SELECT AND EDIT THE OTHER MEDICAL EXPENSE EVENT
THAT NEEDS CORRECTION.
INPUT FIELDS / ROUTING
1:37:07 PM Monday, April 06, 2009
Page 149 of 368
ST35
Field1:
Cheshire Name:
EVENT_STOMEDIT
( STQ1795 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TEvntPick135
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
135
Route
ST34 - STOMUPD ( STQ1790 )
BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on EVNT:
EVNT key = EVNT.EVNTBASE + EVNT.EVNTNUM
EVNT.EVNTNUM = Number of event selected at ST35.
If OM event is selected for editing, see STATEMENT OM EDIT ROSTER POP-UP
specifications for pop-up window programming specifications.
Fields updated in Pop-Up window:
EVNT.EVBEGMM
EVNT.EVBEGDD
EVNT.EVBEGYY
EVNT.EVENDMM
EVNT.EVENDDD
EVNT.EVENDYY
EVORPFLG
If Event date edited is outside the Survey Reference
Period, set EVNT.EVORPFLG = 1/ORP. See
General Specifications for setting this ORP flag.
SOFT EDIT CHECKS
HARD EDIT CHECKS
Edit #1
Date of event, EVBEGMM/EVBEGDD/EVBEGYY, should be on or
before (TODAY).
If not true, display message "INVALID DATE. DATE MUST BE ON
OR BEFORE (TODAY). PLEASE REENTER."
Edit #2
If ((EVNT.RENTSTIL = 2/No, DK, or RF) and ((EVNT.RENT2BUY
1:37:09 PM Monday, April 06, 2009
Page 150 of 368
ST35
^= 2/PurchasedRentToBuy) or (EVNT.RENT2BUY = EMPTY))),
Rental End Date, EVENDMM/EVENDDD/EVENDYY, should be on
or before (TODAY).
If not true, display message "INVALID DATE. RENTAL STOP DATE
MUST BE ON OR BEFORE (TODAY). PLEASE REENTER."
Edit #3
If ((EVNT.RENTSTIL = 2/No, DK, or RF) and ((EVNT.RENT2BUY
^= 2/PurchasedRentToBuy) or (EVNT.RENT2BUY = EMPTY))),
Rental End Date, EVENDMM/EVENDDD/EVENDYY, must be on or
after the Rental Start Date, EVBEGMM/EVBEGDD/EVBEGYY.
If not true, display message: "INVALID DATE. RENTAL STOP
DATE MUST BE ON OR AFTER (RENTAL START DATE). PLEASE
REENTER."
Edit #4
Date of event, EVBEGMM/EVBEGDD/EVBEGYY, cannot match an
existing date entered on this roster.
The following must be true for the event added to be a duplicate of
an existing event:
Both event's EVNTDFLG ^= 1/Yes.
Both event's STOMTYPE match.
Both event's EVENT DATE match. See general specifications for
matching date logic.
Both event's RENTPROB matches, OR
1st Event RENTPROB = 1/Buy and 2nd Event RENTPROB = DK
or RF, OR 1st Event RENTPROB = DK or RF and 2nd Event
RENTPROB = 1/Buy.
The date of the event added should not match any other date on
roster.
If not true, display message "INVALID DATE. THIS DATE HAS
ALREADY BEEN ENTERED. PLEASE REENTER. "
TECHNICAL NOTES
59
SPStatus
SP is Alive and not institutionalized =
MRES.SPALIVE=1/Alive or empty
SP is Alive =
MRES.SPALIVE=1/Alive, 2/AliveAndInstitute, or EMPTY
SP is Institutionalized =
MRES.SPALIVE=2/AliveAndInstitute
SP is Deceased =
MRES.SPALIVE=3/Deceased.
246
ORPEvent
Existing Event Date is outside survery reference period =
EVNT.EVORPFLAG = 1/ORP.
New event is Out of the Survey Reference Period =
See general specifications for Date check logic for
determing ORP events.
DESIGN NOTES
Interviewer can only select events to be edited at this roster.
1:37:09 PM Monday, April 06, 2009
Page 151 of 368
ST36
ST36
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
STOMADD
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
600
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
Int. Instr I:
Question Text:
Int. Instr II:
WHAT TYPE OF OTHER MEDICAL EXPENSE NEEDS TO BE
ADDED?
INPUT FIELDS / ROUTING
1:37:15 PM Monday, April 06, 2009
Page 152 of 368
ST36
STOMADD
Field1:
Cheshire Name:
( STQ1800 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TSTOMAdd
1
No
No
Number Label
1 Glasses
FieldSize:
Min Value:
Max Value:
Mask:
Route
OM2 - EVENT_OMEYEG ( OMQ1030 )
2
English text: GLASSES/CONTACTS
Hearing
OM4 - EVENT_OMHEAR ( OMQ1110 )
3
English text: HEARING/SPEECH DEVICE
Orthopedic
OM6 - ORTHTYPE ( OMQ1220 )
4
English text: ORTHOPEDIC ITEM
DiabeticSupplies
OM10 - EVENT_OMDIAB ( OMQ1570 )
5
English text: DIABETIC SUPPLIES
Ambulance
OM12 - EVENT_OMAMBL ( OMQ1640 )
6
English text: AMBULANCE/RESCUE
Prothesis
OM14 - EVENT_OMPROS ( OMQ1710 )
7
English text: PROSTHESIS
Alteration
OM29 - ALTRTYPE ( OMQ3040 )
8
English text: ALTERATIONS (HOME/CAR)
Oxygen
OM19A - OXGNTYPE ( OMQ1830 )
9
English text: OXYGEN
KidneyDialysis
OM21A - KDNYTYPE ( OMQ2240 )
English text: KIDNEY DIALYSIS
OtherMedical
OM24 - OTHRTYPE ( OMQ2650 )
10
English text: ALL OTHER MEDICAL SUPPLIES
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
1:37:30 PM Monday, April 06, 2009
Page 153 of 368
ST36
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
ST36 calls Other Medical Expense Section. Multiple OMs for type selected
at ST36 may be added in OM section. EVNT records will be identified or
created for Other Medical Expenses added in OM section.
OM returns to ST at BOX ST36.
1:37:30 PM Monday, April 06, 2009
Page 154 of 368
BOX ST36
BOX ST36
Page Order # :
610
BOX INSTRUCTIONS
( STQ1810 )
GO TO ST34 - STOMUPD ( STQ1790 ).
ASSIGNMENTS
TECHNICAL NOTES
DESIGN NOTES
Return to ST from Other Medical Expense Section.
1:37:30 PM Monday, April 06, 2009
Page 155 of 368
ST37
ST37
Page Order # :
Design Screen Type:
Roster
Fields:
Field 1:
EVENT_STOM
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Name:
Statement OM Roster
Roster Type:
Multiple Item Select
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
612
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Display all other medical expense items where:
EVNT.EVNTDFLG^=1/Yes, and
EVNT.EVNTTYPE = OM.
Display in order of entry.
Roster/Grid display:
COL #
HEADER
1
2
1:37:32 PM Monday, April 06, 2009
INSTRUCTIONS
If EVNT.RENTPROB=2/Rent and
((EVNT.RENT2BUY ^=
2/PurchasedRentToBuy) or
(EVNT.RENT2BUY = EMPTY)), display
"R".
Else do not display.
OME Type
If EVNT.STOMTYPE = 91/Other, display
Other Specify Text, EVOS.EVOSTEXT,
on EVOS where EVOS.EVOSEVNT =
this EVNT.EVNTNUM.
Else display EVNT.STOMTYPE response
text.
Page 156 of 368
ST37
3
Purchase or
Repair/Rental
Date
If ((EVNT.OTHRTYPE ^=
5/OstomySupplies and ^=
6/IncontinenceSupplies & ^=
7/Bandages) or (EVNT.OTHRTYPE =
EMPTY)) & ((EVNT.OMSTATUS ^=
1/AlterationNotComplete) or
(EVNT.OMSTATUS = EMPTY)), display
EVENT DATE in "Mon DD YYYY" format.
Else do not display.
4
Rental Stop Date
If EVNT.RENTPROB = 2/Rent and
(EVNT.RENTSTIL = 2/No, DK, or RF)
and ((EVNT.RENT2BUY ^=
2/PurchasedRentToBuy) or
(EVNT.RENT2BUY = EMPTY)), display
EVENT END DATE in "Mon DD YYYY"
format.
Else do not display.
5
Status
If EVNT.OMSTATUS =
1/AlterationNotComplete, display "ON".
Else if EVNT.RENTSTIL = 1/Yes, display
"RR".
Else if EVNT.RENT2BUY =
2/PurchasedRentToBuy, display "OW".
Else do not display.
6
Round
If ((EVNT.OTHRTYPE ^=
5/OstomySupplies and ^=
6/IncontinenceSupplies and ^=
7/Bandages) or (EVNT.OTHRTYPE =
EMPTY)), display 'R' +
EVNT.EVNTRNDC. EX: R45
Else do not display.
7
If Event Date is out of the Survey
Reference Period, display "ORP".
Else do not display.
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
Int. Instr I:
Question Text:
Int. Instr II:
SELECT OTHER MEDICAL EXPENSES THAT ARE IN THIS
CHARGE BUNDLE ON THE (TYPE OF STATEMENT).
INPUT FIELDS / ROUTING
1:37:33 PM Monday, April 06, 2009
Page 157 of 368
ST37
EVENT_STOM
Field1:
Cheshire Name:
( STQ1812 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TEvntPick135
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
135
Route
BOX ST37 - (STQ1813 )
BACKGROUND VARIABLE ASSIGNMENTS
Create an XCEV record for each event selected at ST37 to link the event to the charge
bundle being asked about. XCEV record may already exist.
If XCEV record does not exist, create XCEV record:
XCEV key = XCEV.XCEVBASE + XCEV.XCEVCOST + XCEV.XCEVBAS2 +
XCEV.XCEVEVNT
XCEV.XCEVBASE and XCEV.XCEVBAS2 = BASE.BASEID.
XCEV.XCEVCOST = COST.COSTNUM of charge bundle being asked about.
XCEV.XCEVEVNT = EVNT.EVNTNUM of event selected at ST37.
Set fields as specified below:
XCEVCOST
Create XCEV where XCEV.XCEVCOST = this
COST.COSTNUM.
XCEVEVNT
Create XCEV where XCEV.XCEVEVNT =
EVNT.EVNTNUM of EVNT selected.
XCEVRNDC
Set XCEV.XCEVRNDC = current round.
DELLINK
If XCEV exists and XCEV.DELLINK = 1/Yes, update
XCEV.DELLINK = empty.
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
246
ORPEvent
1:37:35 PM Monday, April 06, 2009
Existing Event Date is outside survery reference period =
EVNT.EVORPFLAG = 1/ORP.
Page 158 of 368
ST37
New event is Out of the Survey Reference Period =
See general specifications for Date check logic for
determing ORP events.
DESIGN NOTES
Interviewer can only select events at this roster.
1:37:35 PM Monday, April 06, 2009
Page 159 of 368
BOX ST37
BOX ST37
Page Order # :
615
BOX INSTRUCTIONS
( STQ1813 )
IF AT LEAST ONE OTHER MEDICAL EXPENSE SELECTED AT ST37 IS
RENTED, GO TO ST38 - MONTHCOV ( STQ1815 ).
ELSE GO TO BOX ST38B - (STQ1820 ).
ASSIGNMENTS
TECHNICAL NOTES
242
OMRental
Other Medical Expense Item is Rented =
EVNT.RENTPROB = 2/Rent.
DESIGN NOTES
1:37:35 PM Monday, April 06, 2009
Page 160 of 368
ST38
ST38
Page Order # :
Design Screen Type:
Numeric
Fields:
Field 1:
MONTHCOV
Field 2:
MONCOV96
HELP
COMMENTS
JUMPBACK
No
Yes
No
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
Enable Functions:
618
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Display the date and OME ITEM TYPE for the ST37 Rental event
being asked about.
Question display:
Multi Field display:
Vertical Alignment
Display all fields at one time.
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
OME ITEM TYPE: (OME ITEM TYPE)
RENTAL DATES: (RENTAL START DATE) - (RENTAL STOP DATE)
Int. Instr I:
Question Text:
Int. Instr II:
HOW MANY MONTHS ARE COVERED BY THIS CHARGE
BUNDLE?
INPUT FIELDS / ROUTING
1:37:40 PM Monday, April 06, 2009
Page 161 of 368
ST38
MONTHCOV
Field1:
Cheshire Name:
( STQ1815 )
XCEV.MONTHCOV
Item Text display:
Item Text:
Label:
Label Position:
MONTHS:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TMonthcov
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Empty
Route
ST38 - MONCOV96 ( STQ1816 )
Don't know
ST38 - MONCOV96 ( STQ1816 )
Refusal
ST38 - MONCOV96 ( STQ1816 )
1:37:51 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
1
72
Route
ST38 - MONCOV96 ( STQ1816 )
Page 162 of 368
ST38
MONCOV96
Field2:
Cheshire Name:
( STQ1816 )
NONE
WE NEED TO TRANFORM MONCOV96=1 BACK TO
XCEV.MONTHCOV=96.
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TMonCov96
1
No
No
Number Label
1 LessThanOneMonth
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX ST38A - (STQ1817 )
English text: LESS THAN 1 MONTH
Attribute
Empty
Route
BOX ST38A - (STQ1817 )
BACKGROUND VARIABLE ASSIGNMENTS
Collect # of months on XCEV:
XCEV key = XCEV.XCEVBASE + XCEV.XCEVCOST + XCEV.XCEVBAS2 +
XCEV.XCEVEVNT
XCEV.XCEVCOST = COST.COSTNUM of charge bundle being asked about.
XCEV.XCEVEVNT = EVNT.EVNTNUM of OM Rental event being asked about.
SOFT EDIT CHECKS
HARD EDIT CHECKS
Edit #1
ST38 - MONTHCOV and ST38 - MONCOV96 cannot both be
EMPTY.
If not true, display message "ENTRY REQUIRED. PLEASE ENTER
NUMBER OF MONTHS OR SELECT "LESS THAN 1 MONTH".
Edit #2
ST38 - MONTHCOV and ST38 - MONCOV96 cannot both be
FILLED.
If not true, display message "INVALID ENTRY. PLEASE ENTER
1:37:56 PM Monday, April 06, 2009
Page 163 of 368
ST38
NUMBER OF MONTHS OR SELECT "LESS THAN 1 MONTH".
TECHNICAL NOTES
DESIGN NOTES
1:37:56 PM Monday, April 06, 2009
Page 164 of 368
BOX ST38A
BOX ST38A
Page Order # :
620
BOX INSTRUCTIONS
( STQ1817 )
IF ANOTHER OTHER MEDICAL EXPENSE SELECTED AT ST37 IS
RENTED, GO TO ST38 - MONTHCOV ( STQ1815 ).
ELSE GO TO BOX ST38B - (STQ1820 ).
ASSIGNMENTS
TECHNICAL NOTES
242
OMRental
Other Medical Expense Item is Rented =
EVNT.RENTPROB = 2/Rent.
DESIGN NOTES
1:37:57 PM Monday, April 06, 2009
Page 165 of 368
BOX ST38B
BOX ST38B
622
Page Order # :
BOX INSTRUCTIONS
( STQ1820 )
IF AT LEAST ONE OTHER MEDICAL EXPENSE SELECTED AT ST37 IS
OSTOMY SUPPLIES, INCONTINENCE SUPPLIES OR BANDAGES, GO TO
ST38A - NUMLINKS ( STQ1821 ).
ELSE GO TO ST39 - STOMMTCH ( STQ1830 ).
ASSIGNMENTS
TECHNICAL NOTES
247
OMPurchases
Other Medical Expense Item is Ostomy Supplies,
Incontinence Supplies, or Bandages =
EVNT.OTHRTYPE = 5/OstomySupplies,
6/IncontinenceSupplies, or 7/Bandages.
DESIGN NOTES
1:37:57 PM Monday, April 06, 2009
Page 166 of 368
ST38A
ST38A
Page Order # :
Design Screen Type:
Numeric
Fields:
Field 1:
NUMLINKS
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
625
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Display the date and OME ITEM TYPE for the ST37 Ostomy
Supplies, Incontinence Supplies, or Bandages being asked about.
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
OME ITEM TYPE: (OME ITEM TYPE)
Int. Instr I:
Question Text:
Int. Instr II:
HOW MANY PURCHASES OF (NAME OF OME ITEM) ARE
COVERED BY THIS CHARGE BUNDLE?
INPUT FIELDS / ROUTING
1:37:59 PM Monday, April 06, 2009
Page 167 of 368
ST38A
NUMLINKS
Field1:
Cheshire Name:
( STQ1821 )
XCEV.NUMLINKS
Item Text display:
Item Text:
Label:
Label Position:
NUMBER OF PURCHASES:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TNumlinks
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
BOX ST38AA - (STQ1822 )
Refusal
BOX ST38AA - (STQ1822 )
FieldSize:
Min Value:
Max Value:
Mask:
1
100
Route
BOX ST38AA - (STQ1822 )
BACKGROUND VARIABLE ASSIGNMENTS
Collect # of purchases on XCEV:
XCEV key = XCEV.XCEVBASE + XCEV.XCEVCOST + XCEV.XCEVBAS2 +
XCEV.XCEVEVNT
XCEV.XCEVCOST = COST.COSTNUM of charge bundle being asked about.
XCEV.XCEVEVNT = EVNT.EVNTNUM of OM Ostomy Supplies, Incontinence supplies, or
bandages being asked about.
ST38A is asked of all Ostomy Supplies, Incontinence Supplies and Bandages linked to
charge bundle.
However, in addition to collecting the number of purchases covered by the charge bundle
at ST38A, if the OM event was added at OM24 - OTHRTYPE, we will copy ST38A -
NUMLINKS to the current round PMRO.GETNUM on PMRO where PMRO.PMRORND =
current round and PMRO.PMROEVNT = this new OM event.
GETNUM
If OM event was just added at OM24 - OTHRTYPE,
set PMRO.GETNUM = this OM event's ST38A NUMLINKS. Set on PMRO where
PMRO.PMROEVNT = this OM EVNT.EVNTNUM
and PMRO.PMRORND = current round.
SOFT EDIT CHECKS
1:38:04 PM Monday, April 06, 2009
Page 168 of 368
ST38A
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:38:04 PM Monday, April 06, 2009
Page 169 of 368
BOX ST38AA
BOX ST38AA
628
Page Order # :
BOX INSTRUCTIONS
( STQ1822 )
IF ANOTHER OTHER MEDICAL EXPENSE SELECTED AT ST37 IS
OSTOMY SUPPLIES, INCONTINENCE SUPPLIES OR BANDAGES, GO TO
ST38A - NUMLINKS ( STQ1821 ).
ELSE GO TO ST39 - STOMMTCH ( STQ1830 ).
ASSIGNMENTS
TECHNICAL NOTES
247
OMPurchases
Other Medical Expense Item is Ostomy Supplies,
Incontinence Supplies, or Bandages =
EVNT.OTHRTYPE = 5/OstomySupplies,
6/IncontinenceSupplies, or 7/Bandages.
DESIGN NOTES
1:38:04 PM Monday, April 06, 2009
Page 170 of 368
ST39
ST39
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
STOMMTCH
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
630
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
Display report below question text.
Display all Events linked to this charge bundle where
XCEV.XCEVEVNT = the EVNT.EVNTNUM and XCEV.XCEVCOST
= the COST.COSTNUM for the Charge Bundle and XCEV.DELLINK
^=1/Yes. Display PMs followed by OM events, HH events and then
other provider service events.
NOTE: This report is shared by other questions. Not all Event types
will be applicable at each screen.
Report header: EVENTS IN CHARGE BUNDLE
Report layout:
Column 1, header =Type
Display EVNT.EVNTTYPE
Column 2, NO HEADER.
If EVNT.RENTPROB=2/Rent and ((EVNT.RENT2BUY ^=
2/PurchasedRentToBuy) or (EVNT.RENT2BUY = EMPTY)), display
1:38:06 PM Monday, April 06, 2009
Page 171 of 368
ST39
"R".
Else do not display.
Column 3, header = Description
If EVNT.EVNTTYPE = OM then
If EVNT.STOMTYPE = 91, display EVOS.EVOSTEXT on EVOS
where EVOS.EVOSEVNT = this EVNT.EVNTNUM.
Else display EVNT.STOMTYPE response text.
Else if EVNT.EVNTTYPE = PM, display EVNT.PMEDNAME.
Else display PROV.PROVNAME on PROV where PROV.PROVNUM
= this EVNT.EVNTPROV.
Column 4, header = Start Date
If EVNT.EVNTTYPE = HF or HP,
display COST START DATE in "Mon DD YYYY" format.
Else if (EVNT.EVNTTYPE = DU, ER, IP, IU, OP, MP, SD or SL) or
(EVNT.EVNTTYPE = OM and
((EVNT.OTHRTYPE ^= 5/OstomySupplies and
^= 6/IncontinenceSupplies and ^= 7/Bandages) or
(EVNT.OTHRTYPE = EMPTY)) and
((EVNT.OMSTATUS ^= 1/AlterationNotComplete) or
(EVNT.OMSTATUS = EMPTY))),
display EVENT DATE in "Mon DD YYYY" format.
Else do not display.
Column 5, header = Stop Date
If EVNT.EVNTTYPE = HF or HP,
display COST STOP DATE in "Mon DD YYYY" format.
Else if (EVNT.EVNTTYPE = IU) or
(EVNT.EVNTTYPE = IP and
EVNT.IPSTATUS ^= 1/StillInHospital) or
(EVNT.EVNTTYPE = OM and EVNT.RENTPROB = 2/Rent and
(EVNT.RENTSTIL = 2/No, DK, or RF) and
((EVNT.RENT2BUY ^= 2/PurchasedRentToBuy) or
(EVNT.RENT2BUY = EMPTY))),
display EVNT END DATE in "Mon DD YYYY" format.
Else do not display.
Column 6, header = Status
If EVNT.VISTTYPE = 2/RepeatVisit, display “RV”.
Else if
(EVNT.EVNTTYPE = OM and
EVNT.OMSTATUS = 1/AlterationNotComplete) or
(EVNT.EVNTTYPE = IP and EVNT.IPSTATUS =
1/StillInHospital),
1:38:09 PM Monday, April 06, 2009
Page 172 of 368
ST39
display "ON".
Else if EVNT.RENTSTIL = 1/Yes, display "RR".
Else if EVNT.RENT2BUY=2/PurchasedRentToBuy, display "OW".
Else do not display.
Column 7, header = # Visits
If EVNT.VISTTYPE = 2/RepeatVisit, display XCEV.RVLINKS on
XCEV where XCEV.XCEVEVNT = this EVNT.EVNTNUM and
XCEV.XCEVCOST = the COST.COSTNUM for this charge bundle.
Else do not display.
Column 8, header = # Purchases
If (EVNT.EVNTYPE = PM) or
(EVNT.EVNTTYPE = OM and
(EVNT.OTHRTYPE = 5/OstomySupplies,
6/IncontinenceSupplies, or 7/Bandages)),
display XCEV.NUMLINKS on XCEV where
XCEV.XCEVEVNT = this EVNT.EVNTNUM and
XCEV.XCEVCOST = the COST.COSTNUM for this charge
bundle.
Else do not display.
Column 9,
If Event Date is out of Survey Reference Period, display “ORP”.
Else do not display.
TEXT:
Context Header:
(ST CLAIM HEADER)
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
Int. Instr I:
ARE ALL THE OTHER MEDICAL EXPENSES FROM THE
CHARGE BUNDLE ON THE (TYPE OF STATEMENT) SHOWN
BELOW?
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING
1:38:12 PM Monday, April 06, 2009
Page 173 of 368
ST39
STOMMTCH
Field1:
Cheshire Name:
( STQ1830 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TSTOMMTCH
1
No
No
Number Label
1 Yes
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX ST40 - (STQ1840 )
2
English text: YES
NoAddOM
3
English text: NO, NEED TO ADD AN OME EVENT
NoDeleteOM
ST40 - EVENT_STOMDEL ( STQ1835 )
ST34 - STOMUPD ( STQ1790 )
English text: NO, NEED TO REMOVE AN OME EVENT
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
246
ORPEvent
Existing Event Date is outside survery reference period =
EVNT.EVORPFLAG = 1/ORP.
New event is Out of the Survey Reference Period =
See general specifications for Date check logic for
determing ORP events.
DESIGN NOTES
1:38:16 PM Monday, April 06, 2009
Page 174 of 368
ST40
ST40
Page Order # :
Design Screen Type:
Roster
Fields:
Field 1:
EVENT_STOMDEL
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
Roster Name:
Statement OM Roster
Roster Type:
Multiple Item Select
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
635
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Always display "(S)" in interviewer instructions in parenthesis.
Multi Field display:
Roster/Grid Instructions:
Display all OME events linked to this charge bundle:
There is an EVNT where:
EVNT.EVNTTYPE = 'OM', and
There is an XCEV where:
XCEV,XCEVEVNT = this EVNT.EVNTNUM, and
XCEV.XCEVCOST = COST.COSTNUM for this charge bundle, and
XCEV.DELLINK ^= 1/Yes.
Display in order of entry.
Roster/Grid display:
COL #
1
1:38:18 PM Monday, April 06, 2009
HEADER
INSTRUCTIONS
If EVNT.RENTPROB=2/Rent and
EVNT.RENT2BUY ^=
2/PurchasedRentToBuy, display "R".
Else do not display.
Page 175 of 368
ST40
2
OME Type
If EVNT.STOMTYPE = 91/Other, display
Other Specify Text, EVOS.EVOSTEXT,
on EVOS where EVOS.EVOSEVNT =
this EVNT.EVNTNUM.
Else display EVNT.STOMTYPE response
text.
3
Purchase or
Repair/Rental
Date
If (EVNT.OTHRTYPE ^=
5/OstomySupplies and
EVNT.OTHRTYPE ^=
6/IncontinenceSupplies and
EVNT.OTHRTYPE ^= 7/Bandages) and
(EVNT.OMSTATUS ^=
1/AlterationNotComplete), display
EVENT DATE in "Mon DD YYYY" format.
Else do not display.
4
Rental Stop Date
if (EVNT.RENTSTIL = 2/No, DK, or RF)
and (EVNT.RENT2BUY ^=
2/PurchasedRentToBuy), display EVENT
END DATE in "Mon DD YYYY" format.
Else do not display.
5
Status
If EVNT.OMSTATUS =
1/AlterationNotComplete, display "ON".
Else if EVNT.RENTSTIL = 1/Yes, display
"RR".
Else if EVNT.RENT2BUY =
2/PurchasedRentToBuy, display "OW".
Else do not display.
6
# Purchases
If (EVNT.OTHRTYPE =
5/OstomySupplies,
6/IncontinenceSupplies, or 7/Bandages),
display XCEV.NUMLINKS on XCEV
where XCEV.XCEVEVNT = this
EVNT.EVNTNUM and
XCEV.XCEVCOST = this
COST.COSTNUM.
Else do not display.
7
Round
If (EVNT.OTHRTYPE ^=
5/OstomySupplies and
EVNT.OTHRTYPE ^=
6/IncontinenceSupplies and
EVNT.OTHRTYPE ^= 7/Bandages),
7/Bandages, display 'R' +
EVNT.EVNTRNDC. EX: R45
Else do not display.
8
If Event Date is out of the Survey
Reference Period, display "ORP".
Else do not display.
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
Int. Instr I:
1:38:19 PM Monday, April 06, 2009
Page 176 of 368
ST40
Question Text:
SELECT THE EVENT(S) THAT YOU WOULD LIKE TO REMOVE
FROM THE CHARGE BUNDLE.
Int. Instr II:
INPUT FIELDS / ROUTING
Field1:
Cheshire Name:
EVENT_STOMDEL
( STQ1835 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TEvntPick135
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
135
Route
ST39 - STOMMTCH ( STQ1830 )
BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on XCEV:
XCEV key = XCEV.XCEVBASE + XCEV.XCEVCOST + XCEV.XCEVBAS2 +
XCEV.XCEVEVNT
XCEV.XCEVBASE and XCEV.XCEVBAS2 = BASE.BASEID.
XCEV.XCEVCOST = COST.COSTNUM of charge bundle being asked about.
XCEV.XCEVEVNT = EVNT.EVNTNUM of event selected at ST40
Each Event selected at ST40 will be flagged as "deleted" on XCEV. The event will no
longer being "linked" to the charge bundle being asked about. See detailed instructions
below.
DELLINK
Set XCEV.DELLINK = 1/Yes on XCEV where
XCEV.XCEVCOST = this COST.COSTNUM and
XCEV.XCEVEVNT = EVNT.EVNTNUM of event
selected.
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
1:38:21 PM Monday, April 06, 2009
Page 177 of 368
ST40
246
ORPEvent
Existing Event Date is outside survery reference period =
EVNT.EVORPFLAG = 1/ORP.
New event is Out of the Survey Reference Period =
See general specifications for Date check logic for
determing ORP events.
DESIGN NOTES
Interviewer can only select events at this roster.
1:38:21 PM Monday, April 06, 2009
Page 178 of 368
BOX ST40
BOX ST40
Page Order # :
640
BOX INSTRUCTIONS
( STQ1840 )
IF ST12 – INCTYPE INCLUDES 4/PMS, GO TO ST41 - EVENT_STPM (
STQ1850 ).
ELSE GO TO BOX ST45 - (STQ1990 ).
ASSIGNMENTS
TECHNICAL NOTES
DESIGN NOTES
1:38:21 PM Monday, April 06, 2009
Page 179 of 368
ST41
ST41
Page Order # :
Design Screen Type:
Roster
Fields:
Field 1:
EVENT_STPM
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Name:
Prescription Medicine Roster
Roster Type:
Multiple Item Select
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
Yes
Yes
No
No
Grid Functions:
Add Line
Delete Line
No
No
650
Display as ' Add a Medicine '
Display as ' Edit a Medicine '
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Display all Prescription Medicine events where:
EVNT.EVNTDFLG ^=1/Yes, and
EVNT.EVNTTYPE='PM'.
Display in alphabetical order.
Roster/Grid display:
COL #
HEADER
INSTRUCTIONS
1
Medicine
Display prescription medicine name,
EVNT.PMEDNAME.
2
Strength
Display prescription medicine strength
text field, EVNT.PMSTRUNI.
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
Int. Instr I:
1:38:23 PM Monday, April 06, 2009
Page 180 of 368
ST41
Question Text:
SELECT OR ADD ALL PRESCRIPTION MEDICINES THAT ARE IN
THIS CHARGE BUNDLE ON THE (TYPE OF STATEMENT).
Int. Instr II:
INPUT FIELDS / ROUTING
EVENT_STPM
Field1:
( STQ1850 )
TEMP
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
String
TEvntPick200
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
200
Route
ST42 - NUMLINKS ( STQ1860 )
BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on EVNT:
EVNT key = EVNT.EVNTBASE + EVNT.EVNTNUM
EVNT.EVNTNUM = Number of PM event selected at ST41.
If Prescription Medicine added at Prescription Medicine Roster, see PRESCRIPTION
MEDICINE ROSTER POP-UP specifications for pop-up window programming instructions.
Variables populated at the Prescription Medicine Roster:
EVNT.EVNTNUM
EVNT.EVNTRNDC
EVNT.EVNTTYPE
EVNT.PMEDNAME
EVNT.PMSTRUNI
EVNT.EVNTPROV
BASE.LASTEVNT
Event number
Round number
PM
Prescription Medicine name
Prescription Medicine strength text field
02
Highest EVNT.EVNTNUM
If PM added at ST41, create a current round PMRO:
PMRO key = PMRO.PMROBASE + PMRO.PMROEVNT + PMRO.PMRORND
PMRO.PMROEVNT = EVNT.EVNTNUM of PM event selected at ST41.
PMRO.PMRORND = current round.
1:38:25 PM Monday, April 06, 2009
Page 181 of 368
ST41
Set PMRO fields as specified below.
FOR ALL PM'S SELECTED AT ST41 ("SELECTED" refers to any PM selected from
Roster, whether or not PM was just ADDED or PRE-EXISTED on the roster), create an
XCEV record for each PM event selected at ST41 to link the event to the charge bundle
being asked about. XCEV record may already exist.
If XCEV record does not exist, create XCEV record:
XCEV key = XCEV.XCEVBASE + XCEV.XCEVCOST + XCEV.XCEVBAS2 +
XCEV.XCEVEVNT
XCEV.XCEVBASE and XCEV.XCEVBAS2 = BASE.BASEID.
XCEV.XCEVCOST = COST.COSTNUM of charge bundle being asked about.
XCEV.XCEVEVNT = EVNT.EVNTNUM of PM event selected at ST41.
Set fields as specified below:
PMROEVNT
If PM added at ST41, create PMRO where
PMRO.PMROEVNT = EVNT.EVNTNUM of event
added.
PMRORND
If PM added at ST41, create PMRO where
PMRO.PMRORND = current round.
PMROTYPE
If PM added at ST41, set PMRO.PMROTYPE = PM.
EVCHGFLG
If PM added at ST41, set EVNT.EVCHGFLG = 1/Yes.
XCEVCOST
For each PM selected at ST41, create XCEV where
XCEV.XCEVCOST = this COST.COSTNUM.
XCEVEVNT
For each PM selected at ST41, create XCEV where
XCEV.XCEVEVNT = EVNT.EVNTNUM of PM
selected (or added).
XCEVRNDC
Set XCEV.XCEVRNDC = current round.
DELLINK
If XCEV exists and XCEV.DELLINK = 1/Yes, update
XCEV.DELLINK = empty.
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
Interviewer can add and/or select PMs at this roster. We do not create
PMROs for existing PMs that are selected.
1:38:25 PM Monday, April 06, 2009
Page 182 of 368
ST42
ST42
Page Order # :
Design Screen Type:
Grid
Fields:
Field 1:
NUMLINKS
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
660
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Display all Prescription Medicine events linked to this charge bundle:
There is an EVNT where:
EVNT.EVNTTYPE = 'PM', and
There is an XCEV where:
XCEV,XCEVEVNT = this EVNT.EVNTNUM, and
XCEV.XCEVCOST = COST.COSTNUM for this charge bundle, and
XCEV.DELLINK ^= 1/Yes.
Display in alphabetical order based on EVNT.PMEDNAME.
Roster/Grid display:
COL #
HEADER
INSTRUCTIONS
1
Medicine Name
Display the name and strength of the
medicine, EVNT.PMEDNAME + ' ' +
EVNT.PMSTRUNI. Display only.
2
# Purchases
XCEV.NUMLINKS. Input column 1.
Report display:
TEXT:
1:38:27 PM Monday, April 06, 2009
Page 183 of 368
ST42
(ST CLAIM HEADER)
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
Context Header:
Int. Instr I:
Question Text:
HOW MANY PURCHASES OF EACH MEDICINE SHOWN BELOW
ARE COVERED BY THIS CHARGE BUNDLE?
Int. Instr II:
INPUT FIELDS / ROUTING
Field1:
NUMLINKS
Cheshire Name:
Item Text display:
( STQ1860 )
XCEV.NUMLINKS
GRID COLUMN #2.
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TNumlinks
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
BOX ST42 - (STQ1880 )
Refusal
BOX ST42 - (STQ1880 )
FieldSize:
Min Value:
Max Value:
Mask:
1
100
Route
BOX ST42 - (STQ1880 )
BACKGROUND VARIABLE ASSIGNMENTS
Collect # of purchases on XCEV:
XCEV key = XCEV.XCEVBASE + XCEV.XCEVCOST + XCEV.XCEVBAS2 +
XCEV.XCEVEVNT
XCEV.XCEVCOST = COST.COSTNUM of charge bundle being asked about.
XCEV.XCEVEVNT = EVNT.EVNTNUM of PM being asked about.
GETNUM
1:38:32 PM Monday, April 06, 2009
If PM was added at ST41, set PMRO.GETNUM =
this PM event''s ST42 - NUMLINKS. Set on PMRO
where PMRO.PMROEVNT = this PM
EVNT.EVNTNUM and PMRO.PMRORND = current
round.
Page 184 of 368
ST42
SOFT EDIT CHECKS
NUMLINKS = 1 - 8. DK, or RF.
If not true, display message "THE AMOUNT ENTERED SEEMS
UNLIKELY. PLEASE VERIFY.".
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:38:32 PM Monday, April 06, 2009
Page 185 of 368
BOX ST42
BOX ST42
670
Page Order # :
BOX INSTRUCTIONS
( STQ1880 )
IF AT LEAST ONE PRESCRIPTION MEDICINE WAS ADDED AT ST41, GO
TO ST43 - STPMINTRO ( STQ1920 ).
ELSE GO TO ST44 - STPMMTCH ( STQ1941 ).
ASSIGNMENTS
TECHNICAL NOTES
DESIGN NOTES
BOX ST42 should only route to ST43 if PM was added as a new PM
event at ST41, not if the PM already existed on roster and was selected.
1:38:32 PM Monday, April 06, 2009
Page 186 of 368
ST43
ST43
Page Order # :
Design Screen Type:
No Entry
Fields:
Field 1:
STPMINTRO
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
710
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Always display "(s)" in parenthesis.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
Before we continue with this statement, I would like to ask you a few
questions about the prescribed medicine(s) I just added. [It would
be very helpful for the following questions if we could look at the
bottle(s) or container(s) for the medicine(s).]
Int. Instr II:
INPUT FIELDS / ROUTING
1:38:35 PM Monday, April 06, 2009
Page 187 of 368
ST43
STPMINTRO
Field1:
Cheshire Name:
( STQ1920 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TContinueEMPTY
1
No
No
Number Label
1 Continue
FieldSize:
Min Value:
Max Value:
Mask:
Route
PM6A_IN - NAVIGATOR ( PMQ1173 )
English text: CONTINUE
Attribute
Empty
Route
PM6A_IN - NAVIGATOR ( PMQ1173 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
ST43 calls PM section. PM will collect event details for all PMs added at
ST41.
PM returns to ST at BOX ST43.
1:38:39 PM Monday, April 06, 2009
Page 188 of 368
BOX ST43
BOX ST43
Page Order # :
720
BOX INSTRUCTIONS
( STQ1930 )
GO TO ST44 - STPMMTCH ( STQ1941 ).
ASSIGNMENTS
TECHNICAL NOTES
DESIGN NOTES
Return from PM section at BOX ST43.
1:38:40 PM Monday, April 06, 2009
Page 189 of 368
ST44
ST44
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
STPMMTCH
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
730
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
Display report below question text.
Display all Events linked to this charge bundle where
XCEV.XCEVEVNT = the EVNT.EVNTNUM and XCEV.XCEVCOST
= the COST.COSTNUM for the Charge Bundle and XCEV.DELLINK
^=1/Yes. Display PMs followed by OM events, HH events and then
other provider service events.
NOTE: This report is shared by other questions. Not all Event types
will be applicable at each screen.
Report header: EVENTS IN CHARGE BUNDLE
Report layout:
Column 1, header =Type
Display EVNT.EVNTTYPE
Column 2, NO HEADER.
If EVNT.RENTPROB=2/Rent and ((EVNT.RENT2BUY ^=
2/PurchasedRentToBuy) or (EVNT.RENT2BUY = EMPTY)), display
1:38:42 PM Monday, April 06, 2009
Page 190 of 368
ST44
"R".
Else do not display.
Column 3, header = Description
If EVNT.EVNTTYPE = OM then
If EVNT.STOMTYPE = 91, display EVOS.EVOSTEXT on EVOS
where EVOS.EVOSEVNT = this EVNT.EVNTNUM.
Else display EVNT.STOMTYPE response text.
Else if EVNT.EVNTTYPE = PM, display EVNT.PMEDNAME.
Else display PROV.PROVNAME on PROV where PROV.PROVNUM
= this EVNT.EVNTPROV.
Column 4, header = Start Date
If EVNT.EVNTTYPE = HF or HP,
display COST START DATE in "Mon DD YYYY" format.
Else if (EVNT.EVNTTYPE = DU, ER, IP, IU, OP, MP, SD or SL) or
(EVNT.EVNTTYPE = OM and
((EVNT.OTHRTYPE ^= 5/OstomySupplies and
^= 6/IncontinenceSupplies and ^= 7/Bandages) or
(EVNT.OTHRTYPE = EMPTY)) and
((EVNT.OMSTATUS ^= 1/AlterationNotComplete) or
(EVNT.OMSTATUS = EMPTY))),
display EVENT DATE in "Mon DD YYYY" format.
Else do not display.
Column 5, header = Stop Date
If EVNT.EVNTTYPE = HF or HP,
display COST STOP DATE in "Mon DD YYYY" format.
Else if (EVNT.EVNTTYPE = IU) or
(EVNT.EVNTTYPE = IP and
EVNT.IPSTATUS ^= 1/StillInHospital) or
(EVNT.EVNTTYPE = OM and EVNT.RENTPROB = 2/Rent and
(EVNT.RENTSTIL = 2/No, DK, or RF) and
((EVNT.RENT2BUY ^= 2/PurchasedRentToBuy) or
(EVNT.RENT2BUY = EMPTY))),
display EVNT END DATE in "Mon DD YYYY" format.
Else do not display.
Column 6, header = Status
If EVNT.VISTTYPE = 2/RepeatVisit, display “RV”.
Else if
(EVNT.EVNTTYPE = OM and
EVNT.OMSTATUS = 1/AlterationNotComplete) or
(EVNT.EVNTTYPE = IP and EVNT.IPSTATUS =
1/StillInHospital),
1:38:45 PM Monday, April 06, 2009
Page 191 of 368
ST44
display "ON".
Else if EVNT.RENTSTIL = 1/Yes, display "RR".
Else if EVNT.RENT2BUY=2/PurchasedRentToBuy, display "OW".
Else do not display.
Column 7, header = # Visits
If EVNT.VISTTYPE = 2/RepeatVisit, display XCEV.RVLINKS on
XCEV where XCEV.XCEVEVNT = this EVNT.EVNTNUM and
XCEV.XCEVCOST = the COST.COSTNUM for this charge bundle.
Else do not display.
Column 8, header = # Purchases
If (EVNT.EVNTYPE = PM) or
(EVNT.EVNTTYPE = OM and
(EVNT.OTHRTYPE = 5/OstomySupplies,
6/IncontinenceSupplies, or 7/Bandages)),
display XCEV.NUMLINKS on XCEV where
XCEV.XCEVEVNT = this EVNT.EVNTNUM and
XCEV.XCEVCOST = the COST.COSTNUM for this charge
bundle.
Else do not display.
Column 9,
If Event Date is out of Survey Reference Period, display “ORP”.
Else do not display.
TEXT:
Context Header:
(ST CLAIM HEADER)
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
Int. Instr I:
ARE ALL THE PRESCRIBED MEDICINES FROM THE CHARGE
BUNDLE ON THE (TYPE OF STATEMENT) SHOWN BELOW?
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING
1:38:48 PM Monday, April 06, 2009
Page 192 of 368
ST44
STPMMTCH
Field1:
Cheshire Name:
( STQ1941 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TSTPMMtch
FieldSize:
Min Value:
Max Value:
Mask:
1
No
No
Number Label
1 Yes
Route
BOX ST45 - (STQ1990 )
2
English text: YES
NoAddPM
3
English text: NO, NEED TO ADD A MEDICINE NAME
NoDeletePM
ST45 - EVENT_STPMDEL ( STQ1951 )
ST41 - EVENT_STPM ( STQ1850 )
English text: NO, NEED TO REMOVE A MEDICINE NAME
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
246
ORPEvent
Existing Event Date is outside survery reference period =
EVNT.EVORPFLAG = 1/ORP.
New event is Out of the Survey Reference Period =
See general specifications for Date check logic for
determing ORP events.
DESIGN NOTES
1:38:53 PM Monday, April 06, 2009
Page 193 of 368
ST45
ST45
Page Order # :
Design Screen Type:
Roster
Fields:
Field 1:
EVENT_STPMDEL
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
Roster Name:
Prescription Medicine Roster
Roster Type:
Multiple Item Select
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
740
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Always display "(S)" in interviewer instructions in parenthesis.
Multi Field display:
Roster/Grid Instructions:
Display all Prescription Medicine events linked to this charge bundle:
There is an EVNT where:
EVNT.EVNTTYPE = 'PM', and
There is an XCEV where:
XCEV,XCEVEVNT = this EVNT.EVNTNUM, and
XCEV.XCEVCOST = COST.COSTNUM for this charge bundle, and
XCEV.DELLINK ^= 1/Yes.
Display in alphabetical order based on EVNT.PMEDNAME.
Roster/Grid display:
COL #
HEADER
INSTRUCTIONS
1
Medicine Name
Display name of PM, EVNT.PMEDNAME.
2
# Purchases
Display XCEV.NUMLINKS on XCEV
where XCEV.XCEVEVNT = this
EVNT.EVNTNUM and
XCEV.XCEVCOST = COST.COSTNUM
for this charge bundle.
Report display:
1:38:54 PM Monday, April 06, 2009
Page 194 of 368
ST45
TEXT:
(ST CLAIM HEADER)
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
Context Header:
Int. Instr I:
Question Text:
SELECT THE PRESCRIBED MEDICINE(S) THAT YOU WOULD
LIKE TO REMOVE FROM THE CHARGE BUNDLE.
Int. Instr II:
INPUT FIELDS / ROUTING
Field1:
Cheshire Name:
EVENT_STPMDEL
( STQ1951 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TEvntPick135
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
135
Route
ST44 - STPMMTCH ( STQ1941 )
BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on XCEV:
XCEV key = XCEV.XCEVBASE + XCEV.XCEVCOST + XCEV.XCEVBAS2 +
XCEV.XCEVEVNT
XCEV.XCEVBASE and XCEV.XCEVBAS2 = BASE.BASEID.
XCEV.XCEVCOST = COST.COSTNUM of charge bundle being asked about.
XCEV.XCEVEVNT = EVNT.EVNTNUM of PM event selected at ST45.
Each PM Event selected at ST45 will be flagged as "deleted" on XCEV. The event will no
longer being "linked" to the charge bundle being asked about. See detailed instructions
below.
DELLINK
Set XCEV.DELLINK = 1/Yes on XCEV where
XCEV.XCEVCOST = this COST.COSTNUM and
XCEV.XCEVEVNT = EVNT.EVNTNUM of event
selected.
SOFT EDIT CHECKS
1:38:56 PM Monday, April 06, 2009
Page 195 of 368
ST45
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
Interviewer can only select PMs at this roster.
1:38:56 PM Monday, April 06, 2009
Page 196 of 368
BOX ST45
BOX ST45
Page Order # :
780
BOX INSTRUCTIONS
( STQ1990 )
IF ALL EVENT DATES SELECTED FOR THIS CHARGE BUNDLE ARE
OUTSIDE THE SURVEY REFERENCE PERIOD, GO TO ST46 ORPMESSAGE ( STQ2000 ).
ELSE GO TO BOX ST46 - (STQ2010 ).
ASSIGNMENTS
TECHNICAL NOTES
246
ORPEvent
Existing Event Date is outside survery reference period =
EVNT.EVORPFLAG = 1/ORP.
New event is Out of the Survey Reference Period =
See general specifications for Date check logic for
determing ORP events.
DESIGN NOTES
1:38:56 PM Monday, April 06, 2009
Page 197 of 368
ST46
ST46
Page Order # :
Design Screen Type:
No Entry
Fields:
Field 1:
ORPMESSAGE
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
790
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
Int. Instr I:
SINCE ALL EVENTS IN THIS BUNDLE ARE OUTSIDE THE
SURVEY REFERENCE PERIOD, WE DO NOT NEED ANY
CHARGE INFORMATION ABOUT THE BUNDLE.
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING
1:38:59 PM Monday, April 06, 2009
Page 198 of 368
ST46
ORPMESSAGE
Field1:
Cheshire Name:
( STQ2000 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TContinueEMPTY
1
No
No
Number Label
1 Continue
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX ST80 - (STQ2930 )
English text: CONTINUE
Attribute
Empty
Route
BOX ST80 - (STQ2930 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:39:04 PM Monday, April 06, 2009
Page 199 of 368
BOX ST46
BOX ST46
Page Order # :
800
BOX INSTRUCTIONS
( STQ2010 )
IF (ST5 - STATTYPE = 2/Insurance, 4/Tricare, OR 6/TricareAndInsurance)
OR (ST5 - MCARTYPE = 4/MSNPartB), GO TO ST47 - ASGNTAKE (
STQ2020 ).
ELSE GO TO BOX ST47 - (STQ2050 ).
ASSIGNMENTS
TECHNICAL NOTES
DESIGN NOTES
1:39:04 PM Monday, April 06, 2009
Page 200 of 368
ST47
ST47
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
ASGNTAKE
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
810
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)
Int. Instr I:
WAS ASSIGNMENT TAKEN FOR THIS CHARGE BUNDLE?
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING
1:39:06 PM Monday, April 06, 2009
Page 201 of 368
ST47
ASGNTAKE
Field1:
Cheshire Name:
( STQ2020 )
COST.ASGNTAKE
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TAsgntake
1
No
No
Number Label
1 Yes
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX ST47 - (STQ2050 )
2
English text: YES
No
BOX ST47 - (STQ2050 )
3
English text: NO
CantTell
BOX ST47 - (STQ2050 )
English text: CAN'T TELL
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
If ST6 - MCARTYPE= 4/MSNPartB. then (ST7 - ASGNTAKE = 1/Yes
or 2/No).
If not true, display error message, "THE MSN SPECIFIES
ASSIGNED OR UNASSIGNED. PLEASE REENTER OR PRESS
"PREVIOUS PAGE" TO CORRECT YOUR ENTRY AT ST5".
TECHNICAL NOTES
DESIGN NOTES
1:39:11 PM Monday, April 06, 2009
Page 202 of 368
BOX ST47
BOX ST47
Page Order # :
840
BOX INSTRUCTIONS
( STQ2050 )
IF ST5 - STATTYPE = 8/MPDPBenefit, GO TO ST47A - TOTALCHG (
STQ2055 ).
ELSE IF ST5 - STATTYPE = 2/Insurance, 4/Tricare OR
6/TricareAndInsurance, GO TO ST48 - TOTALCHG ( STQ2060 ).
ELSE IF ST5 - MCARTYPE = 4/MSNPartB, GO TO ST52 - TOTALCHG (
STQ2080 ).
ELSE IF ST5 - MCARTYPE = 6/MSNPartAInpatient, GO TO ST56 DAYSUSED ( STQ2100 ).
ELSE GO TO ST60 - TOTALCHG ( STQ2120 ).
ASSIGNMENTS
TECHNICAL NOTES
DESIGN NOTES
1:39:11 PM Monday, April 06, 2009
Page 203 of 368
ST47A
ST47A
Page Order # :
Design Screen Type:
Dollar
Fields:
Field 1:
TOTALCHG
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
845
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Display "TOTAL COST OF PRESCRIPTION(S)" in BOLD.
Always display "(S)" in parenthesis.
Display "COST" in "IF A TOTAL COST" in BOLD.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
Int. Instr I:
ENTER THE TOTAL COST OF PRESCRIPTION(S) FROM THE
MEDICARE PRESCRIPTION DRUG BENEFIT STATEMENT. IF A
TOTAL COST IS NOT LISTED, IT MAY BE NECESSARY TO
CALCULATE A TOTAL BY ADDING THE COSTS OF INDIVIDUAL
ITEMS LISTED ON THE STATEMENT.
Question Text:
Int. Instr II:
1:39:14 PM Monday, April 06, 2009
Page 204 of 368
ST47A
INPUT FIELDS / ROUTING
Field1:
TOTALCHG
Cheshire Name:
Item Text display:
( STQ2055 )
CORO.TOTALCHG
Always display "(S)" in parenthesis.
Item Text:
Label:
Label Position:
TOTAL CHARGE OF PRESCRIPTION(S):
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST64 - STTCHGPAID2 ( STQ2695 )
Refusal
ST64 - STTCHGPAID2 ( STQ2695 )
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
ST64 - STTCHGPAID2 ( STQ2695 )
BACKGROUND VARIABLE ASSIGNMENTS
STDATQNO
COST.STDATQNO = 8/ST47A.
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:39:17 PM Monday, April 06, 2009
Page 205 of 368
ST48
ST48
Page Order # :
Design Screen Type:
Numeric
Fields:
Field 1:
TOTALCHG
Field 2:
MCAPPAMT
Field 3:
MCPAYAMT
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
Enable Functions:
850
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Always display "[SEE SHOWCARD…]" in brackets.
Multi Field display:
Vertical Alignment
Display all fields at one time.
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)
Int. Instr I:
ENTER THE FOLLOWING AMOUNTS FROM THE (TYPE OF
STATEMENT). IF AMOUNT NOT AVAILABLE, ENTER "DON'T
KNOW".
[SEE SHOWCARD ST2 FOR TRICARE STATEMENT EXAMPLES.]
Question Text:
1:39:22 PM Monday, April 06, 2009
Page 206 of 368
ST48
Int. Instr II:
INPUT FIELDS / ROUTING
Field1:
TOTALCHG
Cheshire Name:
( STQ2060 )
CORO.TOTALCHG
Item Text display:
Item Text:
Label:
Label Position:
TOTAL CHARGE/BILLED AMOUNT:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST48 - MCAPPAMT ( STQ2061 )
Refusal
ST48 - MCAPPAMT ( STQ2061 )
1:39:31 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
ST48 - MCAPPAMT ( STQ2061 )
Page 207 of 368
ST48
MCAPPAMT
Field2:
Cheshire Name:
( STQ2061 )
COST.MCAPPAMT
Item Text display:
Item Text:
Label:
Label Position:
TOTAL MEDICARE APPROVED AMOUNT:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST48 - MCPAYAMT ( STQ2062 )
Refusal
ST48 - MCPAYAMT ( STQ2062 )
1:39:40 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
ST48 - MCPAYAMT ( STQ2062 )
Page 208 of 368
ST48
MCPAYAMT
Field3:
Cheshire Name:
( STQ2062 )
COST.MCPAYAMT
Item Text display:
Item Text:
Label:
Label Position:
TOTAL MEDICARE PAYMENT:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
BOX ST48 - (STQ2065 )
Refusal
BOX ST48 - (STQ2065 )
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
BOX ST48 - (STQ2065 )
BACKGROUND VARIABLE ASSIGNMENTS
CALCULATE COST.AREMAING:
If ST47 - ASGNTAKE = 1/Yes and ((ST48 - MCAPPAMT ^= DK, RF) and (ST48 MCPAYAMT ^= DK, RF)), set COST.AREMAING = (MCAPPAMT - MCPAYAMT);
Else if (ST47 - ASGNTAKE = 2/No or 3/CantTell) and ((ST48 - TOTALCHG ^= DK, RF) and
(ST48 - MCPAYAMT ^= DK, RF)), set COST.AREMAING = (TOTALCHG - MCPAYAMT);
Else if ST47 - ASGNTAKE = 3/CantTell and ((ST48 - MCAPPAMT ^= DK, RF) and (ST48 MCPAYAMT ^= DK, RF)), set COST.AREMAING = (MCAPPAMT - MCPAYAMT);
Else set COST.AREMAING = empty.
If Calculated Amount Remaining is < 0, reset COST.AREMAING = 0.
STDATQNO
COST.STDATQNO = 1/ST48.
TOTALAMT
COST.TOTALAMT = ST48 - TOTALCHG.
AREMAING
Set COST.AREMAING based on calculation
instructions above.
ARCALFLG
Set COST.ARCALFLG = 1/Yes.
SOFT EDIT CHECKS
Edit #1
TOTALCHG = 4.99 - 20,000.00.
1:39:45 PM Monday, April 06, 2009
Page 209 of 368
ST48
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY."
Edit #2
MCAPPAMT = 3.99 - 16,000.00.
If not true, display message "UNLKELY RESPONSE. PLEASE
VERIFY ."
Edit #3
MCPAYAMT= 3.99 - 16,000.00.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY ."
Edit #4
If (MCAPPAMT ^= DK and MCAPPAMT ^= RF) and (TOTALCHG ^=
DK and TOTALCHG ^= RF), then MCAPPAMT <= TOTALCHG.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY."
Edit #5
If (MCPAYAMT^= DK and MCPAYAMT ^= RF) and (TOTALCHG ^=
DK and TOTALCHG ^= RF), then MCPAYAMT <= TOTALCHG.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY."
Edit #6
If (MCPAYAMT ^= DK and MCPAYAMT ^= RF) and (MCAPPAMT^=
DK and MCAPPAMT ^= RF), then MCPAYAMT <= MCAPPAMT.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY."
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:39:45 PM Monday, April 06, 2009
Page 210 of 368
BOX ST48
BOX ST48
Page Order # :
860
BOX INSTRUCTIONS
( STQ2065 )
IF AMOUNT REMAINING = DK OR EMPTY, GO TO BOX ST51 - (STQ2072 ).
ELSE IF (AMOUNT REMAINING < $1.00) OR ((ST48 - MCAPPAMT ^= DK
OR RF) AND (AMOUNT REMAINING < .02 * ST48 - MCAPPAMT)), GO TO
BOX ST80 - (STQ2930 ).
ELSE GO TO ST49 - STTCHGPAID1 ( STQ2066 ).
ASSIGNMENTS
TECHNICAL NOTES
230
AmountRemaining
Amount Remaining =
COST.AREMAING.
DESIGN NOTES
1:39:45 PM Monday, April 06, 2009
Page 211 of 368
ST49
ST49
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
STTCHGPAID1
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
870
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Always display "(S)" in interviewer instructions in parenthesis.
If SP was covered by TRICARE and any other insurance plan
besides Medicare during the current round, display "such as
TRICARE or an insurance plan".
Else if SP was covered by TRICARE and is not covered by any
other insurance plan besides Medicare during the current round,
display "such as TRICARE"
Else if SP was not covered by TRICARE and was covered by any
other insurance plan besides Medicare during the current round,
display "such as an insurance plan".
Else do not display.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
1:39:49 PM Monday, April 06, 2009
(ST CLAIM HEADER)
EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)
Page 212 of 368
ST49
Int. Instr I:
REVIEW CHARGE BUNDLE ON (TYPE OF STATEMENT) WITH
RESPONDENT IF YOU HAVEN'T ALREADY DONE SO. POINT
OUT PROVIDER NAME, DATE(S), AND TYPE OF SERVICE.
THEN ASK:
Question Text:
So, I have an amount remaining of $(AMOUNT REMAINING) that
Medicare didn't pay. [Have you/Has (SP)] or any other source,
[such as (TRICARE/an insurance plan/TRICARE or an insurance
plan)], paid any of this amount?
Int. Instr II:
INPUT FIELDS / ROUTING
Field1:
STTCHGPAID1
Cheshire Name:
( STQ2066 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TTchgPaid1
1
No
No
Number Label
1 SomeonePaid
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX ST64A - (STQ2700 )
2
English text: SP OR ANY SOURCE PAID
NothingPaid
BOX ST64A - (STQ2700 )
3
English text: NOTHING HAS BEEN PAID
AmountRemainingWrong
ST50 - CHANGAMT ( STQ2067 )
English text: AMOUNT REMAINING SEEMS WRONG
Attribute
Don't know
Route
BOX ST64A - (STQ2700 )
Refusal
BOX ST64A - (STQ2700 )
BACKGROUND VARIABLE ASSIGNMENTS
ARWRONG
1:39:57 PM Monday, April 06, 2009
If ST49 - STTCHGPAID1 =
3/AmountRemaingWrong, set COST.ARWRONG =
1/Yes.
Page 213 of 368
ST49
If ST49 - STTCHGPAID1 = 1/SomeonePaid, set
CORO.TCHGPAID = 1/Yes.
Else if ST49 - STTCHGPAID1 = 2/NothingPaid, set
CORO.TCHGPAID = 2/No.
Else if ST49 - STTCHGPAID1 = DK, set
CORO.TCHGPAID = DK.
Else if ST49 - STTCHGPAID1 = RF, set
CORO.TCHGPAID = RF.
TCHGPAID
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
52
DeletedPlans
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
258
TricarePlan
SP covered by TRICARE during the current round =
There is a PLAN where PLAN.PLANTYPE = 6/Tricare
& PLRO where (PLRO.PLROPLAN = PLAN.PLANNUM &
PLRO.PLRORND = current round & PLRO.COVTIME^=
empty).
Exclude Deleted Plans. See T.N. 52.
259
InsurancePlan
SP covered by Insurance plan other than Medicare
during current round =
PLAN where (PLANTYPE = 2/Medicaid, 3/PublicPlan, or
4/PrivatePlan) & PLRO where
(PLROPLAN=PLAN.PLANNUM & PLRORND=current
round & COVTIME^=empty).
Exclude Deleted Plans. See T.N. 52.
DESIGN NOTES
1:39:57 PM Monday, April 06, 2009
Page 214 of 368
ST50
ST50
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
CHANGAMT
Enable Functions:
HELP
COMMENTS
JUMPBACK
Yes
Yes
No
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
880
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)
Int. Instr I:
THESE AMOUNTS WERE ENTERED FROM THE (TYPE OF
STATEMENT) STATEMENT:
Question Text:
TOTAL CHARGE/BILLED AMOUNT: (TOTAL CHARGE AMOUNT)
TOTAL MEDICARE APPROVED AMOUNT: (MEDICARE
APPROVED AMOUNT)
TOTAL MEDICARE PAYMENT: (MEDICARE PAYMENT)
AMOUNT REMAINING AFTER MEDICARE PAYMENT: (AMOUNT
1:39:59 PM Monday, April 06, 2009
Page 215 of 368
ST50
REMAINING)
DO YOU WANT TO MAKE ANY CHANGES?
Int. Instr II:
INPUT FIELDS / ROUTING
CHANGAMT
Field1:
Cheshire Name:
( STQ2067 )
COST.CHANGAMT
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNo
FieldSize:
Min Value:
Max Value:
Mask:
1
No
No
Number Label
1 Yes
2
Route
ST51 - TOTALCHG ( STQ2068 )
English text: YES
No
BOX ST51 - (STQ2072 )
English text: NO
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
230
AmountRemaining
Amount Remaining =
COST.AREMAING.
DESIGN NOTES
1:40:03 PM Monday, April 06, 2009
Page 216 of 368
ST51
ST51
Page Order # :
Design Screen Type:
Numeric
Fields:
Field 1:
TOTALCHG
Field 2:
MCAPPAMT
Field 3:
MCPAYAMT
HELP
COMMENTS
JUMPBACK
No
No
No
Enable Functions:
890
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Vertical Alignment
Display all fields at one time.
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)
Int. Instr I:
MAKE ALL THE NECESSARY CORRECTIONS TO THE AMOUNTS
THAT WERE ENTERED FROM THE (TYPE OF STATEMENT).
Question Text:
Int. Instr II:
1:40:08 PM Monday, April 06, 2009
Page 217 of 368
ST51
INPUT FIELDS / ROUTING
Field1:
TOTALCHG
Cheshire Name:
Item Text display:
( STQ2068 )
CORO.TOTALCHG
Display previously collected response. Allow field to be
updated.
Item Text:
Label:
Label Position:
TOTAL CHARGE/BILLED AMOUNT:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST51 - MCAPPAMT ( STQ2069 )
Refusal
ST51 - MCAPPAMT ( STQ2069 )
1:40:17 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
ST51 - MCAPPAMT ( STQ2069 )
Page 218 of 368
ST51
MCAPPAMT
Field2:
Cheshire Name:
Item Text display:
( STQ2069 )
COST.MCAPPAMT
Display previously collected response. Allow field to be
updated.
Item Text:
Label:
Label Position:
TOTAL MEDICARE APPROVED AMOUNT:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST51 - MCPAYAMT ( STQ2070 )
Refusal
ST51 - MCPAYAMT ( STQ2070 )
1:40:26 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
ST51 - MCPAYAMT ( STQ2070 )
Page 219 of 368
ST51
MCPAYAMT
Field3:
Cheshire Name:
Item Text display:
( STQ2070 )
COST.MCPAYAMT
Display previously collected response. Allow field to be
updated.
Item Text:
Label:
Label Position:
TOTAL MEDICARE PAYMENT:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
BOX ST51 - (STQ2072 )
Refusal
BOX ST51 - (STQ2072 )
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
BOX ST51 - (STQ2072 )
BACKGROUND VARIABLE ASSIGNMENTS
CALCULATE COST.AREMAING:
if ST47 - ASGNTAKE = 1/Yes and ((ST51 - MCAPPAMT ^= DK, RF) and (ST51 -
MCPAYAMT ^= DK, RF)), set COST.AREMAING = (MCAPPAMT - MCPAYAMT);
Else if (ST47 - ASGNTAKE = 2/No or 3/CantTell) and ((ST51 - TOTALCHG ^= DK, RF) and
(ST51 -MCPAYAMT ^= DK, RF)), set COST.AREMAING = (TOTALCHG - MCPAYAMT);
Else if ST47 - ASGNTAKE = 3/CantTell and ((ST51 - MCAPPAMT ^= DK, RF) and (ST51 -
MCPAYAMT ^= DK, RF)), set COST.AREMAING = (MCAPPAMT - MCPAYAMT);
Else set COST.AREMAING = empty.
If Calculated Amount Remaining is < 0, reset COST.AREMAING = 0.
TOTALAMT
COST.TOTALAMT = ST51 - TOTALCHG.
AREMAING
Set COST.AREMAING based on calculation
instructions above.
SOFT EDIT CHECKS
Edit #1
TOTALCHG = 4.99 - 20,000.00.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY."
1:40:31 PM Monday, April 06, 2009
Page 220 of 368
ST51
Edit #2
MCAPPAMT = 3.99 - 16,000.00.
If not true, display message "UNLKELY RESPONSE. PLEASE
VERIFY ."
Edit #3
MCPAYAMT= 3.99 - 16,000.00.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY ."
Edit #4
If (MCAPPAMT^= DK and MCAPPAMT ^= RF) and (TOTALCHG ^=
DK and TOTALCHG ^= RF), then MCAPPAMT <= TOTALCHG.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY."
Edit #5
If (MCPAYAMT^= DK and MCPAYAMT ^= RF) and (TOTALCHG ^=
DK and TOTALCHG ^= RF), then MCPAYAMT <= TOTALCHG.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY."
Edit #6
If (MCPAYAMT ^= DK and MCPAYAMT ^= RF) and (MCAPPAMT^=
DK and MCAPPAMT ^= RF), then MCPAYAMT <= MCAPPAMT.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY."
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:40:31 PM Monday, April 06, 2009
Page 221 of 368
BOX ST51
BOX ST51
900
Page Order # :
BOX INSTRUCTIONS
( STQ2072 )
IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY)
AND ((AMOUNT REMAINING < $1.00) OR ((ST51 - MCAPPAMT ^= DK AND
ST51 - MCAPPAMT ^= RF) AND (AMOUNT REMAINING < .02 * ST51 MCAPPAMT))), GO TO BOX ST80 - (STQ2930 ).
ELSE GO TO ST64 - STTCHGPAID2 ( STQ2695 ).
ASSIGNMENTS
TECHNICAL NOTES
230
AmountRemaining
Amount Remaining =
COST.AREMAING.
DESIGN NOTES
1:40:31 PM Monday, April 06, 2009
Page 222 of 368
ST52
ST52
Page Order # :
Design Screen Type:
Numeric
Fields:
Field 1:
TOTALCHG
Field 2:
MCAPPAMT
Field 3:
MCPAYAMT
Field 4:
MAYBBILL
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
Enable Functions:
910
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Vertical Alignment
Display all fields at one time.
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)
Int. Instr I:
ENTER THE FOLLOWING AMOUNTS FROM THE MSN:
Question Text:
Int. Instr II:
1:40:36 PM Monday, April 06, 2009
Page 223 of 368
ST52
INPUT FIELDS / ROUTING
Field1:
TOTALCHG
Cheshire Name:
( STQ2080 )
CORO.TOTALCHG
Item Text display:
Item Text:
Label:
Label Position:
AMOUNT CHARGED:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST52 - MCAPPAMT ( STQ2081 )
Refusal
ST52 - MCAPPAMT ( STQ2081 )
1:40:45 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
ST52 - MCAPPAMT ( STQ2081 )
Page 224 of 368
ST52
MCAPPAMT
Field2:
Cheshire Name:
( STQ2081 )
COST.MCAPPAMT
Item Text display:
Item Text:
Label:
Label Position:
MEDICARE APPROVED:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST52 - MCPAYAMT ( STQ2082 )
Refusal
ST52 - MCPAYAMT ( STQ2082 )
1:40:54 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
ST52 - MCPAYAMT ( STQ2082 )
Page 225 of 368
ST52
MCPAYAMT
Field3:
Cheshire Name:
Item Text display:
( STQ2082 )
COST.MCPAYAMT
Always display (PROVIDER/YOU) in label in parenthesis.
Item Text:
Label:
Label Position:
MEDICARE PAID (PROVIDER/YOU):
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST52 - MAYBBILL ( STQ2083 )
Refusal
ST52 - MAYBBILL ( STQ2083 )
1:41:03 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
ST52 - MAYBBILL ( STQ2083 )
Page 226 of 368
ST52
MAYBBILL
Field4:
Cheshire Name:
( STQ2083 )
COST.MAYBBILL
Item Text display:
Item Text:
Label:
Label Position:
YOU MAY BE BILLED:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmtnor
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
BOX ST52 - (STQ2085 )
Route
BOX ST52 - (STQ2085 )
BACKGROUND VARIABLE ASSIGNMENTS
CALCULATE COST.AREMAING:
If ST47 - ASGNTAKE = 1/Yes, set COST.AREMAING = ST52 -MAYBBILL.
Else if ST47 - ASGNTAKE = 2/No and (ST52 - TOTALCHG = DK or RF) or (ST52 -
MCPAYAMT = DK or RF), set COST.AREMAING = DK;
Else set COST.AREMAING = (TOTALCHG - MCPAYAMT). If calculated Amount
Remaining is < 0, then reset COST.AREMAING = 0.
STDATQNO
COST.STDATQNO = 5/ST52.
TOTALAMT
COST.TOTALAMT = ST52 - TOTALCHG.
AREMAING
Set COST.AREMAING based on calculation
instructions above.
SOFT EDIT CHECKS
Edit #1
TOTALCHG = 4.99 - 20,000.00.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY."
Edit #2
MCAPPAMT = 3.99 - 16,000.00.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY."
Edit #3
MCPAYAMT = 3.99 - 16,000.00.
1:41:08 PM Monday, April 06, 2009
Page 227 of 368
ST52
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY."
Edit #4
MAYBBILL = 0 - 20,000.00.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY."
Edit #5
If (TOTALCHG ^= DK and TOTALCHG ^= RF) and (MCAPPAMT ^=
DK and MCAPPAMT ^= RF), then MCAPPAMT <= TOTALCHG.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY."
Edit #6
If (TOTALCHG ^= DK and TOTALCHG ^= RF) and (MCPAYAMT ^=
DK and MCPAYAMT ^= RF), then MCPAYAMT <= TOTALCHG.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY."
Edit #7
If (TOTALCHG ^= DK and TOTALCHG ^= RF)
and (MAYBBILL ^= DK), then MAYBBILL should be <= TOTALCHG.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY."
Edit #8
If (MCAPPAMT ^= DK and MCAPPAMT ^= RF) and (MCPAYAMT ^=
DK and MCPAYAMT ^= RF), then MCPAYAMT <= MCAPPAMT.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY."
Edit #9
If COST.ASGNTAKE = 2/No, and (MAYBBILL ^= DK) and
(MCPAYAMT ^= DK and MCPAYAMT ^= RF),
then MCPAYAMT <= MAYBBILL.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY."
Edit #10
If COST.ASGNTAKE=1/Yes and (MAYBBILL ^= DK) and
(MCAPPAMT ^= DK and MCAPPAMT ^= RF),
then MAYBBILL <= MCAPPAMT.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY."
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:41:08 PM Monday, April 06, 2009
Page 228 of 368
BOX ST52
BOX ST52
Page Order # :
920
BOX INSTRUCTIONS
( STQ2085 )
IF AMOUNT REMAINING = DK OR EMPTY, GO TO BOX ST55 - (STQ2095 ).
ELSE IF AMOUNT REMAINING < $1.00, GO TO BOX ST80 - (STQ2930 ).
ELSE GO TO ST53 - STTCHGPAID1 ( STQ2086 ).
ASSIGNMENTS
TECHNICAL NOTES
230
AmountRemaining
Amount Remaining =
COST.AREMAING.
DESIGN NOTES
1:41:08 PM Monday, April 06, 2009
Page 229 of 368
ST53
ST53
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
STTCHGPAID1
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
930
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Always display "(S)" in interviewer instructions in parenthesis.
If SP was covered by TRICARE and any other insurance plan
besides Medicare during the current round, display "such as
TRICARE or an insurance plan".
Else if SP was covered by TRICARE and is not covered by any
other insurance plan besides Medicare during the current round,
display "such as TRICARE"
Else if SP was not covered by TRICARE and was covered by any
other insurance plan besides Medicare during the current round,
display "such as an insurance plan".
Else do not display.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
1:41:12 PM Monday, April 06, 2009
(ST CLAIM HEADER)
EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)
Page 230 of 368
ST53
Int. Instr I:
REVIEW CHARGE BUNDLE ON THE (TYPE OF STATEMENT)
WITH RESPONDENT IF YOU HAVEN'T ALREADY DONE SO.
POINT OUT PROVIDER NAME, DATE(S), AND TYPE OF
SERVICE. THEN ASK:
Question Text:
So, I have an amount remaining of $(AMOUNT REMAINING) that
Medicare didn't pay. [Have you/Has (SP)] or any other source,
[such as (TRICARE/an insurance plan/TRICARE or an insurance
plan)], paid any of this amount?
Int. Instr II:
INPUT FIELDS / ROUTING
Field1:
STTCHGPAID1
Cheshire Name:
( STQ2086 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TTchgPaid1
1
No
No
Number Label
1 SomeonePaid
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX ST64A - (STQ2700 )
2
English text: SP OR ANY SOURCE PAID
NothingPaid
BOX ST64A - (STQ2700 )
3
English text: NOTHING HAS BEEN PAID
AmountRemainingWrong
ST54 - CHANGAMT ( STQ2087 )
English text: AMOUNT REMAINING SEEMS WRONG
Attribute
Don't know
Route
BOX ST64A - (STQ2700 )
Refusal
BOX ST64A - (STQ2700 )
BACKGROUND VARIABLE ASSIGNMENTS
ARWRONG
1:41:20 PM Monday, April 06, 2009
If ST53 - STTCHGPAID1 =
3/AmountRemaingWrong, set COST.ARWRONG =
1/Yes.
Page 231 of 368
ST53
If ST53 - STTCHGPAID1 = 1/SomeonePaid, set
CORO.TCHGPAID = 1/Yes.
Else if ST53 - STTCHGPAID1 = 2/NothingPaid, set
CORO.TCHGPAID = 2/No.
Else if ST53 - STTCHGPAID1 = DK, set
CORO.TCHGPAID = DK.
Else if ST53 - STTCHGPAID1 = RF, set
CORO.TCHGPAID = RF.
TCHGPAID
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
52
DeletedPlans
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
258
TricarePlan
SP covered by TRICARE during the current round =
There is a PLAN where PLAN.PLANTYPE = 6/Tricare
& PLRO where (PLRO.PLROPLAN = PLAN.PLANNUM &
PLRO.PLRORND = current round & PLRO.COVTIME^=
empty).
Exclude Deleted Plans. See T.N. 52.
259
InsurancePlan
SP covered by Insurance plan other than Medicare
during current round =
PLAN where (PLANTYPE = 2/Medicaid, 3/PublicPlan, or
4/PrivatePlan) & PLRO where
(PLROPLAN=PLAN.PLANNUM & PLRORND=current
round & COVTIME^=empty).
Exclude Deleted Plans. See T.N. 52.
DESIGN NOTES
1:41:20 PM Monday, April 06, 2009
Page 232 of 368
ST54
ST54
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
CHANGAMT
Enable Functions:
HELP
COMMENTS
JUMPBACK
Yes
Yes
No
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
940
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)
Int. Instr I:
THESE AMOUNTS WERE ENTERED FROM THE (TYPE OF
STATEMENT) :
Question Text:
AMOUNT CHARGED: (TOTAL CHARGE AMOUNT)
MEDICARE APPROVED: (MEDICARE APPROVED AMOUNT)
MEDICARE PAID: (MEDICARE PAYMENT)
YOU MAY BE BILLED: (MAY BE BILLED)
1:41:23 PM Monday, April 06, 2009
Page 233 of 368
ST54
DO YOU WANT TO MAKE ANY CHANGES?
Int. Instr II:
INPUT FIELDS / ROUTING
Field1:
CHANGAMT
Cheshire Name:
( STQ2087 )
COST.CHANGAMT
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNo
FieldSize:
Min Value:
Max Value:
Mask:
1
No
No
Number Label
1 Yes
2
Route
ST55 - TOTALCHG ( STQ2088 )
English text: YES
No
BOX ST55 - (STQ2095 )
English text: NO
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
230
AmountRemaining
Amount Remaining =
COST.AREMAING.
DESIGN NOTES
1:41:27 PM Monday, April 06, 2009
Page 234 of 368
ST55
ST55
Page Order # :
Design Screen Type:
Numeric
Fields:
Field 1:
TOTALCHG
Field 2:
MCAPPAMT
Field 3:
MCPAYAMT
Field 4:
MAYBBILL
HELP
COMMENTS
JUMPBACK
Yes
Yes
No
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
Enable Functions:
950
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Vertical Alignment
Display all fields at one time.
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)
Int. Instr I:
MAKE ALL THE NECESSARY CORRECTIONS TO THE AMOUNTS
THAT WERE ENTERED FROM THE (TYPE OF STATEMENT).
Question Text:
Int. Instr II:
1:41:31 PM Monday, April 06, 2009
Page 235 of 368
ST55
INPUT FIELDS / ROUTING
Field1:
TOTALCHG
Cheshire Name:
Item Text display:
( STQ2088 )
CORO.TOTALCHG
Display previously collected response. Allow field to be
updated.
Item Text:
Label:
Label Position:
AMOUNT CHARGED:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST55 - MCAPPAMT ( STQ2089 )
Refusal
ST55 - MCAPPAMT ( STQ2089 )
1:41:41 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
ST55 - MCAPPAMT ( STQ2089 )
Page 236 of 368
ST55
MCAPPAMT
Field2:
Cheshire Name:
Item Text display:
( STQ2089 )
COST.MCAPPAMT
Display previously collected response. Allow field to be
updated.
Item Text:
Label:
Label Position:
MEDICARE APPROVED:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST55 - MCPAYAMT ( STQ2090 )
Refusal
ST55 - MCPAYAMT ( STQ2090 )
1:41:50 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
ST55 - MCPAYAMT ( STQ2090 )
Page 237 of 368
ST55
MCPAYAMT
Field3:
Cheshire Name:
Item Text display:
( STQ2090 )
COST.MCPAYAMT
Display previously collected response. Allow field to be
updated.
Always display (PROVIDER/YOU) in label in parenthesis.
Item Text:
Label:
Label Position:
MEDICARE PAID (PROVIDER/YOU):
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST55 - MAYBBILL ( STQ2091 )
Refusal
ST55 - MAYBBILL ( STQ2091 )
1:41:59 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
ST55 - MAYBBILL ( STQ2091 )
Page 238 of 368
ST55
MAYBBILL
Field4:
Cheshire Name:
Item Text display:
( STQ2091 )
COST.MAYBBILL
Display previously collected response. Allow field to be
updated.
Item Text:
Label:
Label Position:
YOU MAY BE BILLED:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmtnor
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
BOX ST55 - (STQ2095 )
Route
BOX ST55 - (STQ2095 )
BACKGROUND VARIABLE ASSIGNMENTS
CALCULATE COST.AREMAING:
If ST47 - ASGNTAKE = 1/Yes, set COST.AREMAING = ST55 -MAYBBILL.
Else if ST47 - ASGNTAKE = 2/No and (ST55 - TOTALCHG = DK or RF) or (ST55 -
MCPAYAMT = DK or RF), set COST.AREMAING = DK;
Else set COST.AREMAING = (TOTALCHG - MCPAYAMT). If calculated Amount
Remaining is < 0, reset COST.AREMAING = 0.
TOTALAMT
COST.TOTALAMT = ST55 - TOTALCHG.
AREMAING
Set COST.AREMAING based on calculation
instructions above.
SOFT EDIT CHECKS
Edit #1
TOTALCHG = 4.99 - 20,000.00.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY."
Edit #2
MCAPPAMT = 3.99 - 16,000.00.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY."
Edit #3
MCPAYAMT = 3.99 - 16,000.00.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY."
1:42:03 PM Monday, April 06, 2009
Page 239 of 368
ST55
Edit #4
MAYBBILL = 0 - 20,000.00.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY."
Edit #5
If (TOTALCHG ^= DK and TOTALCHG ^= RF) and (MCAPPAMT ^=
DK and MCAPPAMT ^= RF), then MCAPPAMT <= TOTALCHG.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY."
Edit #6
If (TOTALCHG ^= DK and TOTALCHG ^= RF) and (MCPAYAMT ^=
DK and MCPAYAMT ^= RF), then MCPAYAMT <= TOTALCHG.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY."
Edit #7
If (TOTALCHG ^= DK and TOTALCHG ^= RF) and (MAYBBILL ^=
DK), then MAYBBILL should be <= TOTALCHG.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY."
Edit #8
If (MCAPPAMT ^= DK and MCAPPAMT ^= RF) and (MCPAYAMT ^=
DK and MCPAYAMT ^= RF), then MCPAYAMT <= MCAPPAMT.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY."
Edit #9
If COST.ASGNTAKE = 2/No, and (MAYBBILL ^= DK) and
(MCPAYAMT ^= DK and MCPAYAMT ^= RF),
then MCPAYAMT <= MAYBBILL.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY."
Edit #10
If COST.ASGNTAKE=1/Yes and (MAYBBILL ^= DK) and
(MCAPPAMT ^= DK and MCAPPAMT ^= RF),
then MAYBBILL <= MCAPPAMT.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY."
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:42:03 PM Monday, April 06, 2009
Page 240 of 368
BOX ST55
BOX ST55
Page Order # :
960
BOX INSTRUCTIONS
( STQ2095 )
IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY)
AND (AMOUNT REMAINING < $1.00), GO TO BOX ST80 - (STQ2930 ).
ELSE GO TO ST64 - STTCHGPAID2 ( STQ2695 ).
ASSIGNMENTS
TECHNICAL NOTES
230
AmountRemaining
Amount Remaining =
COST.AREMAING.
DESIGN NOTES
1:42:04 PM Monday, April 06, 2009
Page 241 of 368
ST56
ST56
Page Order # :
Design Screen Type:
Numeric
Fields:
Field 1:
DAYSUSED
Field 2:
NONCOVRD
Field 3:
COINSUR
Field 4:
MAYBBILL
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
Enable Functions:
970
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Vertical Alignment
Display all fields at one time.
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)
Int. Instr I:
ENTER THE FOLLOWING AMOUNTS FROM THE MSN.
Question Text:
Int. Instr II:
1:42:07 PM Monday, April 06, 2009
DISREGARD "AMOUNT CHARGED" IF IT APPEARS ON THE
STATEMENT.
Page 242 of 368
ST56
INPUT FIELDS / ROUTING
Field1:
Cheshire Name:
DAYSUSED
( STQ2100 )
COST.DAYSUSED
Item Text display:
Item Text:
Label:
Label Position:
BENEFIT DAYS USED:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TDaysuseh
1
No
No
Number Label
1 [Continuous answer.]
1:42:14 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
0
120
Route
ST56 - NONCOVRD ( STQ2101 )
Page 243 of 368
ST56
NONCOVRD
Field2:
Cheshire Name:
( STQ2101 )
COST.NONCOVRD
Item Text display:
Item Text:
Label:
Label Position:
NON-COVERED CHARGES:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST56 - COINSUR ( STQ2102 )
Refusal
ST56 - COINSUR ( STQ2102 )
1:42:23 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
ST56 - COINSUR ( STQ2102 )
Page 244 of 368
ST56
COINSUR
Field3:
Cheshire Name:
( STQ2102 )
COST.COINSUR
Item Text display:
Item Text:
Label:
Label Position:
DEDUCTIBLE AND COINSURANCE:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST56 - MAYBBILL ( STQ2103 )
Refusal
ST56 - MAYBBILL ( STQ2103 )
1:42:32 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
ST56 - MAYBBILL ( STQ2103 )
Page 245 of 368
ST56
MAYBBILL
Field4:
Cheshire Name:
( STQ2103 )
COST.MAYBBILL
Item Text display:
Item Text:
Label:
Label Position:
YOU MAY BE BILLED:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmtnor
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
BOX ST56 - (STQ2105 )
Route
BOX ST56 - (STQ2105 )
BACKGROUND VARIABLE ASSIGNMENTS
STDATQNO
COST.STDATQNO = 6/ST56ST60.
AREMAING
COST.AREMAING = ST56 - MAYBBILL.
SOFT EDIT CHECKS
Edit #1
DAYSUSED = 1 - 60.
If not true, display messge "UNLIKELY RESPONSE, PLEASE
VERIFY."
Edit #2
NONCOVRD = 0 - 20,000.00.
If not true, display messge "UNLIKELY RESPONSE, PLEASE
VERIFY."
Edit #3
COINSUR = 0 - 20,000.00.
If not true, display messge "UNLIKELY RESPONSE, PLEASE
VERIFY."
Edit #4
MAYBBILL = 0 - 20,000.00.
If not true, display messge "UNLIKELY RESPONSE, PLEASE
VERIFY."
HARD EDIT CHECKS
1:42:37 PM Monday, April 06, 2009
Page 246 of 368
ST56
TECHNICAL NOTES
DESIGN NOTES
1:42:37 PM Monday, April 06, 2009
Page 247 of 368
BOX ST56
BOX ST56
Page Order # :
980
BOX INSTRUCTIONS
( STQ2105 )
IF AMOUNT REMAINING = DK OR EMPTY, GO TO BOX ST59 - (STQ2115 ).
ELSE IF AMOUNT REMAINING < $1.00, GO TO BOX ST80 - (STQ2930 ).
ELSE GO TO ST57 - STTCHGPAID1 ( STQ2106 ).
ASSIGNMENTS
TECHNICAL NOTES
230
AmountRemaining
Amount Remaining =
COST.AREMAING.
DESIGN NOTES
1:42:37 PM Monday, April 06, 2009
Page 248 of 368
ST57
ST57
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
STTCHGPAID1
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
990
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Always display "(S)" in interviewer instructions in parenthesis.
If SP was covered by TRICARE and any other insurance plan
besides Medicare during the current round, display "such as
TRICARE or an insurance plan".
Else if SP was covered by TRICARE and is not covered by any
other insurance plan besides Medicare during the current round,
display "such as TRICARE"
Else if SP was not covered by TRICARE and was covered by any
other insurance plan besides Medicare during the current round,
display "such as an insurance plan".
Else do not display.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
1:42:41 PM Monday, April 06, 2009
(ST CLAIM HEADER)
EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)
Page 249 of 368
ST57
Int. Instr I:
REVIEW CHARGE BUNDLE ON (TYPE OF STATEMENT) WITH
RESPONDENT IF YOU HAVEN'T ALREADY DONE SO. POINT
OUT PROVIDER NAME, DATE(S), AND TYPE OF SERVICE.
THEN ASK:
Question Text:
So, I have an amount remaining $(AMOUNT REMAINING) that
Medicare didn't pay. [Have you/Has (SP)] or any other source,
[such as (TRICARE/an insurance plan/TRICARE or an insurance
plan)], paid any of this amount?
Int. Instr II:
INPUT FIELDS / ROUTING
Field1:
STTCHGPAID1
Cheshire Name:
( STQ2106 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TTchgPaid1
1
No
No
Number Label
1 SomeonePaid
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX ST64A - (STQ2700 )
2
English text: SP OR ANY SOURCE PAID
NothingPaid
BOX ST64A - (STQ2700 )
3
English text: NOTHING HAS BEEN PAID
AmountRemainingWrong
ST58 - CHANGAMT ( STQ2107 )
English text: AMOUNT REMAINING SEEMS WRONG
Attribute
Don't know
Route
BOX ST64A - (STQ2700 )
Refusal
BOX ST64A - (STQ2700 )
BACKGROUND VARIABLE ASSIGNMENTS
ARWRONG
1:42:49 PM Monday, April 06, 2009
If ST57 - STTCHGPAID1 =
3/AmountRemaingWrong, set COST.ARWRONG =
1/Yes.
Page 250 of 368
ST57
If ST57 - STTCHGPAID1 = 1/SomeonePaid, set
CORO.TCHGPAID = 1/Yes.
Else if ST57 - STTCHGPAID1 = 2/NothingPaid, set
CORO.TCHGPAID = 2/No.
Else if ST57 - STTCHGPAID1 = DK, set
CORO.TCHGPAID = DK.
Else if ST57 - STTCHGPAID1 = RF, set
CORO.TCHGPAID = RF.
TCHGPAID
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
52
DeletedPlans
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
258
TricarePlan
SP covered by TRICARE during the current round =
There is a PLAN where PLAN.PLANTYPE = 6/Tricare
& PLRO where (PLRO.PLROPLAN = PLAN.PLANNUM &
PLRO.PLRORND = current round & PLRO.COVTIME^=
empty).
Exclude Deleted Plans. See T.N. 52.
259
InsurancePlan
SP covered by Insurance plan other than Medicare
during current round =
PLAN where (PLANTYPE = 2/Medicaid, 3/PublicPlan, or
4/PrivatePlan) & PLRO where
(PLROPLAN=PLAN.PLANNUM & PLRORND=current
round & COVTIME^=empty).
Exclude Deleted Plans. See T.N. 52.
DESIGN NOTES
1:42:49 PM Monday, April 06, 2009
Page 251 of 368
ST58
ST58
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
CHANGAMT
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
1000
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)
Int. Instr I:
THESE AMOUNTS WERE ENTERED FROM THE MSN:
Question Text:
BENEFITS DAYS USED: (DAYS USED)
NON-COVERED CHARGES: (NON COVERED CHARGES)
DEDUCTIBLE AND COINSURANCE: (COINSURANCE)
YOU MAY BE BILLED: (MAY BE BILLED)
Int. Instr II:
1:42:52 PM Monday, April 06, 2009
DO YOU WANT TO MAKE ANY CHANGES?
Page 252 of 368
ST58
INPUT FIELDS / ROUTING
Field1:
CHANGAMT
Cheshire Name:
( STQ2107 )
COST.CHANGAMT
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNo
FieldSize:
Min Value:
Max Value:
Mask:
1
No
No
Number Label
1 Yes
2
Route
ST59 - DAYSUSED ( STQ2108 )
English text: YES
No
BOX ST59 - (STQ2115 )
English text: NO
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
230
AmountRemaining
Amount Remaining =
COST.AREMAING.
DESIGN NOTES
1:42:55 PM Monday, April 06, 2009
Page 253 of 368
ST59
ST59
Page Order # :
Design Screen Type:
Numeric
Fields:
Field 1:
DAYSUSED
Field 2:
NONCOVRD
Field 3:
COINSUR
Field 4:
MAYBBILL
HELP
COMMENTS
JUMPBACK
No
No
No
Enable Functions:
1010
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Vertical Alignment
Display all fields at one time.
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)
Int. Instr I:
MAKE ALL THE NECESSARY CORRECTIONS TO THE AMOUNTS
THAT WERE ENTERED FROM THE (TYPE OF STATEMENT).
Question Text:
Int. Instr II:
1:42:59 PM Monday, April 06, 2009
Page 254 of 368
ST59
INPUT FIELDS / ROUTING
Field1:
Cheshire Name:
Item Text display:
DAYSUSED
( STQ2108 )
COST.DAYSUSED
Display previously collected response. Allow field to be
updated.
Item Text:
Label:
Label Position:
BENEFIT DAYS USED:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Integer
TDaysuseh
1
No
No
Number Label
1 [Continuous answer.]
1:43:06 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
0
120
Route
ST59 - NONCOVRD ( STQ2109 )
Page 255 of 368
ST59
NONCOVRD
Field2:
Cheshire Name:
Item Text display:
( STQ2109 )
COST.NONCOVRD
Display previously collected response. Allow field to be
updated.
Item Text:
Label:
Label Position:
NON-COVERED CHARGES:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST59 - COINSUR ( STQ2110 )
Refusal
ST59 - COINSUR ( STQ2110 )
1:43:15 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
ST59 - COINSUR ( STQ2110 )
Page 256 of 368
ST59
COINSUR
Field3:
Cheshire Name:
Item Text display:
( STQ2110 )
COST.COINSUR
Display previously collected response. Allow field to be
updated.
Item Text:
Label:
Label Position:
DEDUCTIBLE AND COINSURANCE:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST59 - MAYBBILL ( STQ2111 )
Refusal
ST59 - MAYBBILL ( STQ2111 )
1:43:24 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
ST59 - MAYBBILL ( STQ2111 )
Page 257 of 368
ST59
MAYBBILL
Field4:
Cheshire Name:
Item Text display:
( STQ2111 )
COST.MAYBBILL
Display previously collected response. Allow field to be
updated.
Item Text:
Label:
Label Position:
YOU MAY BE BILLED:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmtnor
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
BOX ST59 - (STQ2115 )
Route
BOX ST59 - (STQ2115 )
BACKGROUND VARIABLE ASSIGNMENTS
AREMAING
COST.AREMAING = ST59 - MAYBBILL.
SOFT EDIT CHECKS
Edit #1
DAYSUSED = 1 - 60.
If not true, display messge "UNLIKELY RESPONSE, PLEASE
VERIFY."
Edit #2
NONCOVRD = 0 - 20,000.00.
If not true, display messge "UNLIKELY RESPONSE, PLEASE
VERIFY."
Edit #3
COINSUR = 0 - 20,000.00.
If not true, display messge "UNLIKELY RESPONSE, PLEASE
VERIFY."
Edit #4
MAYBBILL = 0 - 20,000.00.
If not true, display messge "UNLIKELY RESPONSE, PLEASE
VERIFY."
HARD EDIT CHECKS
1:43:29 PM Monday, April 06, 2009
Page 258 of 368
ST59
TECHNICAL NOTES
DESIGN NOTES
1:43:29 PM Monday, April 06, 2009
Page 259 of 368
BOX ST59
BOX ST59
Page Order # :
1020
BOX INSTRUCTIONS
( STQ2115 )
IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY)
AND (AMOUNT REMAINING < $1.00), GO TO BOX ST80 - (STQ2930 ).
ELSE GO TO ST64 - STTCHGPAID2 ( STQ2695 ).
ASSIGNMENTS
TECHNICAL NOTES
230
AmountRemaining
Amount Remaining =
COST.AREMAING.
DESIGN NOTES
1:43:29 PM Monday, April 06, 2009
Page 260 of 368
ST60
ST60
Page Order # :
Design Screen Type:
Numeric
Fields:
Field 1:
TOTALCHG
Field 2:
NONCOVRD
Field 3:
COINSUR
Field 4:
MAYBBILL
HELP
COMMENTS
JUMPBACK
No
No
No
Enable Functions:
1030
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Vertical Alignment
Display all fields at one time.
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)
Int. Instr I:
ENTER THE FOLLOWING AMOUNTS FROM THE MSN.
Question Text:
Int. Instr II:
1:43:34 PM Monday, April 06, 2009
Page 261 of 368
ST60
INPUT FIELDS / ROUTING
Field1:
TOTALCHG
Cheshire Name:
( STQ2120 )
CORO.TOTALCHG
Item Text display:
Item Text:
Label:
Label Position:
AMOUNT CHARGED:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST60 - NONCOVRD ( STQ2121 )
Refusal
ST60 - NONCOVRD ( STQ2121 )
1:43:43 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
ST60 - NONCOVRD ( STQ2121 )
Page 262 of 368
ST60
NONCOVRD
Field2:
Cheshire Name:
( STQ2121 )
COST.NONCOVRD
Item Text display:
Item Text:
Label:
Label Position:
NON-COVERED CHARGES:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST60 - COINSUR ( STQ2122 )
Refusal
ST60 - COINSUR ( STQ2122 )
1:43:52 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
ST60 - COINSUR ( STQ2122 )
Page 263 of 368
ST60
COINSUR
Field3:
Cheshire Name:
Item Text display:
( STQ2122 )
COST.COINSUR
LABEL DISPLAY INSTRUCTIONS:
If ST6 - 5/MSNPartBOutpatient or 8/MSNPartAHospice ,
display "DEDUCTIBLE AND COINSURANCE:".
Else display "COINSURANCE:".
Item Text:
Label:
Label Position:
(DEDUCTIBLE AND COINSURANCE/COINSURANCE):
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST60 - MAYBBILL ( STQ2123 )
Refusal
ST60 - MAYBBILL ( STQ2123 )
1:44:01 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
ST60 - MAYBBILL ( STQ2123 )
Page 264 of 368
ST60
MAYBBILL
Field4:
Cheshire Name:
( STQ2123 )
COST.MAYBBILL
Item Text display:
Item Text:
Label:
Label Position:
YOU MAY BE BILLED:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmtnor
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
BOX ST60 - (STQ2125 )
Route
BOX ST60 - (STQ2125 )
BACKGROUND VARIABLE ASSIGNMENTS
STDATQNO
COST.STDATQNO = 6/ST56ST60.
TOTALAMT
COST.TOTALAMT = ST60 - TOTALCHG.
AREMAING
COST.AREMAING = ST60 - MAYBBILL.
SOFT EDIT CHECKS
Edit #1
TOTALCHG = 4.99 - 20,000.00.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY ."
Edit #2
NONCOVRD = 0 - 20,000.00.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY ."
Edit #3
COINSUR = 0 - 20,000.00.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY ."
Edit #4
MAYBBILL = 0 - 20,000.00.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY ."
Edit #5
If (NONCOVRD ^= DK and NONCOVRD ^= RF) and (TOTALCHG
1:44:06 PM Monday, April 06, 2009
Page 265 of 368
ST60
^= DK and TOTALCHG ^= RF), then NONCOVRD <= TOTALCHG.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY ."
Edit #6
If (COINSUR ^= DK and COINSUR ^= RF) and (TOTALCHG ^= DK
and TOTALCHG ^= RF), then COINSUR <= TOTALCHG.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY ."
Edit #7
If (MAYBBILL ^= DK and MAYBBILL ^= RF) and (TOTALCHG ^= DK
and TOTALCHG ^= RF), then MAYBBILL <= TOTALCHG.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY ."
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:44:06 PM Monday, April 06, 2009
Page 266 of 368
BOX ST60
BOX ST60
Page Order # :
1040
BOX INSTRUCTIONS
( STQ2125 )
IF AMOUNT REMAINING = DK OR EMPTY, GO TO BOX ST63 - (STQ2135 ).
ELSE IF AMOUNT REMAINING < $1.00, GO TO BOX ST80 - (STQ2930 ).
ELSE GO TO ST61 - STTCHGPAID1 ( STQ2126 ).
ASSIGNMENTS
TECHNICAL NOTES
230
AmountRemaining
Amount Remaining =
COST.AREMAING.
DESIGN NOTES
1:44:06 PM Monday, April 06, 2009
Page 267 of 368
ST61
ST61
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
STTCHGPAID1
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
1050
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Always display "(S)" in interviewer instructions in parenthesis.
If SP was covered by TRICARE and any other insurance plan
besides Medicare during the current round, display "such as
TRICARE or an insurance plan".
Else if SP was covered by TRICARE and is not covered by any
other insurance plan besides Medicare during the current round,
display "such as TRICARE"
Else if SP was not covered by TRICARE and was covered by any
other insurance plan besides Medicare during the current round,
display "such as an insurance plan".
Else do not display.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
1:44:10 PM Monday, April 06, 2009
(ST CLAIM HEADER)
EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)
Page 268 of 368
ST61
Int. Instr I:
REVIEW CHARGE BUNDLE ON (TYPE OF STATEMENT) WITH
RESPONDENT IF YOU HAVEN'T ALREADY DONE SO. POINT
OUT PROVIDER NAME, DATE(S), AND TYPE OF SERVICE.
THEN ASK:
Question Text:
So, I have an amount remaining (AMOUNT REMAINING) that
Medicare didn't pay. [Have you/Has (SP)] or any other source,
[such as (TRICARE/an insurance plan/TRICARE or an insurance
plan)], paid any of this amount?
Int. Instr II:
INPUT FIELDS / ROUTING
Field1:
STTCHGPAID1
Cheshire Name:
( STQ2126 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TTchgPaid1
1
No
No
Number Label
1 SomeonePaid
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX ST64A - (STQ2700 )
2
English text: SP OR ANY SOURCE PAID
NothingPaid
BOX ST64A - (STQ2700 )
3
English text: NOTHING HAS BEEN PAID
AmountRemainingWrong
ST62 - CHANGAMT ( STQ2127 )
English text: AMOUNT REMAINING SEEMS WRONG
Attribute
Don't know
Route
BOX ST64A - (STQ2700 )
Refusal
BOX ST64A - (STQ2700 )
BACKGROUND VARIABLE ASSIGNMENTS
ARWRONG
1:44:18 PM Monday, April 06, 2009
If ST61 - STTCHGPAID1 =
3/AmountRemaingWrong, set COST.ARWRONG =
1/Yes.
Page 269 of 368
ST61
If ST61 - STTCHGPAID1 = 1/SomeonePaid, set
CORO.TCHGPAID = 1/Yes.
Else if ST61 - STTCHGPAID1 = 2/NothingPaid, set
CORO.TCHGPAID = 2/No.
Else if ST61 - STTCHGPAID1 = DK, set
CORO.TCHGPAID = DK.
Else if ST61 - STTCHGPAID1 = RF, set
CORO.TCHGPAID = RF.
TCHGPAID
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
52
DeletedPlans
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
258
TricarePlan
SP covered by TRICARE during the current round =
There is a PLAN where PLAN.PLANTYPE = 6/Tricare
& PLRO where (PLRO.PLROPLAN = PLAN.PLANNUM &
PLRO.PLRORND = current round & PLRO.COVTIME^=
empty).
Exclude Deleted Plans. See T.N. 52.
259
InsurancePlan
SP covered by Insurance plan other than Medicare
during current round =
PLAN where (PLANTYPE = 2/Medicaid, 3/PublicPlan, or
4/PrivatePlan) & PLRO where
(PLROPLAN=PLAN.PLANNUM & PLRORND=current
round & COVTIME^=empty).
Exclude Deleted Plans. See T.N. 52.
DESIGN NOTES
1:44:18 PM Monday, April 06, 2009
Page 270 of 368
ST62
ST62
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
CHANGAMT
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
1060
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)
Int. Instr I:
THESE AMOUNTS WERE ENTERED FROM THE MSN:
Question Text:
AMOUNT CHARGED: (TOTAL CHARGE AMOUNT)
NON-COVERED CHARGES: (NON COVERED CHARGES)
DEDUCTIBLE AND COINSURANCE: (COINSURANCE)
YOU MAY BE BILLED: (MAY BE BILLED)
Int. Instr II:
1:44:20 PM Monday, April 06, 2009
DO YOU WANT TO MAKE ANY CHANGES?
Page 271 of 368
ST62
INPUT FIELDS / ROUTING
Field1:
CHANGAMT
Cheshire Name:
( STQ2127 )
COST.CHANGAMT
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNo
FieldSize:
Min Value:
Max Value:
Mask:
1
No
No
Number Label
1 Yes
2
Route
ST63 - TOTALCHG ( STQ2128 )
English text: YES
No
BOX ST63 - (STQ2135 )
English text: NO
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
230
AmountRemaining
Amount Remaining =
COST.AREMAING.
DESIGN NOTES
1:44:24 PM Monday, April 06, 2009
Page 272 of 368
ST63
ST63
Page Order # :
Design Screen Type:
Numeric
Fields:
Field 1:
TOTALCHG
Field 2:
NONCOVRD
Field 3:
COINSUR
Field 4:
MAYBBILL
HELP
COMMENTS
JUMPBACK
No
No
No
Enable Functions:
1070
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Vertical Alignment
Display all fields at one time.
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)
Int. Instr I:
MAKE ALL THE NECESSARY CORRECTIONS TO THE AMOUNTS
THAT WERE ENTERED FROM THE (TYPE OF STATEMENT).
Question Text:
Int. Instr II:
1:44:29 PM Monday, April 06, 2009
Page 273 of 368
ST63
INPUT FIELDS / ROUTING
Field1:
TOTALCHG
Cheshire Name:
Item Text display:
( STQ2128 )
CORO.TOTALCHG
Display previously collected response. Allow field to be
updated.
Item Text:
Label:
Label Position:
AMOUNT CHARGED:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST63 - NONCOVRD ( STQ2129 )
Refusal
ST63 - NONCOVRD ( STQ2129 )
1:44:38 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
ST63 - NONCOVRD ( STQ2129 )
Page 274 of 368
ST63
NONCOVRD
Field2:
Cheshire Name:
Item Text display:
( STQ2129 )
COST.NONCOVRD
Display previously collected response. Allow field to be
updated.
Item Text:
Label:
Label Position:
NON-COVERED CHARGES:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST63 - COINSUR ( STQ2130 )
Refusal
ST63 - COINSUR ( STQ2130 )
1:44:47 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
ST63 - COINSUR ( STQ2130 )
Page 275 of 368
ST63
COINSUR
Field3:
Cheshire Name:
Item Text display:
( STQ2130 )
COST.COINSUR
Display previously collected response. Allow field to be
updated.
LABEL DISPLAY INSTRUCTIONS:
If ST6 - 5/MSNPartBOutpatient or 8/MSNPartAHospice ,
display "DEDUCTIBLE AND COINSURANCE:".
Else display "COINSURANCE:".
Item Text:
Label:
Label Position:
(DEDUCTIBLE AND COINSURANCE/COINSURANCE):
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
Route
ST63 - MAYBBILL ( STQ2131 )
Refusal
ST63 - MAYBBILL ( STQ2131 )
1:44:56 PM Monday, April 06, 2009
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
ST63 - MAYBBILL ( STQ2131 )
Page 276 of 368
ST63
MAYBBILL
Field4:
Cheshire Name:
Item Text display:
( STQ2131 )
COST.MAYBBILL
Display previously collected response. Allow field to be
updated.
Item Text:
Label:
Label Position:
YOU MAY BE BILLED:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TAmtnor
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Don't know
FieldSize:
Min Value:
Max Value:
Mask:
0
999999.99
Dollars
Route
BOX ST63 - (STQ2135 )
Route
BOX ST63 - (STQ2135 )
BACKGROUND VARIABLE ASSIGNMENTS
TOTALAMT
COST.TOTALAMT = ST63 - TOTALCHG.
AREMAING
COST.AREMAING = ST63 - MAYBBILL.
SOFT EDIT CHECKS
Edit #1
TOTALCHG = 4.99 - 20,000.00.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY ."
Edit #2
NONCOVRD = 0 - 20,000.00.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY ."
Edit #3
COINSUR = 0 - 20,000.00.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY ."
Edit #4
MAYBBILL = 0 - 20,000.00.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY ."
Edit #5
If (NONCOVRD ^= DK and NONCOVRD ^= RF) and (TOTALCHG
1:45:01 PM Monday, April 06, 2009
Page 277 of 368
ST63
^= DK and TOTALCHG ^= RF), then NONCOVRD <= TOTALCHG.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY ."
Edit #6
If (COINSUR ^= DK and COINSUR ^= RF) and (TOTALCHG ^= DK
and TOTALCHG ^= RF), then COINSUR <= TOTALCHG.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY ."
Edit #7
If (MAYBBILL ^= DK and MAYBBILL ^= RF) and (TOTALCHG ^= DK
and TOTALCHG ^= RF), then MAYBBILL <= TOTALCHG.
If not true, display message "UNLIKELY RESPONSE. PLEASE
VERIFY ."
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:45:01 PM Monday, April 06, 2009
Page 278 of 368
BOX ST63
BOX ST63
Page Order # :
1080
BOX INSTRUCTIONS
( STQ2135 )
IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY)
AND (AMOUNT REMAINING < $1.00), GO TO BOX ST80 - (STQ2930 ).
ELSE GO TO ST64 - STTCHGPAID2 ( STQ2695 ).
ASSIGNMENTS
TECHNICAL NOTES
230
AmountRemaining
Amount Remaining =
COST.AREMAING.
DESIGN NOTES
1:45:01 PM Monday, April 06, 2009
Page 279 of 368
ST64
ST64
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
STTCHGPAID2
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
1088
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
If ST5 - STATTYPE ^= 8/MPDPBenefit, display "AMOUNT
REMAINING: $(AMOUNT REMAINING)".
Else do not display.
If ST5 - MCARTYPE ^= 6/MsnPartAInpatient, display "[TOTAL
CHARGE = $(TOTAL CHARGE)]".
Else do not display.
Question display:
Interviewer Instructions:
Always display "(S)" in interviewer instructions in parenthesis.
If ST5 - STATTYPE ^= 8/MPDPBenefit, display "PROVIDER NAME".
Else do not display.
If ST5 - STATTYPE ^= 8/MPDPBenefit, display "THEN ASK:"
Else display "SELECT…".
Question Text:
If ST5 - STATTYPE = 8/MPDPBenefit, display "The total cost of
prescriptions…".
Else do not display.
If ST5 - STATTYPE = 8/MPDPBenefit, display "[Have you/Had
(SP)]".
Else then:
If SP was covered by TRICARE and any other insurance plan
besides Medicare during the current round, display "such as
TRICARE or an insurance plan".
Else if SP was covered by TRICARE and is not covered by any
1:45:04 PM Monday, April 06, 2009
Page 280 of 368
ST64
other insurance plan besides Medicare during the current round,
display "such as TRICARE"
Else if SP was not covered by TRICARE and was covered by any
other insurance plan besides Medicare during the current round,
display "such as an insurance plan".
Else do not display.
If only "DU" event types included in this charge bundle, display
"[Have you/Has (SP)]".
Else display "Besides Medicare [have you/has (SP)]".
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
[TOTAL CHARGE = $(TOTAL CHARGE)]
[AMOUNT REMAINING: $(AMOUNT REMAINING)]
Int. Instr I:
REVIEW CHARGE BUNDLE ON [TYPE OF STATEMENT] WITH
RESPONDENT IF YOU HAVEN'T ALREADY DONE SO. POINT
OUT (PROVIDER NAME), DATE(S), AND TYPE OF SERVICE(S).
(THEN ASK:/SELECT "SP OR ANY SOURCE PAID" IF ALREADY
KNOWN. OTHERWISE ASK:)
Question Text:
[The total cost of prescriptions reported on this statement is (TOTAL
CHARGE).] [[Have you/Has (SP)]/Besides Medicare, [have you/has
(SP)]] or any other source [, such as (an insurance
plan/TRICARE/TRICARE or an insurance plan),] paid anything for
this?
Int. Instr II:
INPUT FIELDS / ROUTING
1:45:07 PM Monday, April 06, 2009
Page 281 of 368
ST64
STTCHGPAID2
Field1:
Cheshire Name:
( STQ2695 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TTChgpaid2
FieldSize:
Min Value:
Max Value:
Mask:
1
No
No
Number Label
1 SomeonePaid
2
Route
BOX ST64A - (STQ2700 )
English text: SP OR ANY SOURCE PAID
NothingPaid
BOX ST64A - (STQ2700 )
English text: NOTHING HAS BEEN PAID
Attribute
Don't know
Route
BOX ST64A - (STQ2700 )
Refusal
BOX ST64A - (STQ2700 )
BACKGROUND VARIABLE ASSIGNMENTS
If ST64 - STTCHGPAID2 = 1/SomeonePaid, set
CORO.TCHGPAID = 1/Yes.
Else if ST64 - STTCHGPAID2 = 2/NothingPaid, set
CORO.TCHGPAID = 2/No.
Else if ST64 - STTCHGPAID2 = DK, set
CORO.TCHGPAID = DK.
Else if ST64 - STTCHGPAID2 = RF, set
CORO.TCHGPAID = RF.
TCHGPAID
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
52
DeletedPlans
1:45:15 PM Monday, April 06, 2009
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
Page 282 of 368
ST64
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
258
TricarePlan
SP covered by TRICARE during the current round =
There is a PLAN where PLAN.PLANTYPE = 6/Tricare
& PLRO where (PLRO.PLROPLAN = PLAN.PLANNUM &
PLRO.PLRORND = current round & PLRO.COVTIME^=
empty).
Exclude Deleted Plans. See T.N. 52.
259
InsurancePlan
SP covered by Insurance plan other than Medicare
during current round =
PLAN where (PLANTYPE = 2/Medicaid, 3/PublicPlan, or
4/PrivatePlan) & PLRO where
(PLROPLAN=PLAN.PLANNUM & PLRORND=current
round & COVTIME^=empty).
Exclude Deleted Plans. See T.N. 52.
DESIGN NOTES
1:45:15 PM Monday, April 06, 2009
Page 283 of 368
BOX ST64A
BOX ST64A
Page Order # :
1092
BOX INSTRUCTIONS
( STQ2700 )
IF SP OR ANY SOURCE HAS PAID, GO TO BOX ST64B - (STQ2701 ).
ELSE IF (NOTHING HAS BEEN PAID) OR (RESPONDENT DOES NOT
KNOW IF ANYTHING HAS BEEN PAID), GO TO BOX ST78B - (STQ2923 ).
ELSE GO TO BOX ST80 - (STQ2930 ).
ASSIGNMENTS
TECHNICAL NOTES
231
SPOrAnySourcePaid
SP or any source paid =
For this COST, there is a CORO where
(CORO.COROCOST=COST.COSTNUM &
CORO.CORORND=current round & CORO.TCHGPAID =
1/Yes).
232
NothingPaid
Nothing paid or Respondent does not know if anything
has been paid =
CORO.TCHGPAID = 2/No or DK on CORO where
(CORO.COROCOST = this COST.COSTNUM and
CORO.CORORND = current round).
DESIGN NOTES
1:45:15 PM Monday, April 06, 2009
Page 284 of 368
BOX ST64B
BOX ST64B
1:45:15 PM Monday, April 06, 2009
Page Order # :
1093
Page 285 of 368
BOX ST64B
BOX INSTRUCTIONS
( STQ2701 )
CREATE SOURCE OF PAYMENT ROSTER .
GO TO ST65 - STADDSOP1 ( STQ2702 ).
ASSIGNMENTS
TSOP table is loaded once for each new Charge Bundle being asked about in ST..
TSOP key = TSOP.TSOPBASE + TSOP.TSOPNUM.
Before proceeding, delete all TSOP records and load all eligible Sources of Payments:
1st Record:
Always store SP/FAMILY:
TSOP.TSOPTEXT = "SP/FAMILY"
TSOP.TSOPTYPE = 1/SPFamily
2nd Record:
Always store Provider discount:
TSOP.TSOPTEXT = "PROVIDER DISCOUNT/COURTESY"
TSOP.TSOPTYPE = 2/ProvDiscount
3rd Record:
Always store Medicare:
TSOP.TSOPTEXT = "MEDICARE".
TSOP.TSOPTYPE = 6/Medicare
TSOP.TSOPPLAN = '01'
TSOP.TSOPPTYP = 1/Medicare
TSOP.TSOPDISP = "(MCAR)".
Next, store all Medicare HMOs SP was covered by during the survey reference period (not
flagged as deleted).
If there is a PLAN with PLAN.PLANTYPE = 5/MHMO and a PLRO where PLRO.PLRORND
>= (current round -2), store MHMO plan:
TSOP.TSOPTEXT = PLAN.PLNAME
TSOP.TSOPTYPE = 8/MHMO
TSOP.TSOPPLAN = PLAN.PLANNUM of MHMO plan
TSOP.TSOPPTYP = PLAN.PLANTYPE of MHMO plan
TSOP.TSOPDISP = "(MHMO)".
Repeat for all MHMO plans.
Next, store VA if elibigle.
If (INTTYPE=8/ExitInterviewHadPrev and previous round HRND.VACOVER=1/Yes) or
(INTTYPE ^= 8/ExitInterviewHadPrev and current round HRND.VACOVER=1/Yes), store
VA:
TSOP.TSOPTEXT = "V.A. - DEPT. OF VETERANS AFFAIRS"
TSOP.TSOPTYPE = 5/VA.
Next, store MEDICARE SUBSIDY:
TSOP.TSOPTEXT = "MEDICARE SUBSIDY"
TSOP.TSOPTYPE = 11/MedicareSubsidy.
Next, store EXTRA HELP:
TSOP.TSOPTEXT = "EXTRA HELP"
TSOP.TSOPTYPE = 12/ExtraHelp.
1:45:15 PM Monday, April 06, 2009
Page 286 of 368
BOX ST64B
Next, store Medicaid, Public, Private, and Tricare plans SP was covered by during the
survey reference period (not flagged as deleted).
If there is a PLAN with (PLAN.PLANTYPE = 2/Medicaid, 3/PublicPlan, 4/PrivatePlan,
6/Tricare or 7/MPDP) and a PLRO where PLRO.PLRORND >= (current round -2), store
Plan:
TSOP.TSOPTEXT =
If PLAN.PLANTYPE = 2/Medicaid, TSOP.TSOPTEXT = 'MEDICAID/MEDICAID HMO';
Else if PLAN.PLANTYPE = 6/Tricare, TSOP.TSOPTEXT = "TRICARE".
Else TSOP.TSOPTEXT = PLAN.PLNAME;
If PLAN.PLANTYPE = 7/MPDP, set TSOP.TSOPTYPE = 10/MedicarePartD.
Else set TSOP.TSOPTYPE = 3/PlanNotMHMO
TSOP.TSOPPLAN = PLAN.PLANNUM of HI plan.
TSOP.TSOPPTYP = PLAN.PLANTYPE of HI plan.
TSOP.TSOPDISP =
If PLAN.PLANTYPE = 2/Medicaid, TSOP.TSOPDISP = "(MCAD)".
Else if PLAN.PLANTYPE = 3/PublicPlan, TSOP.TSOPDISP = "(PUBL)".
Else if PLAN.PLANTYPE = 4/PrivatePlan, TSOP.TSOPDISP = "(PRIV)".
Else if PLAN.PLANTYPE = 6/Tricare, TSOP.TSOPDISP = "(TRIC)".
Else if PLAN.PLANTYPE = 7/MPDP, TSOP.TSOPDISP = "(MPDP)".
Repeat for all Medicaid, Public, Private, Tricare and Medicare Prescription Drug plans.
Next, store Discount Membership Plans SP was covered by during the current round:
If there is a DMEM and a DMRO where DMRO.DMRORND = current round, store Discount
Membership plan:
TSOP.TSOPTEXT = DMEM.DMNAMEX
TSOP.TSOPTYPE = 9/DM
TSOP.TSOPDMEM = DMEM.DMEMNUM
Repeat for all DMEMs.
Next, store all Other Sources of Payments (not flagged as deleted).
Store OSOP:
TSOP.TSOPTEXT = OSOP.OSOPTEXT
TSOP.TSOPTYPE = 4/OSOP
TSOP.TSOPOSOP = OSOP.OSOPNUM
TSOP.TSOPDISP = "(OTHER)".
Repeat for all OSOPs.
TSOPNUM
Beginning with 01, create TSOP where
TSOP.TSOPNUM = highest TSOP.TSOPNUM + 01.
TSOPTEXT
Set TSOP.TSOPTEXT as specified above.
TSOPTYPE
Set TSOP.TSOPTYPE as specified above.
LOADFLAG
Set TSOP.LOADFLAG = 1/Yes.
TSOPPTYP
If SOP is a Health Insurance plan, set
TSOP.TSOPPYPE = PLAN.PLANTYPE.
TSOPPLAN
If SOP is a Health Insurance plan, set
TSOP.TSOPPLAN = PLAN.PLANNUM.
TSOPOSOP
If SOP is an Other Source of Payment, set
TSOP.TSOPOSOP = OSOP.OSOPNUM.
TSOPDISP
Set TSOP.TSOPDISP as specified above.
TSOPDMEM
If SOP is a Discount Membership plan, set
TSOP.TSOPDMEM = DMEM.DMEMNUM.
TECHNICAL NOTES
52
DeletedPlans
1:45:15 PM Monday, April 06, 2009
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
Page 287 of 368
BOX ST64B
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
53
PlanTypes
Medicare: PLANTYPE=1/Medicare.
Medicaid: PLANTYPE=2/Medicaid.
Medicare Managed Care: PLANTYPE=5/MHMO.
Tricare: PLANTYPE=6/Tricare.
Public: PLANTYPE=3/PublicPlan.
Private: PLANTYPE=4/PrivatePlan.
Medicare Prescription Drug: PLANTYPE=7/MPDP.
252
DeletedOSOPs
Deleted OSOPs that are not valid for displays or checks =
Any OSOP where (OSOP.OSOPHIDE=1/Yes or
OSOP.LOSEOSFG ^=EMPTY) is a deleted OSOP.
117
DeletedDM
Deleted Discount Membership plans that are not valid for
displays or checks =
Any DMEM where (DMEM.LOSEDMFG ^= EMPTY) is a
deleted DM.
38
DMCurrentRnd
SP reported having a Discount Membership plan anytime
during the current round =
There is a DMEM and DMRO where
(DMRO.DMRODMEM = DMEM.DMEMNUM and
DMRO.DMRORND = current round and DMRO.DMHAVE
= 1/Yes).
Exclude Deleted DM's. See T.N. 117.
DESIGN NOTES
1:45:15 PM Monday, April 06, 2009
Page 288 of 368
ST65
ST65
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
STADDSOP1
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
1095
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
If ST5 - STATTYPE ^= 8/MPDPBenefit, display "AMONT
REMAINING: $(AMOUNT REMAINING)".
Else do not display.
If ST5 - MCARTYPE ^= 6/MsnPartAInpatient, display "[TOTAL
CHARGE = $(TOTAL CHARGE)]".
Else do not display.
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
Display report above question text.
Display all eligible Source of Payments stored on TSOP based on
the following logic:
If ST5 - STATTYPE = 8/MedcarePartD, THEN:
Do not display TSOP.TSOPTYPE = 2/ProvDisount and 6/Medicare.
Display all remaining Sources of Payments in the following order
based on TSOP.TSOPTYPE:
= 1/SPFamily
= 11/MedicareSubsidy
= 12/ExtraHelp
= 8/MHMO
1:45:17 PM Monday, April 06, 2009
Page 289 of 368
ST65
= 10/MedicarePartD
= 5/VA
= 3/PlanNotMHMO
= 4/OSOP
= 9/DM
ELSE THEN:
Do not display TSOP.TSOPTYPE = 11/MedicareSubsidy,
12/ExtraHelp and 6/Medicare.
Display all remaining Sources of Payments in the following order
based on TSOP.TSOPTYPE:
= 1/SPFamily
= 2/ProvDiscount
= 8/MHMO
= 10/MedicarePartD
= 5/VA
= 3/PlanNotMHMO
= 4/OSOP
= 9/DM
If there is more than Source of Payment per Source of Payment
Type, display in order of entry in TSOP.
Report header: SOURCES OF PAYMENT
Report layout:
Column 1, header="SOP NAME".
Column 1, display = TSOP.TSOPTEXT.
Column 2, header = "SOP TYPE".
Column 2, display =
If TSOP.TSOPDISP ^= empty, display TSOP.TSOPDISP.
Else do not display.
TEXT:
Context Header:
(ST CLAIM HEADER)
TOTAL CHARGE = $(TOTAL CHARGE)
[AMOUNT REMAINING: $(AMOUNT REMAINING)]
Int. Instr I:
ARE ALL OF THE SOURCES OF PAYMENT FOR THIS CHARGE
BUNDLE LISTED BELOW?
Question Text:
Int. Instr II:
SELECT "NO" TO ADD A SOURCE OF PAYMENT.
INPUT FIELDS / ROUTING
1:45:19 PM Monday, April 06, 2009
Page 290 of 368
ST65
STADDSOP1
Field1:
Cheshire Name:
( STQ2702 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNo
1
No
No
Number Label
1 Yes
2
English text: YES
No
FieldSize:
Min Value:
Max Value:
Mask:
Route
ST67 - TSOPAMT ( STQ2720 )
ST66 - SOP_ST1 ( STQ2703 )
English text: NO
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
ST65 is called from CPS when adding SOPs. TSOP will already be loaded
in CPS section.
1:45:23 PM Monday, April 06, 2009
Page 291 of 368
ST66
ST66
Page Order # :
Design Screen Type:
Roster
Fields:
Field 1:
SOP_ST1
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Name:
Source Of Payment Roster
Roster Type:
Multiple Item Select
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
Yes
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
1100
Display as ' Add Source of Payment '
DISPLAY INSTRUCTIONS:
Context header display:
If ST5 - STATTYPE ^= 8/MPDPBenefit, display "AMOUNT
REMAINING: $(AMOUNT REMAINING)".
Else do not display.
Question display:
Multi Field display:
Roster/Grid Instructions:
Display all eligible Source of Payments stored on TSOP based on
the following logic:
If ST5 - STATTYPE = 8/MedcarePartD, THEN:
Do not display TSOP.TSOPTYPE = 2/ProvDisount and 6/Medicare.
Display all remaining Sources of Payments in the following order
based on TSOP.TSOPTYPE:
= 1/SPFamily
= 11/MedicareSubsidy
= 12/ExtraHelp
= 8/MHMO
= 10/MedicarePartD
= 5/VA
= 3/PlanNotMHMO
= 4/OSOP
= 9/DM
ELSE THEN:
Do not display TSOP.TSOPTYPE = 11/MedicareSubsidy,
12/ExtraHelp and 6/Medicare.
Display all remaining Sources of Payments in the following order
1:45:24 PM Monday, April 06, 2009
Page 292 of 368
ST66
based on TSOP.TSOPTYPE:
= 1/SPFamily
= 2/ProvDiscount
= 8/MHMO
= 10/MedicarePartD
= 5/VA
= 3/PlanNotMHMO
= 4/OSOP
= 9/DM
If there is more than Source of Payment per Source of Payment
Type, display in order of entry in TSOP.
Display all loaded Source of Payments as protected rows.
Roster/Grid display:
COL #
HEADER
INSTRUCTIONS
1
SOP Name
Display TSOP.TSOPTEXT.
2
SOP Type
If TSOP.TSOPDISP ^= empty, display
TSOP.TSOPDISP.
Else do not display.
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
TOTAL CHARGE = $(TOTAL CHARGE)
[AMOUNT REMAINING: $(AMOUNT REMAINING)]
Int. Instr I:
ADD ALL ADDITIONAL SOURCES OF PAYMENT FOR THIS
CHARGE BUNDLE.
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING
1:45:27 PM Monday, April 06, 2009
Page 293 of 368
ST66
( STQ2703 )
SOP_ST1
Field1:
Cheshire Name:
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TSOPPick
FieldSize:
Min Value:
Max Value:
Mask:
1
No
No
Number Label
1 [Continuous answer.]
135
Route
ST67 - TSOPAMT ( STQ2720 )
BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on TSOP:
TSOP key = TSOP.TSOPBASE + TSOP.TSOPNUM.
TSOP.TSOPNUM = Number of Source of Payment selected at ST66.
If adding SOP, see SOURCE OF PAYMENT ROSTER POP-UP specifications for pop-up
window programming instructions.
Fields collected in Pop-Up window:
TSOP.TSOPNUM
TSOP.TSOPTEXT
TSOP.TSOPISHI
SOFT EDIT CHECKS
HARD EDIT CHECKS
Edit #1
If MEDICAID is already on the Source of Payment roster, ST66 -
TSOPISHI should ^= 1/Medicaid.
If not true, display "An add has failed. It was a duplicate."
Edit #2
If TRICARE is already on the Source of Payment roster, ST66 -
TSOPISHI should ^= 9/Tricare.
If not true, display "An add has failed. It was a duplicate."
TECHNICAL NOTES
263
MedicaidSOP
1:45:29 PM Monday, April 06, 2009
Medicaid already on SOP roster =
There is a TSOP where TSOP.TSOPPTYP=2/Medicaid.
Page 294 of 368
ST66
264
TricareSOP
Tricare already on SOP roster =
There is a TSOP where TSOP.TSOPPTYP = 6/Tricare.
DESIGN NOTES
1:45:29 PM Monday, April 06, 2009
Page 295 of 368
ST67
ST67
Page Order # :
Design Screen Type:
Grid
Fields:
Field 1:
TSOPAMT
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
1110
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
If ST5 - STATTYPE ^= 8/MPDPBenefit, display "AMOUNT
REMAINING: $(AMOUNT REMAINING)".
Else do not display.
Question display:
Interviewer Instruction display:
If currently administering CPS section, do not display Interviewer
Instructions I.
Else then
If ST5 - STATTYPE = 3/MedicareAndInsurance, display "REFER
TO INSURANCE STATEMENT."
Else if ST5 = 5/MedicareAndTricare, display "REFER TO
TRICARE STATEMENT."
Else if ST5 = 6/TricareAndInsurance or
7/MedicareAndTricareAndInsurance, display "REFER TO
INSURANCE AND TRICARE STATEMENTS."
Else if ST5 = 8/MPDPBenefit, display "REFER TO MEDICARE
PRESCRIPTION DRUG BENEFIT STATEMENT"
Else do not display.
Always display "(else)" and "(SOURCE)" in parenthesis.
Multi Field display:
Roster/Grid Instructions:
Display all eligible Source of Payments stored on TSOP based on
the following logic:
If ST5 - STATTYPE = 8/MedcarePartD, THEN:
Do not display TSOP.TSOPTYPE = 2/ProvDisount and 6/Medicare.
1:45:32 PM Monday, April 06, 2009
Page 296 of 368
ST67
Display all remaining Sources of Payments in the following order
based on TSOP.TSOPTYPE:
= 1/SPFamily
= 11/MedicareSubsidy
= 12/ExtraHelp
= 8/MHMO
= 10/MedicarePartD
= 5/VA
= 3/PlanNotMHMO
= 4/OSOP
= 9/DM
ELSE THEN:
Do not display TSOP.TSOPTYPE = 11/MedicareSubsidy,
12/ExtraHelp and 6/Medicare.
Display all remaining Sources of Payments in the following order
based on TSOP.TSOPTYPE:
= 1/SPFamily
= 2/ProvDiscount
= 8/MHMO
= 10/MedicarePartD
= 5/VA
= 3/PlanNotMHMO
= 4/OSOP
= 9/DM
If there is more than Source of Payment per Source of Payment
Type, display in order of entry in TSOP.
CALCULATION INSTRUCTIONS FOR COLUMN 4:
If ST5 - STATTYPE = 8/MedcarePartD, THEN display
COST.TOTALCHG.
Else display COST.AREMAING.
If TSOPAMT added, deleted, or updated, in any row at ST67,
calculate and display (AMOUNT REMAINING MINUS TOTAL
PAYMENTS) in Column 4.
AMOUNT REMAINING MINUS TOTAL PAYMENTS:
If at least one row at ST67 has TSOPAMT = DK or RF, display "NOT
KNOWN".
Else if ST5 - STATTYPE = 8/MedcarePartD, THEN display
(COST.TOTALCHG - TOTAL PAYMENTS).
Else display (COST.AREMAING - TOTAL PAYMENTS).
TOTAL PAYMENTS:
For each row at ST67 where (TSOPAMT ^= EMPTY and TSOPAMT
^= DK and TSOPAMT ^= RF), calculate TOTAL PAYMENTS =
TOTAL PAYMENTS + TSOPAMT.
Note: Calculation is for ST67 display only. Do not update
COST.AREMAING.
Roster/Grid display:
1:45:34 PM Monday, April 06, 2009
COL #
HEADER
INSTRUCTIONS
1
SOP Name
Display TSOP.TSOPTEXT. Display Only.
2
SOP Type
If TSOP.TSOPDISP ^= empty, display
TSOP.TSOPDISP.
Else do not display.
Display only.
Page 297 of 368
ST67
3
SOP Payment
TSOP.TSOPAMT. Input field 1.
4
Amount
Remaining
DISPLAY CALCULATION AS
SPECIFIED ABOVE.
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
TOTAL CHARGE = $(TOTAL CHARGE)
[AMOUNT REMAINING: $(AMOUNT REMAINING)]
Int. Instr I:
(REFER TO INSURANCE STATEMENT/REFER TO TRICARE
STATEMENT/REFER TO INSURANCE AND TRICARE
STATEMENTS/REFER TO MEDICARE PRESCRIPTION DRUG
BENEFIT STATEMENT).
Question Text:
Who (else) paid besides Medicare? How much did (SOURCE) pay?
Int. Instr II:
ENTER ALL PAYMENT AMOUNTS. CORRECT PAYMENT
AMOUNTS AS NECESSARY.
INPUT FIELDS / ROUTING
1:45:38 PM Monday, April 06, 2009
Page 298 of 368
ST67
TSOPAMT
Field1:
Cheshire Name:
( STQ2720 )
TSOP.TSOPAMT
SQL tblTSOP is not transformed to TSOP in Cheshire.
Item Text display:
GRID COLUMN #3
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TTsopamt
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Empty
Route
BOX ST67A - (STQ2780 )
Don't know
BOX ST67A - (STQ2780 )
Refusal
BOX ST67A - (STQ2780 )
FieldSize:
Min Value:
Max Value:
Mask:
0.01
999999.99
Dollars
Route
BOX ST67A - (STQ2780 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
TSOPAMT = 0.50 - 999,999.99, DK or RF.
If not true, display message: "UNLIKELY RESPONSE. PLEASE
VERIFY."
HARD EDIT CHECKS
At least one TSOPAMT = DK or RF or the sum of all TSOPAMT
values for this cost > 0.00.
If not true, display message "THE SUM OF ALL PAYMENT
AMOUNTS MUST BE GREATER THAN $0.00 OR AT LEAST ONE
PAYMENT AMOUNT MUST BE 'DON'T KNOW' OR 'REFUSED'."
TECHNICAL NOTES
DESIGN NOTES
1:45:42 PM Monday, April 06, 2009
Page 299 of 368
BOX ST67A
BOX ST67A
Page Order # :
1120
BOX INSTRUCTIONS
( STQ2780 )
IF AT LEAST ONE SOURCE OF PAYMENT WAS ADDED AT ST66, GO TO
BOX ST67B - (STQ2810 ).
ELSE GO TO BOX ST69F - (STQ2842 ).
ASSIGNMENTS
TECHNICAL NOTES
DESIGN NOTES
1:45:42 PM Monday, April 06, 2009
Page 300 of 368
BOX ST67B
BOX ST67B
Page Order # :
1125
BOX INSTRUCTIONS
( STQ2810 )
IF AT LEAST ONE SOURCE OF PAYMENT ADDED AT ST66 IS A HEALTH
INSURANCE PLAN, GO TO ST67BINT - PLANINTRO ( STQ2814 ).
ELSE GO TO BOX ST69B - (STQ2827 ).
ASSIGNMENTS
TECHNICAL NOTES
248
SOPPlan
Source of Payment is a HI Plan =
Medicaid: TSOP.TSOPISHI=1/Medicaid
Public: TSOP.TSOPISHI=2/PublicPlan
Private: TSOP.TSOPISHI=3/PrivatePlan
MHMO: TSOP.TSOPISHI=7/MHMO
Tricare: TSOP.TSOPISHI=9/Tricare.
MPDP: TSOP.TSOPISHI=10/MedicarePartD
DESIGN NOTES
1:45:42 PM Monday, April 06, 2009
Page 301 of 368
ST67BINT
ST67BINT
Page Order # :
Design Screen Type:
No Entry
Fields:
Field 1:
PLANINTRO
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
1127
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Always display "(s)" in parenthesis.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
Before we continue, I would like to ask you a few questions about
the health insurance plan(s) you just added.
Int. Instr II:
INPUT FIELDS / ROUTING
1:45:45 PM Monday, April 06, 2009
Page 302 of 368
ST67BINT
PLANINTRO
Field1:
Cheshire Name:
( STQ2814 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TContinueEMPTY
1
No
No
Number Label
1 Continue
FieldSize:
Min Value:
Max Value:
Mask:
Route
ST67B_IN - NAVIGATOR ( STQ2815 )
English text: CONTINUE
Attribute
Empty
Route
ST67B_IN - NAVIGATOR ( STQ2815 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:45:49 PM Monday, April 06, 2009
Page 303 of 368
ST67B_IN
ST67B_IN
Page Order # :
Design Screen Type:
Instance Navigator
Fields:
Field 1:
NAVIGATOR
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
1129
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Display all HI SOPs added at ST66.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING
1:45:52 PM Monday, April 06, 2009
Page 304 of 368
ST67B_IN
NAVIGATOR
Field1:
Cheshire Name:
( STQ2815 )
N/A
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TInstanceNavigator
1
No
No
Number Label
1 SelectItemInList
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX ST67C - (STQ2820 )
English text: ITEM SELECTED IN INSTANCE NAVIGATOR
SelectContinueInterview
BOX ST69B - (STQ2827 )
English text: CONTINUE INTERVIEW SELECTED
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
248
SOPPlan
Source of Payment is a HI Plan =
Medicaid: TSOP.TSOPISHI=1/Medicaid
Public: TSOP.TSOPISHI=2/PublicPlan
Private: TSOP.TSOPISHI=3/PrivatePlan
MHMO: TSOP.TSOPISHI=7/MHMO
Tricare: TSOP.TSOPISHI=9/Tricare.
MPDP: TSOP.TSOPISHI=10/MedicarePartD
DESIGN NOTES
1:45:55 PM Monday, April 06, 2009
Page 305 of 368
BOX ST67C
BOX ST67C
1:45:55 PM Monday, April 06, 2009
Page Order # :
1131
Page 306 of 368
BOX ST67C
BOX INSTRUCTIONS
( STQ2820 )
CREATE A NEW HEALTH INSURANCE PLAN FOR FIRST/NEXT SOURCE
OF PAYMENT ADDED AT ST66 .
IF SOURCE OF PAYMENT IS A MEDICARE MANAGED CARE PLAN AND
SP HAS A MEDICARE MANAGED CARE PLAN THAT IS CURRENT, GO TO
ST68 - STMHMOCHNG1 ( STQ2821 ).
ELSE IF SOURCE OF PAYMENT IS A MEDICARE MANAGED CARE PLAN
AND SP DOES NOT HAVE A MEDICARE MANAGED CARE PLAN THAT IS
CURRENT, GO TO ST69 - STSOPCURR1 ( STQ2822 ).
ELSE IF SOURCE OF PAYMENT IS A MEDICARE PRESCRIPTION DRUG
PLAN AND SP HAS A MEDICARE PRESCRIPTION DRUG PLAN THAT IS
CURRENT, GO TO ST69A - STMPDPCHNG ( STQ2823 ).
ELSE IF SOURCE OF PAYMENT IS MEDICARE PRESCRIPTION DRUG
PLAN AND SP DOES NOT HAVE A MEDICARE PRESCRIPTION DRUG
PLAN THAT IS CURRENT, GO TO ST69B - STSOPCURR2 ( STQ2824 ).
ELSE IF SOURCE OF PAYMENT IS MEDICAID, GO TO HI6 - COVTIME (
HIQ4770 ).
ELSE IF SOURCE OF PAYMENT IS A PUBLIC PLAN, GO TO HI13 COVTIME ( HIQ5780 ).
ELSE IF SOURCE OF PAYMENT IS A PRIVATE PLAN, GO TO HI21 COVTIME ( HIQ6230 ).
ELSE GO TO HIT2 - COVTIME ( HIQ5330 ).
ASSIGNMENTS
If SOP added is an MHMO, Public plan, Private plan, or Medicare Prescription Drug plan
create a new PLAN and current round PLRO record. See detailed instructions below.
If SOP added is Medicaid then:
If there is a PLAN where PLAN.PLANTYPE=2/Medicaid, regardless if
PLAN.PLANDFLG=1/Yes or LOSEPLFG ^= empty, this stopped Medicaid plan will be
restarted. Update existing PLAN flags = empty and create a current round PLRO record.
See detailed instructions below.
Else if there is no PLAN where PLAN.PLANTYPE=2/Medicaid, ccreate a new PLAN and
current round PLRO record. Set PLAN.PLNAME = MEDICAID. See detailed instructions
below.
If SOP added is Tricare then:
If there is a PLAN where PLAN.PLANTYPE=6/Tricare, regardless if
PLAN.PLANDFLG=1/Yes or LOSEPLFG ^= empty, this stopped Tricare plan will be
restarted. Update existing PLAN flags = empty and create a current round PLRO record.
See detailed instructions below.
Else if there is no PLAN where PLAN.PLANTYPE=6/Tricare, create a new PLAN and
current round PLRO record. Set PLAN.PLNAME = TRICARE. See detailed instructions
below.
PLAN KEY = PLAN.PLANBASE + PLAN.PLANNUM
1:45:56 PM Monday, April 06, 2009
Page 307 of 368
BOX ST67C
PLRO KEY = PLRO.PLROBASE + PLRO.PLROPLAN + PLRO.PLRORND
Set PLAN/PLRO fields as instructed below:
PLANNUM
If creating a new PLAN, create PLAN where
PLAN.PLANNUM = highest PLAN.PLANNUM + 01.
PLANRNDC
If creating a new PLAN, set PLAN.PLANRNDC =
current round.
PLANTYPE
Set PLANTYPE based on TSOPISHI:
=1/Medicaid, PLANTYPE=2/Medicaid.
=2/PublicPlan, PLANTYPE=3/PublicPlan.
=3/PrivatePlan, PLANTYPE=4/PrivatePlan.
=7/MHMO, PLANTYPE=5/MHMO.
=9/Tricare, PLANTYPE=6/Tricare.
=10/MedicarePartD, PLANTYPE=7/MPDP.
PLNAME
If creating a new PLAN,
If SOP is Medicaid, set PLAN.PLNAME =
"MEDICAID".
Else if SOP is Tricare, set PLAN.PLNAME =
"TRICARE".
Else set PLAN.PLNAME = TSOP.TSOPTEXT.
PLROPLAN
Create PLRO where PLRO.PLROPLAN = new
PLAN.PLANNUM.
PLRORND
PLRO.PLRORND = current round.
COVANYTM
If TSOP.TSOPISHI = 7/MHMO or 10/MedicarePartD,
set PLRO.COVANYTM = 1/Yes.
TSOPTYPE
If TSOP.TSOPISHI = 1/Medicaid, 2/PublicPlan,
3/PrivatePlan, 9/Tricare, set TSOP.TSOPTYPE =
3/PlanNotMHMO.
Else if TSOP.TSOPISHI = 7/MHMO, set
TSOP.TSOPTYPE = 8/MHMO.
Else if TSOP.TSOPISHI=10/MedicarePartD, set
TSOP.TSOPTYPE =10/MedicarePartD.
TSOPPTYP
Set TSOP.TSOPPTYP = PLAN.PLANTYPE.
TSOPPLAN
Set TSOP.TSOPPLAN = PLAN.PLANNUM.
TSOPDISP
Set TSOP.TSOPDISP based on PLAN.PLANTYPE:
= 2/Medicaid, TSOPDISP = "(MCAD)".
= 3/PublicPlan, TSOPDISP = "(PUBL)".
= 4/PrivatePlan, TSOPDISP = "(PRIV)".
= 5/MHMO, TSOPDISP = “(MHMO)”.
= 6/Tricare, TSOPDISP = "(TRIC)".
=7/MPDP, TSOPDISP = "(MPDP)".
PLANDFLG
If restarting Medicaid or Tricare plan, set
PLAN.PLANDFLG = empty.
LOSEPLFG
If restarting Medicaid or Tricare plan, set
PLAN.LOSEPLFG = empty.
PLSOPFLG
If creating new PLAN, set PLAN.PLSOPFLG = 1/Yes.
TECHNICAL NOTES
248
SOPPlan
1:45:56 PM Monday, April 06, 2009
Source of Payment is a HI Plan =
Medicaid: TSOP.TSOPISHI=1/Medicaid
Public: TSOP.TSOPISHI=2/PublicPlan
Private: TSOP.TSOPISHI=3/PrivatePlan
MHMO: TSOP.TSOPISHI=7/MHMO
Page 308 of 368
BOX ST67C
Tricare: TSOP.TSOPISHI=9/Tricare.
MPDP: TSOP.TSOPISHI=10/MedicarePartD
52
DeletedPlans
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
65
MHMOCurrent
SP has a current Medicare Managed Care plan =
There is a PLAN where PLAN.PLANTYPE=5/MHMO &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.COVCURNT=1/Yes).
Exclude Deleted Plans. See T.N. 52.
342
MPDPCurrent
SP has a "current" Medicare Prescription Drug plan =
There is a PLAN where PLAN.PLANTYPE=7/MPDP &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.COVCURNT=1/Yes).
Exclude Deleted Plans. See T.N. 52.
DESIGN NOTES
BOX ST67C calls HI section for Medicaid, Tricare, Public Plans, and
Private Plans added to SOP roster.
ST68 and ST69 collects status of MHMO plan added to SOP roster.
ST69 calls HI section for MHMO plan if "current".
HI returns to ST at BOX ST69A.
ST69A and ST69B collect the status of MPDP plan added to SOP roster.
ST does not call HI section for MPDP plan details.
1:45:56 PM Monday, April 06, 2009
Page 309 of 368
ST68
ST68
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
STMHMOCHNG1
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
1135
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
ST68 is asked when a MHMO is added at the SOP roster and there
is already a current MHMO reported in the current round. The
purpose of ST68 is to remind the respondent of the current MHMO
already reported and determine if the plan status has changed.
Display name of current Medicare Managed Care Plan,
PLAN.PLNAME.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
I recorded previously that (CURRENT MEDICARE MANAGED
CARE PLAN NAME) was [your/(SP's)] current Medicare Managed
Care Plan. Has this information changed?
Int. Instr II:
1:45:59 PM Monday, April 06, 2009
Page 310 of 368
ST68
INPUT FIELDS / ROUTING
Field1:
STMHMOCHNG1
Cheshire Name:
( STQ2821 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
ST69 - STSOPCURR1 ( STQ2822 )
English text: YES
No
BOX ST69A - (STQ2825 )
English text: NO
Attribute
Don't know
Route
BOX ST69A - (STQ2825 )
Refusal
BOX ST69A - (STQ2825 )
BACKGROUND VARIABLE ASSIGNMENTS
COVCURNT
If ST68 - STMHMOCHNG1 = 2/No, DK, RF, set
current round PLRO.COVCURNT = 2/No on MHMO
PLAN added to SOP roster.
SOFT EDIT CHECKS
Edit #1:
ST68 - STMHMOCHNG1 = 1/Yes.
If not true, display message "INFORMATION FOR THIS PLAN WILL
NOT BE COLLECTED NOW."
HARD EDIT CHECKS
TECHNICAL NOTES
52
DeletedPlans
1:46:06 PM Monday, April 06, 2009
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
Page 311 of 368
ST68
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
65
MHMOCurrent
SP has a current Medicare Managed Care plan =
There is a PLAN where PLAN.PLANTYPE=5/MHMO &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.COVCURNT=1/Yes).
Exclude Deleted Plans. See T.N. 52.
DESIGN NOTES
1:46:06 PM Monday, April 06, 2009
Page 312 of 368
ST69
ST69
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
STSOPCURR1
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
1137
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
If SP is alive and not institutionalized, display "currently".
Else do not display.
Display name of Medicare Managed Care Plan Name,
PLAN.PLNAME, added at ST66 Source of Payment Roster.
If SP is deceased or institutionalized, display "on (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)".
Else do not display.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
1:46:10 PM Monday, April 06, 2009
[Are you/Is (SP)/Was (SP)] (currently) covered or enrolled in (ST66
SOP MEDICARE MANAGED CARE PLAN NAME) [on (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)]?
Page 313 of 368
ST69
Int. Instr II:
INPUT FIELDS / ROUTING
Field1:
STSOPCURR1
Cheshire Name:
( STQ2822 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
HIMC6 - MHMORX ( HIQ4020 )
VERIFY IN HI.
English text: YES
No
BOX ST69A - (STQ2825 )
English text: NO
Attribute
Don't know
Route
BOX ST69A - (STQ2825 )
Refusal
BOX ST69A - (STQ2825 )
BACKGROUND VARIABLE ASSIGNMENTS
COVCURNT
Set PLRO.COVCURNT on PLRO where
PLRO.PLROPLAN = PLAN.PLANNUM of MHMO
added at SOP roster and PLRO.PLRORND =
current round:
If ST69 - STSOPCURR1 = 1/Yes, set
PLRO.COVCURNT = 1/Yes.
Else set PLRO.COVCURNT = 2/No.
COVCURNT
If ST68 - STMHMOCHNG1 = 1/Yes and ST69 STSOPCURR1 = 1/Yes, update
PLRO.PLROCOVURNT = 2/No on PLRO where
PLRO.PLROPLAN = PLAN.PLANNUM of preexisting current MHMO and PLRO.PLRORNDC =
current round.
1:46:17 PM Monday, April 06, 2009
Page 314 of 368
ST69
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
59
SPStatus
SP is Alive and not institutionalized =
MRES.SPALIVE=1/Alive or empty
SP is Alive =
MRES.SPALIVE=1/Alive, 2/AliveAndInstitute, or EMPTY
SP is Institutionalized =
MRES.SPALIVE=2/AliveAndInstitute
SP is Deceased =
MRES.SPALIVE=3/Deceased.
DESIGN NOTES
ST69 calls HI section for MHMOs if MHMO added is current.
HI returns to ST at BOX ST69A.
1:46:17 PM Monday, April 06, 2009
Page 315 of 368
ST69A
ST69A
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
STMPDPCHNG
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
1153
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
ST69A is asked when a MPDP is added at the SOP roster and
there is already a current MPDP reported in the current round. The
purpose of ST69A is to remind the respondent of the current MPDP
already reported and determine if the plan status has changed.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
I recorded previously that (CURRENT MEDICARE PRESCRIPTION
DRUG PLAN) was [your/(SP's)] current Medicare Prescription Drug
Care Plan.
Has this information changed?
Int. Instr II:
1:46:20 PM Monday, April 06, 2009
Page 316 of 368
ST69A
INPUT FIELDS / ROUTING
Field1:
STMPDPCHNG
Cheshire Name:
( STQ2823 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
ST69B - STSOPCURR2 ( STQ2824 )
English text: YES
No
BOX ST69A - (STQ2825 )
English text: NO
Attribute
Don't know
Route
BOX ST69A - (STQ2825 )
Refusal
BOX ST69A - (STQ2825 )
BACKGROUND VARIABLE ASSIGNMENTS
COVCURNT
If ST69A - STMDPDCHNG = 2/No, DK, RF, set
current round PLRO.COVCURNT = 2/No for MPDP
PLAN added to SOP roster.
SOFT EDIT CHECKS
Edit #1:
ST69A - STMPDPCHNG = 1/Yes.
If not true, display message "INFORMATION FOR THIS PLAN WILL
NOT BE COLLECTED NOW."
HARD EDIT CHECKS
TECHNICAL NOTES
52
DeletedPlans
1:46:27 PM Monday, April 06, 2009
Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
Page 317 of 368
ST69A
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
342
MPDPCurrent
SP has a "current" Medicare Prescription Drug plan =
There is a PLAN where PLAN.PLANTYPE=7/MPDP &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.COVCURNT=1/Yes).
Exclude Deleted Plans. See T.N. 52.
DESIGN NOTES
1:46:27 PM Monday, April 06, 2009
Page 318 of 368
ST69B
ST69B
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
STSOPCURR2
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
1154
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
If SP is alive and not institutionalized, display "currently".
Else do not display.
Display name of Medicare Prescription Drug Plan, PLAN.PLNAME,
added at ST66 Source of Payment Roster.
If SP is deceased or institutionalized, display "on (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)".
Else do not display.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
1:46:31 PM Monday, April 06, 2009
[Are you/Is (SP)/Was (SP)] (currently) covered or enrolled in (ST66
SOP MEDICARE PRESCRIPTION DRUG PLAN) [on (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)]?
Page 319 of 368
ST69B
Int. Instr II:
INPUT FIELDS / ROUTING
Field1:
STSOPCURR2
Cheshire Name:
( STQ2824 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX ST69A - (STQ2825 )
English text: YES
No
BOX ST69A - (STQ2825 )
English text: NO
Attribute
Don't know
Route
BOX ST69A - (STQ2825 )
Refusal
BOX ST69A - (STQ2825 )
BACKGROUND VARIABLE ASSIGNMENTS
COVCURNT
Set PLRO.COVCURNT on PLRO where
PLRO.PLROPLAN = PLAN.PLANNUM of MPDP
added at SOP roster and PLRO.PLRORND =
current round:
If ST69B - STSOPCURR2 = 1/Yes, set
PLRO.COVCURNT = 1/Yes.
Else set PLRO.COVCURNT = 2/No.
COVCURNT
If ST69A - STMPDPCHNG = 1/Yes and ST69B STSOPCURR2 = 1/Yes, update
PLRO.PLROCOVURNT = 2/No on PLRO where
PLRO.PLROPLAN = PLAN.PLANNUM of preexisting current MPDP and PLRO.PLRORNDC =
current round.
SOFT EDIT CHECKS
1:46:38 PM Monday, April 06, 2009
Page 320 of 368
ST69B
HARD EDIT CHECKS
TECHNICAL NOTES
59
SPStatus
SP is Alive and not institutionalized =
MRES.SPALIVE=1/Alive or empty
SP is Alive =
MRES.SPALIVE=1/Alive, 2/AliveAndInstitute, or EMPTY
SP is Institutionalized =
MRES.SPALIVE=2/AliveAndInstitute
SP is Deceased =
MRES.SPALIVE=3/Deceased.
DESIGN NOTES
1:46:38 PM Monday, April 06, 2009
Page 321 of 368
BOX ST69A
BOX ST69A
Page Order # :
1155
BOX INSTRUCTIONS
( STQ2825 )
GO TO ST67B_IN - NAVIGATOR ( STQ2815 ).
ASSIGNMENTS
TECHNICAL NOTES
248
SOPPlan
Source of Payment is a HI Plan =
Medicaid: TSOP.TSOPISHI=1/Medicaid
Public: TSOP.TSOPISHI=2/PublicPlan
Private: TSOP.TSOPISHI=3/PrivatePlan
MHMO: TSOP.TSOPISHI=7/MHMO
Tricare: TSOP.TSOPISHI=9/Tricare.
MPDP: TSOP.TSOPISHI=10/MedicarePartD
DESIGN NOTES
HI returns to ST at BOX ST69A.
1:46:38 PM Monday, April 06, 2009
Page 322 of 368
BOX ST69B
BOX ST69B
Page Order # :
1157
BOX INSTRUCTIONS
( STQ2827 )
IF AT LEAST ONE SOURCE OF PAYMENT ADDED AT ST66 IS A
DISCOUNT MEMBERSHIP PLAN, GO TO ST69C - DMEMINTRO ( STQ2828
).
ELSE TO GO BOX ST69E - (STQ2840 ).
ASSIGNMENTS
TECHNICAL NOTES
374
SOPDmem
Source of Payment is a Discount Membership Plan =
TSOP.TSOPISHI = 8/DM.
DESIGN NOTES
1:46:38 PM Monday, April 06, 2009
Page 323 of 368
ST69C
ST69C
Page Order # :
Design Screen Type:
No Entry
Fields:
Field 1:
DMEMINTRO
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
1158
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Always display "(s)" in parenthesis.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
Before we continue, I would like to ask you a few questions about
the discount membership plan(s) you just added.
Int. Instr II:
INPUT FIELDS / ROUTING
1:46:41 PM Monday, April 06, 2009
Page 324 of 368
ST69C
DMEMINTRO
Field1:
Cheshire Name:
( STQ2828 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TContinueEMPTY
1
No
No
Number Label
1 Continue
FieldSize:
Min Value:
Max Value:
Mask:
Route
ST69C_IN - NAVIGATOR ( STQ2830 )
English text: CONTINUE
Attribute
Empty
Route
ST69C_IN - NAVIGATOR ( STQ2830 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:46:45 PM Monday, April 06, 2009
Page 325 of 368
ST69C_IN
ST69C_IN
Page Order # :
Design Screen Type:
Instance Navigator
Fields:
Field 0:
NAVIGATOR
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
1159
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Display all DM's added at ST66 SOP roster.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING
1:46:47 PM Monday, April 06, 2009
Page 326 of 368
ST69C_IN
NAVIGATOR
Field0:
Cheshire Name:
( STQ2830 )
N/A
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TInstanceNavigator
1
No
No
Number Label
1 SelectItemInList
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX ST69C - (STQ2835 )
English text: ITEM SELECTED IN INSTANCE NAVIGATOR
SelectContinueInterview
BOX ST69E - (STQ2840 )
English text: CONTINUE INTERVIEW SELECTED
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:46:51 PM Monday, April 06, 2009
Page 327 of 368
BOX ST69C
BOX ST69C
Page Order # :
1160
BOX INSTRUCTIONS
( STQ2835 )
CREATE A NEW DISCOUNT MEMBERSHIP PLAN FOR THE SOURCE OF
PAYMENT ADDED AT ST66 .
GO TO DM4 - DMSERVIC ( DMQ1070 ).
.
ASSIGNMENTS
DM details are collected on DMEM and DMRO:
DMEM key = DMEM.DMEMBASE + DMEM.DMEMNUM
DMEM.DMEMNUM = Number of DM created at BOX ST69C.
DMRO key = DMRO.DMROBASE + DMRO.DMRODMEM + DMRO.DMRORND
DMRO.DMRODMEM = DMEM.DMEMNUM of DM created at BOX ST69C.
DMRO.DMRORND = current round.
If SOP added is a Discount Membership plan, create a new DMEM and current round
DMRO record. See detailed instructions below.
DMEMNUM
DMEM.DMEMNUM = highest DMEM.DMEMNUM +
01.
DMEMRNDC
DMEM.DMEMRNDC = current round.
DMRODMEM
DMRO.DMRODMEM = DMEM.DMEMNUM.
DMRORND
DMRO.DMRORND = curent round.
DMHAVE
DMRO.DMHAVE = 1/Yes.
DMNAMEX
DMEM.DMNAMEX = TSOP.TSOPTEXT.
DMSOPFLG
DMEM.DMSOPFLG = 1/Yes.
TSOPTYPE
TSOP.TSOPTYPE = 9/DM.
TSOPDMEM
TSOP.TSOPDMEM = DMEM.DMEMNUM.
TECHNICAL NOTES
DESIGN NOTES
Calls DM section for Discount Membership plans added to SOP roster.
DM returns to ST at BOX ST69D.
1:46:51 PM Monday, April 06, 2009
Page 328 of 368
BOX ST69D
BOX ST69D
Page Order # :
1165
BOX INSTRUCTIONS
( STQ2838 )
GO TO ST69C_IN - NAVIGATOR ( STQ2830 ).
ASSIGNMENTS
TECHNICAL NOTES
374
SOPDmem
Source of Payment is a Discount Membership Plan =
TSOP.TSOPISHI = 8/DM.
DESIGN NOTES
DM returns to ST at BOX ST69D.
NOTE ON ELSE CONDITION:
Once all items at ST69C_IN Instance Navigator screen are DONE,
routing will return to ST69C_IN until Interviewer selects CONTINUE
INTERVIEW. When ST69C_IN CONTINUE INTERVIEW is selected,
BOX ST69D specifies routing to the next item.
The next item on the route is to BOX ST69E to check for OSOP's added
at SOP roster.
1:46:51 PM Monday, April 06, 2009
Page 329 of 368
BOX ST69E
BOX ST69E
Page Order # :
1167
BOX INSTRUCTIONS
( STQ2840 )
IF AN "OTHER SOURCE OF PAYMENT" ADDED AT ST66, CREATE AN
OSOP FOR EACH SOURCE OF PAYMENT ADDED AT ST66 THAT IS AN
"OTHER SOURCE OF PAYMENT" .
GO TO BOX ST69F - (STQ2842 ).
ASSIGNMENTS
Other Source of Payment details will be collected on OSOP:
OSOP key = OSOP.OSOPBASE + OSOP.OSOPNUM
OSOP.OSOPNUM = Number of Other Source of Payment generated at BOX ST69E.
Create OSOP record for each OTHER SOURCE OF PAYMENT added at ST66.
Set OSOP fields as specified below.
OSOPNUM
OSOP.OSOPNUM = highest OSOP.OSOPNUM +
01.
OSOPRNDC
OSOP.OSOPRNDC = current round.
OSOPTEXT
OSOP.OSOPTEXT = TSOP.TSOPTEXT.
TSOPTYPE
TSOP.TSOPTYPE = 4/OSOP.
TSOPOSOP
TSOP.TSOPOSOP = OSOP.OSOPNUM.
TSOPDISP
TSOP.TSOPDISP = "(OTHER)".
TECHNICAL NOTES
339
SOPIsOSOP
Source of Payment is an "Other Source of Payment" =
TSOP.TSOPISHI = 4/NotHIPlanVA, 5/MilitaryPlanNotVA,
or 6/NotSPsPlan.
DESIGN NOTES
1:46:52 PM Monday, April 06, 2009
Page 330 of 368
BOX ST69F
BOX ST69F
Page Order # :
1168
BOX INSTRUCTIONS
( STQ2842 )
IF ST5 - STATTYPE = 8/MPDPBenefit and ((TOTAL CHARGE ^= DK and
TOTAL CHARGE ^= RF) and (ALL PAYMENTS ENTERED AT ST67 ^= DK
AND ^= RF)) AND ((TOTAL CHARGE IS > TOTAL PAYMENTS ENTERED AT
ST67) AND (THE DIFFERENCE BETWEEN TOTAL CHARGE AND TOTAL
PAYMENTS ENTERED AT ST67 IS > $1.00)), GO TO ST73 - AMTSCORR (
STQ2875 ).
IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY)
AND (AT LEAST ONE PAYMENT ENTERED AT ST67 = DK OR RF) AND (AT
LEAST ONE PAYMENT ENTERED AT ST67 ^= DK AND ^= RF) AND (TOTAL
OF ALL NON-MISSING PAYMENTS ENTERED AT ST67 IS > AMOUNT
REMAINING), GO TO ST71 - AMTSCORR ( STQ2860 ).
ELSE IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^=
EMPTY) AND (ALL PAYMENTS ENTERED AT ST67 ^= DK AND ^= RF) AND
(THE ABSOLUTE VALUE OF THE DIFFERENCE BETWEEN THE TOTAL
PAYMENTS ENTERED AT ST67 AND AMOUNT REMAINING IS > $1.00),
GO TO ST70 - AMTSCORR ( STQ2850 ).
ELSE GO TO BOX ST77C - (STQ2910 ).
ASSIGNMENTS
TECHNICAL NOTES
230
AmountRemaining
Amount Remaining =
COST.AREMAING.
255
TotalPayments
Total of non-missing Payments entered in SOP grid =
For each TSOP where (TSOP.TSOPAMT ^= DK and
TSOP.TSOPAMT ^= RF and TSOP.TSOPAMT ^=
EMPTY), then Total Payments = Total Payments +
TSOP.TSOPAMT.
DESIGN NOTES
1:46:52 PM Monday, April 06, 2009
Page 331 of 368
ST70
ST70
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
AMTSCORR
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
1170
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
If (COST.MCPAYAMT ^= EMPTY and COST.MCPAYAMT ^= DK
and COST.MCPAYAMT ^= RF), display "AFTER MEDICARE
PAYMENT".
Else do not display.
Question display:
Total Payments = If (TSOP.TSOPAMT ^= DK and TSOP.TSOPAMT
^= RF and TSOP.TSOPAMT ^= EMPTY), Total Payments = Total
Payments + TSOP.TSOPAMT.
If Total Payments > Amount Remaining then
Display "more payments than the amount left after Medicare
paid".
Display "overpaid".
DIFFERENCE = Display the remainder of (Total Payments Amount Remaining)
Else then
Display "some amount still unpaid".
Display "unpaid".
DIFFERENCE = Display the remainder of (Amount Remaining Total Payments).
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
1:46:56 PM Monday, April 06, 2009
Display report above question text.
Page 332 of 368
ST70
Display all Source of Payments where TSOP.TSOPAMT ^= empty in
the following order based on TSOP.TSOPTYPE:
= 1/SPFamily
= 2/ProvDiscount
=11/MedicareSubsidy
=12/ExtraHelp
= 6/Medicare
= 8/MHMO
=10/MedicarePartD
= 5/VA
= 3/PlanNotMHMO
= 4/OSOP
= 9/DM
If there is more than Source of Payment per Source of Payment
Type, display in order of entry in TSOP.
Not all TSOP.TSOPTYPEs will be applicable.
Report header:
"NON-MEDICARE PAYMENTS"
Report layout:
Column 1, header="SOP NAME".
Column 1, display = TSOP.TSOPTEXT.
Column 2, header = "PAYMENT".
Column 2, display =
If TSOP.TSOPAMT = DK, display "DK".
Else if TSOP.TSOPAMT = RF, display "RF".
Else display TSOP.TSOPAMT.
TEXT:
Context Header:
(ST CLAIM HEADER)
TOTAL CHARGE = $(TOTAL CHARGE)
AMOUNT REMAINING (AFTER MEDICARE PAYMENT):
$(AMOUNT REMAINING)
Int. Instr I:
Question Text:
There seems to be (some amount still unpaid/more payments than
the amount left after Medicare paid). The total of non-Medicare
payments is $(TOTAL PAYMENTS). The amount (unpaid/overpaid)
is $(DIFFERENCE BETWEEN PAYMENTS AND AMOUNT
REMAINING). Is that correct?
Int. Instr II:
INPUT FIELDS / ROUTING
1:46:59 PM Monday, April 06, 2009
Page 333 of 368
ST70
AMTSCORR
Field1:
Cheshire Name:
( STQ2850 )
CORO.AMTSCORR
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TAmtscorr
FieldSize:
Min Value:
Max Value:
Mask:
1
No
No
Number Label
1 YesEntriesCorrect
Route
BOX ST77C - (STQ2910 )
2
English text: ENTRIES ABOVE ARE CORRECT
NoAddCorrectSOP
ST65 - STADDSOP1 ( STQ2702 )
3
English text: NO, SOP NEEDS ADDITION OR CORRECTION
AmountRemainingIncorrect
ST72 - ENTERCOM ( STQ2870 )
English text: AMOUNT REMAINING SEEMS INCORRECT
Attribute
Don't know
Route
BOX ST77C - (STQ2910 )
Refusal
BOX ST77C - (STQ2910 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
230
AmountRemaining
1:47:08 PM Monday, April 06, 2009
Amount Remaining =
COST.AREMAING.
Page 334 of 368
ST70
255
TotalPayments
Total of non-missing Payments entered in SOP grid =
For each TSOP where (TSOP.TSOPAMT ^= DK and
TSOP.TSOPAMT ^= RF and TSOP.TSOPAMT ^=
EMPTY), then Total Payments = Total Payments +
TSOP.TSOPAMT.
DESIGN NOTES
1:47:08 PM Monday, April 06, 2009
Page 335 of 368
ST71
ST71
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
AMTSCORR
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
1190
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
If (COST.MCPAYAMT ^= EMPTY and COST.MCPAYAMT ^= DK
and COST.MCPAYAMT ^= RF), display "AFTER MEDICARE
PAYMENT".
Else do not display.
Question display:
If COST.TOTALAMT = DK, RF or empty, display "AMOUNT
REMAINING".
Else display "TOTAL CHARGE".
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
Display report above question text.
Display all Source of Payments where TSOP.TSOPAMT ^= empty in
the following order based on TSOP.TSOPTYPE:
= 1/SPFamily
= 2/ProvDiscount
=11/MedicareSubsidy
=12/ExtraHelp
= 6/Medicare
= 8/MHMO
=10/MedicarePartD
= 5/VA
= 3/PlanNotMHMO
= 4/OSOP
1:47:11 PM Monday, April 06, 2009
Page 336 of 368
ST71
= 9/DM
If there is more than Source of Payment per Source of Payment
Type, display in order of entry in TSOP.
Not all TSOP.TSOPTYPEs will be applicable.
Report header:
"NON-MEDICARE PAYMENTS"
Report layout:
Column 1, header="SOP NAME".
Column 1, display = TSOP.TSOPTEXT.
Column 2, header = "PAYMENT".
Column 2, display =
If TSOP.TSOPAMT = DK, display "DK".
Else if TSOP.TSOPAMT = RF, display "RF".
Else display TSOP.TSOPAMT.
TEXT:
Context Header:
(ST CLAIM HEADER)
TOTAL CHARGE = $(TOTAL CHARGE)
AMOUNT REMAINING (AFTER MEDICARE PAYMENT):
$(AMOUNT REMAINING)
Int. Instr I:
Question Text:
Int. Instr II:
THE AMOUNTS ENTERED FOR THE SOURCES OF PAYMENT
EQUAL OR EXCEED THE (TOTAL CHARGE/AMOUNT
REMAINING), WITH AT LEAST ONE SOP BEING A MISSING
AMOUNT. VERIFY ALL AMOUNTS AS ENTERED.
INPUT FIELDS / ROUTING
1:47:19 PM Monday, April 06, 2009
Page 337 of 368
ST71
AMTSCORR
Field1:
Cheshire Name:
( STQ2860 )
CORO.AMTSCORR
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TAmtscorr
FieldSize:
Min Value:
Max Value:
Mask:
1
No
No
Number Label
1 YesEntriesCorrect
Route
BOX ST77C - (STQ2910 )
2
English text: ENTRIES ABOVE ARE CORRECT
NoAddCorrectSOP
ST65 - STADDSOP1 ( STQ2702 )
3
English text: NO, SOP NEEDS ADDITION OR CORRECTION
AmountRemainingIncorrect
ST72 - ENTERCOM ( STQ2870 )
English text: AMOUNT REMAINING SEEMS INCORRECT
Attribute
Don't know
Route
BOX ST77C - (STQ2910 )
Refusal
BOX ST77C - (STQ2910 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
230
AmountRemaining
Amount Remaining =
COST.AREMAING.
DESIGN NOTES
1:47:26 PM Monday, April 06, 2009
Page 338 of 368
ST72
ST72
Page Order # :
Design Screen Type:
No Entry
Fields:
Field 1:
ENTERCOM
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
1200
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
If (COST.MCPAYAMT ^= EMPTY and COST.MCPAYAMT ^= DK
and COST.MCPAYAMT ^= RF), display "AFTER MEDICARE
PAYMENT".
Else do not display.
Question display:
If NO payments entered at ST67 = DK or RF, display "THE TOTAL
OF NON-MEDICARE…".
Else do not display.
Total Payments = If (TSOP.TSOPAMT ^= DK and TSOP.TSOPAMT
^= RF and TSOP.TSOPAMT ^= EMPTY), Total Payments = Total
Payments + TSOP.TSOPAMT.
If Total Payments > Amount Remaining then
Display "OVERPAID".
DIFFERENCE = Display the remainder of (Total Payments Amount Remaining)
Else then
Display "UNPAID".
DIFFERENCE = Display the remainder of (Amount Remaining Total Payments).
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
1:47:28 PM Monday, April 06, 2009
Display report above question text.
Page 339 of 368
ST72
Display all Source of Payments where TSOP.TSOPAMT ^= empty in
the following order based on TSOP.TSOPTYPE:
= 1/SPFamily
= 2/ProvDiscount
=11/MedicareSubsidy
=12/ExtraHelp
= 6/Medicare
= 8/MHMO
=10/MedicarePartD
= 5/VA
= 3/PlanNotMHMO
= 4/OSOP
= 9/DM
If there is more than Source of Payment per Source of Payment
Type, display in order of entry in TSOP.
Not all TSOP.TSOPTYPEs will be applicable.
Report header:
"NON-MEDICARE PAYMENTS"
Report layout:
Column 1, header="SOP NAME".
Column 1, display = TSOP.TSOPTEXT.
Column 2, header = "PAYMENT".
Column 2, display =
If TSOP.TSOPAMT = DK, display "DK".
Else if TSOP.TSOPAMT = RF, display "RF".
Else display TSOP.TSOPAMT.
TEXT:
Context Header:
(ST CLAIM HEADER)
TOTAL CHARGE = $(TOTAL CHARGE)
AMOUNT REMAINING (AFTER MEDICARE PAYMENT):
$(AMOUNT REMAINING)
Int. Instr I:
Question Text:
Int. Instr II:
[THE TOTAL OF NON-MEDICARE PAYMENTS IS $(TOTAL
PAYMENTS). THE AMOUNT (UNPAID/OVERPAID) IS
$(DIFFERENCE BETWEEN PAYMENTS AND AMOUNT
REMAINING).]
USE COMMENTS TO EXPLAIN WHY THE AMOUNT REMAINING
SEEMS INCORRECT.
INPUT FIELDS / ROUTING
1:47:31 PM Monday, April 06, 2009
Page 340 of 368
ST72
ENTERCOM
Field1:
( STQ2870 )
TEMP
Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TContinueEMPTY
1
No
No
Number Label
1 Continue
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX ST77C - (STQ2910 )
English text: CONTINUE
Attribute
Empty
Route
BOX ST77C - (STQ2910 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
230
AmountRemaining
Amount Remaining =
COST.AREMAING.
255
TotalPayments
Total of non-missing Payments entered in SOP grid =
For each TSOP where (TSOP.TSOPAMT ^= DK and
TSOP.TSOPAMT ^= RF and TSOP.TSOPAMT ^=
EMPTY), then Total Payments = Total Payments +
TSOP.TSOPAMT.
DESIGN NOTES
1:47:36 PM Monday, April 06, 2009
Page 341 of 368
ST73
ST73
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
AMTSCORR
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
1210
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Total Payments = If (TSOP.TSOPAMT ^= DK and TSOP.TSOPAMT
^= RF and TSOP.TSOPAMT ^= EMPTY), Total Payments = Total
Payments + TSOP.TSOPAMT.
DIFFERENCE = Display the remainder of (Total Charge - Total
Payments).
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
Display report above question text.
Display all Source of Payments where TSOP.TSOPAMT ^= empty in
the following order based on TSOP.TSOPTYPE:
= 1/SPFamily
= 2/ProvDiscount
=11/MedicareSubsidy
=12/ExtraHelp
= 6/Medicare
= 8/MHMO
=10/MedicarePartD
= 5/VA
= 3/PlanNotMHMO
= 4/OSOP
1:47:39 PM Monday, April 06, 2009
Page 342 of 368
ST73
= 9/DM
If there is more than Source of Payment per Source of Payment
Type, display in order of entry in TSOP.
Not all TSOP.TSOPTYPEs will be applicable.
Report header:
"NON-MEDICARE PAYMENTS"
Report layout:
Column 1, header="SOP NAME".
Column 1, display = TSOP.TSOPTEXT.
Column 2, header = "PAYMENT".
Column 2, display =
If TSOP.TSOPAMT = DK, display "DK".
Else if TSOP.TSOPAMT = RF, display "RF".
Else display TSOP.TSOPAMT.
TEXT:
Context Header:
(ST CLAIM HEADER)
TOTAL CHARGE = $(TOTAL CHARGE)
Int. Instr I:
Question Text:
There seems to be some amount still unpaid. The total of non-
Medicare payments is $(TOTAL PAYMENTS). The amount unpaid
is $(DIFFERENCE BETWEEN TOTAL CHARGE AND
PAYMENTS). Is that correct?
Int. Instr II:
INPUT FIELDS / ROUTING
1:47:47 PM Monday, April 06, 2009
Page 343 of 368
ST73
AMTSCORR
Field1:
CORO.AMTSCORR
Cheshire Name:
Item Text display:
( STQ2875 )
Do not display response option
3/AmountRemainingIncorrect.
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TAmtscorr
1
No
No
Number Label
1 YesEntriesCorrect
2
3
FieldSize:
Min Value:
Max Value:
Mask:
Route
ST74 - INFOEXPLAIN ( STQ2877 )
English text: ENTRIES ABOVE ARE CORRECT
NoAddCorrectSOP
ST65 - STADDSOP1 ( STQ2702 )
English text: NO, SOP NEEDS ADDITION OR CORRECTION
AmountRemainingIncorrect
DO NOT DISPLAY.
English text: AMOUNT REMAINING SEEMS INCORRECT
Attribute
Don't know
Route
BOX ST77C - (STQ2910 )
Refusal
BOX ST77C - (STQ2910 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:47:53 PM Monday, April 06, 2009
Page 344 of 368
ST74
ST74
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
INFOEXPLAIN
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
1220
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Total Payments = If (TSOP.TSOPAMT ^= DK and TSOP.TSOPAMT
^= RF and TSOP.TSOPAMT ^= EMPTY), Total Payments = Total
Payments + TSOP.TSOPAMT.
DIFFERENCE = Display the remainder of (Total Charge - Total
Payments).
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
AMOUNT UNPAID: (DIFFERNCE BETWEEN TOTAL CHARGE
AND PAYMENTS)
Int. Instr I:
Question Text:
Int. Instr II:
1:47:56 PM Monday, April 06, 2009
IS THERE ADDITIONAL INFORMATION ON THE MEDICARE
PRESCRIPTION DRUG BENEFIT STATEMENT THAT EXPLAINS
THE AMOUNT STILL UNPAID?
Page 345 of 368
ST74
INPUT FIELDS / ROUTING
Field1:
INFOEXPLAIN
Cheshire Name:
( STQ2877 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNo
1
No
No
Number Label
1 Yes
2
English text: YES
No
FieldSize:
Min Value:
Max Value:
Mask:
Route
ST75 - ENTERCOM2 ( STQ2880 )
BOX ST77C - (STQ2910 )
English text: NO
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:47:59 PM Monday, April 06, 2009
Page 346 of 368
ST75
ST75
Page Order # :
Design Screen Type:
No Entry
Fields:
Field 1:
ENTERCOM2
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
1230
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Total Payments = If (TSOP.TSOPAMT ^= DK and TSOP.TSOPAMT
^= RF and TSOP.TSOPAMT ^= EMPTY), Total Payments = Total
Payments + TSOP.TSOPAMT.
DIFFERENCE = Display the remainder of (Total Charge - Total
Payments).
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
AMOUNT UNPAID: $(DIFFERENCE BETWEEN TOTAL CHARGE
AND PAYMENTS)
Int. Instr I:
Question Text:
Int. Instr II:
1:48:02 PM Monday, April 06, 2009
USE COMMENTS TO ENTER ANY INFORMATION THAT
EXPLAINS THE AMOUNT STILL UNPAID.
Page 347 of 368
ST75
INPUT FIELDS / ROUTING
Field1:
ENTERCOM2
Cheshire Name:
( STQ2880 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TContinueEMPTY
1
No
No
Number Label
1 Continue
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX ST77C - (STQ2910 )
English text: CONTINUE
Attribute
Empty
Route
BOX ST77C - (STQ2910 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:48:07 PM Monday, April 06, 2009
Page 348 of 368
BOX ST77C
BOX ST77C
1:48:07 PM Monday, April 06, 2009
Page Order # :
1240
Page 349 of 368
BOX ST77C
BOX INSTRUCTIONS
( STQ2910 )
CREATE PAYMENTS FOR AMOUNTS ENTERED AT ST67 .
GO TO BOX ST77D - (STQ2915 ).
ASSIGNMENTS
Payments details are stored on PAYM:
PAYM key = PAYM.PAYMBASE + PAYM.PAYMCOST + PAYM.PAYMNUM.
PAYM.PAYMCOST = COST.COSTNUM of this charge bundle being asked about.
PAYM.PAYMNUM = Unique Number assigned to unique payer linked to this charge bundle.
PAYM records are only created for payers where TSOP.TSOPAMT ^= NULL.
TSOP.TSOPAMT may be >= 0, DK, or RF.
Only one PAYM record will be created per unique payer per charge bundle, regardless of
PAYM.PAYMRNDC.
DETAILS:
For each payer where TSOP.TSOPAMT >=0, DK, or RF:
If TSOP.TSOPPAYM ^= NULL then do;
There is a PAYM record linked to this charge bundle for this payer where
TSOP.TSOPPAYM = PAYM.PAYMCOST + PAYM.PAYMNUM and PAYM.PAYMCOST =
this charge bundle COST.COSTNUM.
Update existing PAYM.PAYMAMT = TSOP.TSOPAMT.
Else if there is a PAYM where PAYM.PAYMCOST = this charge bundle COST.COSTNUM
and
((TSOP.TSOPTYPE = 1/SPFamily and PAYM.PAYMTYPE = 1/SPFamily) or
(TSOP.TSOP TYPE = 2/ProvDiscount and PAYM.PAYMTYPE = 2/ProvDiscount) or
(TSOP.TSOPTYPE = 5/VA and PAYM.PAYMTYPE = 5/VA) or
(TSOP.TSOPTYPE = 6/Medicare and PAYM.PAYMTYPE = 6/Medicare) or
(TSOP.TSOPTYPE = 7/OtherMilitaryPlanNotVA and PAYM.PAYMTYPE =
7/OtherMilitaryPlanNotVA) or
(TSOP.TSOPTYPE = 11/MedicareSubsidy and PAYM.PAYMTYPE =
11/MedicareSubsidy) or
(TSOP.TSOPTYPE = 12/ExtraHelp and PAYM.PAYMTYPE = 12/ExtraHelp) or
((TSOP.TSOPTYPE = 4/OSOP and PAYM.PAYMTYPE = 4/OSOP) and
(TSOP.TSOPOSOP = PAYM.PAYMOSOP)) or
((TSOP.TSOPTYPE = 9/DM and PAYM.PAYMTYPE = 9/DM) and (TSOP.TSOPDMEM =
PAYM.PAYMDMEM)) or
((TSOP.TSOPTYPE = 3/PlanNotMHMO and PAYM.PAYMTYPE = 3/PlanNotMHMO) and
(TSOP.TSOPPLAN = PAYM.PAYMPLAN)) or
((TSOP.TSOPTYPE = 8/MHMO and PAYM.PAYMTYPE = 8/MHMO) and
(TSOP.TSOPPLAN = PAYM.PAYMPLAN)) or
((TSOP.TSOPTYPE = 10/MedicarePartD and PAYM.PAYMTYPE = 10/MedicarePartD)
and (TSOP.TSOPPLAN = PAYM.PAYMPLAN))), then do:
This PAYM record is linked to the current round charge bundle for this payer:
Update PAYM.PAYMAMT = TSOP.TSOPAMT.
Else do;
Create a new current round PAYM record for this payer.
Set PAYM.PAYMAMT = TSOP.TSOPAMT.
Set additional fields on PAYM as specified below.
1:48:07 PM Monday, April 06, 2009
Page 350 of 368
BOX ST77C
PAYMCOST
If creating a new PAYM record, create PAYM where
PAYM.PAYMCOST = this COST.COSTNUM.
PAYMNUM
If creating a new PAYM record, set
PAYM.PAYMNUM = highest PAYM.PAYMNUM for
PAYM.PAYMCOST + 01.
PAYMRNDC
If creating a new PAYM record, set
PAYM.PAYMRNDC = current round.
PAYMTYPE
If creating a new PAYM record, set
PAYM.PAYMTYPE = TSOP.TSOPTYPE.
PAYMPLAN
If creating a new PAYM record, if TSOP.TSOPTYPE
= 3/PlanNotMHMO, 8/MHMO or 10/MedicarePartD,
set PAYM.PAYMPLAN = TSOP.TSOPPLAN.
PAYMOSOP
If creating a new PAYM record, if TSOP.TSOPTYPE
= 4/OSOP, set PAYM.PAYMOSOP =
TSOP.TSOPOSOP.
PAYMISHI
If creating a new PAYM record, if TSOP.TSOPISHI
^= empty, set PAYM.PAYMISHI = TSOP.TSOPISHI.
PAYMAMT
PAYM.PAYMAMT = TSOP.TSOPAMT.
PAYMDMEM
If creating a new PAYM record, if TSOP.TSOPTYPE
= 9/DM, set PAYM.PAYMDMEM =
TSOP.TSOPDMEM.
TECHNICAL NOTES
DESIGN NOTES
1:48:07 PM Monday, April 06, 2009
Page 351 of 368
BOX ST77D
BOX ST77D
Page Order # :
1245
BOX INSTRUCTIONS
( STQ2915 )
IF THE SP OR FAMILY MADE A PAYMENT AND PAYMENT IS GREATER
THAN $5.00, GO TO ST78 - EXPPAYBK ( STQ2920 ).
ELSE GO TO BOX ST80 - (STQ2930 ).
ASSIGNMENTS
TECHNICAL NOTES
234
SPFamilyPayment
SP/Family Payment =
For this COST, there is PAYM where
(PAYM.PAYMCOST = COST.COSTNUM &
PAYM.PAYMTYPE = 1/SPFamily & PAYM.PAYMDFLG^1/Yes).
SP/family payment = PAYM.PAYMAMT.
DESIGN NOTES
1:48:07 PM Monday, April 06, 2009
Page 352 of 368
ST78
ST78
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
EXPPAYBK
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
1250
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Display SP/Family payment.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)
TOTAL CHARGE = $(TOTAL CHARGE)
Int. Instr I:
Question Text:
I have recorded that [you have/(SP) has] paid $(SP/FAMILY
PAYMENT). Do you expect any source to pay [you/(SP)] back any
or all of that amount?
Int. Instr II:
INPUT FIELDS / ROUTING
1:48:10 PM Monday, April 06, 2009
Page 353 of 368
ST78
( STQ2920 )
EXPPAYBK
Field1:
Cheshire Name:
CORO.EXPPAYBK
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX ST78A - (STQ2922 )
English text: YES
No
BOX ST78A - (STQ2922 )
English text: NO
Attribute
Don't know
Route
BOX ST78A - (STQ2922 )
Refusal
BOX ST78A - (STQ2922 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
234
SPFamilyPayment
SP/Family Payment =
For this COST, there is PAYM where
(PAYM.PAYMCOST = COST.COSTNUM &
PAYM.PAYMTYPE = 1/SPFamily & PAYM.PAYMDFLG^1/Yes).
SP/family payment = PAYM.PAYMAMT.
DESIGN NOTES
1:48:16 PM Monday, April 06, 2009
Page 354 of 368
BOX ST78A
BOX ST78A
Page Order # :
1251
BOX INSTRUCTIONS
( STQ2922 )
IF ST78 - EXPPAYBK = 1/Yes AND ((CURRENTLY ADMINISTERING CPS
AND CHARGES WERE FIRST COLLECTED 2 ROUNDS PREVIOUS TO
CURRENT ROUND) OR (SP IS IN THE EXIT SAMPLE)), GO TO ST80 EXPAYUNT ( STQ2926 ).
ELSE GO TO BOX ST80 - (STQ2930 ).
ASSIGNMENTS
TECHNICAL NOTES
16
ExitSample
SP is in the Exit Sample =
(MRES.INTTYPE = 8/ExitInterviewHadPrev or
9/ExitInterviewSkipPrev) on MRES where
MRES.MRESRND = current round.
271
COST2RoundsOld
Charges first collected 2 rounds previous to current
round =
COST.COSTRNDC = (current round - 2).
DESIGN NOTES
1:48:16 PM Monday, April 06, 2009
Page 355 of 368
BOX ST78B
BOX ST78B
Page Order # :
1252
BOX INSTRUCTIONS
( STQ2923 )
IF (CURRENTLY ADMINISTERING CPS AND CHARGES WERE FIRST
COLLECTED 2 ROUNDS PREVIOUS TO CURRENT ROUND) OR (SP IS IN
THE EXIT SAMPLE), GO TO ST79 - EXPAYOUT ( STQ2924 ).
ELSE GO TO BOX ST80 - (STQ2930 ).
ASSIGNMENTS
TECHNICAL NOTES
16
ExitSample
SP is in the Exit Sample =
(MRES.INTTYPE = 8/ExitInterviewHadPrev or
9/ExitInterviewSkipPrev) on MRES where
MRES.MRESRND = current round.
271
COST2RoundsOld
Charges first collected 2 rounds previous to current
round =
COST.COSTRNDC = (current round - 2).
DESIGN NOTES
1:48:16 PM Monday, April 06, 2009
Page 356 of 368
ST79
ST79
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
EXPAYOUT
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
1253
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)
TOTAL CHARGE = $(TOTAL CHARGE)
Int. Instr I:
Question Text:
Do you expect anyone to pay any of this amount?
Int. Instr II:
INPUT FIELDS / ROUTING
1:48:19 PM Monday, April 06, 2009
Page 357 of 368
ST79
EXPAYOUT
Field1:
Cheshire Name:
( STQ2924 )
CORO.EXPAYOUT
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNoDKRF
1
No
No
Number Label
1 Yes
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
ST80 - EXPAYUNT ( STQ2926 )
English text: YES
No
BOX ST80 - (STQ2930 )
English text: NO
Attribute
Don't know
Route
BOX ST80 - (STQ2930 )
Refusal
BOX ST80 - (STQ2930 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:48:25 PM Monday, April 06, 2009
Page 358 of 368
ST80
ST80
Page Order # :
Design Screen Type:
Quantity Unit
Fields:
Field 1:
EXPAYUNT
Field 2:
EXPAYPCT
Field 3:
EXPAYAMT
HELP
COMMENTS
JUMPBACK
No
No
No
Enable Functions:
1258
Roster Name:
Roster Type:
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Vertical Alignment
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
(ST CLAIM HEADER)
EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)
TOTAL CHARGE = $(TOTAL CHARGE)
Int. Instr I:
Question Text:
How much do you expect wil be paid?
Int. Instr II:
1:48:29 PM Monday, April 06, 2009
Page 359 of 368
ST80
INPUT FIELDS / ROUTING
Field1:
EXPAYUNT
Cheshire Name:
( STQ2926 )
CORO.EXPAYUNT
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TExpayunt
1
No
No
Number Label
1 Percentage
2
English text: PERCENTAGE
Dollars
FieldSize:
Min Value:
Max Value:
Mask:
Route
ST80 - EXPAYPCT ( STQ2927 )
ST80 - EXPAYAMT ( STQ2928 )
English text: DOLLARS
Attribute
Don't know
Route
BOX ST80 - (STQ2930 )
Refusal
BOX ST80 - (STQ2930 )
1:48:39 PM Monday, April 06, 2009
Page 360 of 368
ST80
Field2:
Cheshire Name:
EXPAYPCT
( STQ2927 )
CORO.EXPAYPCT
Item Text display:
Item Text:
Label:
Label Position:
PERCENTAGE:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TExpaypctReal
1
No
No
Number Label
1 [Continuous answer.]
Field3:
Cheshire Name:
EXPAYAMT
FieldSize:
Min Value:
Max Value:
Mask:
0.0
100
Percent
Route
BOX ST80 - (STQ2930 )
( STQ2928 )
CORO.EXPAYPCT
Item Text display:
Item Text:
Label:
Label Position:
DOLLARS:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Real
TExpayamt
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
0.49
999999.99
Dollars
Route
BOX ST80 - (STQ2930 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
Edit #1
1:48:43 PM Monday, April 06, 2009
Page 361 of 368
ST80
If ST80 - EXPAYUNT = 1/Percentage, then ST80 - EXPAYPCT
should = 20 - 100.
If not true, display message "PERCENTAGE SEEMS UNLIKELY.
PLEASE VERIFY."
Edit #2
If ST80 - EXPAYUNT = 2/Dollars and (SP/Family's payment ^= DK
and ^= RF) , then ST80 - EXPAYAMT should <= SP/Family's
payment.
If not true, display message "THE AMOUNT ENTERED IS
GREATER THAN THE SP/FAMILY PAYMENT. PLEASE VERIFY."
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:48:44 PM Monday, April 06, 2009
Page 362 of 368
BOX ST80
BOX ST80
Page Order # :
1260
BOX INSTRUCTIONS
( STQ2930 )
IF CURRENTLY ADMINISTERING NS, GO TO BOX NSBEG - (NSQ1010 ).
ELSE IF CURRENTLY ADMINISTERING CPS, GO TO BOX CPSBEG (CPS1010 ).
ELSE IF ST5 - STATTYPE = 8/MPDPBenefit, GO TO ST82 - ASTATEMENT (
STQ2970 ).
ELSE GO TO ST81 - ABUNDLE ( STQ2960 ).
ASSIGNMENTS
EVERSTMT
Set HRND.EVERSTMT = 1/Yes, indication that at
least one charge bundle has been entered in the
current round.
TECHNICAL NOTES
DESIGN NOTES
If administering CPS, BOX ST80 routes back to the beginning of CPS to
reevaluate which COST BUNDLES still need to be asked about in CPS.
Else if administering NS, BOX ST80 routes back to the beginning of NS
to reevaluate which current round EVENTS still need charge bundle data
collected.
Else (administering ST), BOX ST80 routes to the ST END LOOP Probe
for more statements.
1:48:44 PM Monday, April 06, 2009
Page 363 of 368
ST81
ST81
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
ABUNDLE
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
1290
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
IS THERE ANOTHER CHARGE BUNDLE TO ENTER FROM THIS
(TYPE OF STATEMENT)?
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING
1:48:46 PM Monday, April 06, 2009
Page 364 of 368
ST81
ABUNDLE
Field1:
Cheshire Name:
( STQ2960 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNo
1
No
No
Number Label
1 Yes
2
English text: YES
No
FieldSize:
Min Value:
Max Value:
Mask:
Route
ST4 - MATCHST ( STQ1110 )
ST82 - ASTATEMENT ( STQ2970 )
English text: NO
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:48:50 PM Monday, April 06, 2009
Page 365 of 368
ST82
ST82
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
ASTATEMENT
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
Yes
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
1300
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
Int. Instr I:
IS THERE ANOTHER MSN, INSURANCE, TRICARE, OR
MEDICARE PRESCRIPTION DRUG BENEFIT STATEMENT TO
ENTER?
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING
1:48:52 PM Monday, April 06, 2009
Page 366 of 368
ST82
ASTATEMENT
Field1:
Cheshire Name:
( STQ2970 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesNo
1
No
No
Number Label
1 Yes
2
English text: YES
No
FieldSize:
Min Value:
Max Value:
Mask:
Route
ST4 - MATCHST ( STQ1110 )
BOX STEND - (STQ3010 )
English text: NO
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
1:48:56 PM Monday, April 06, 2009
Page 367 of 368
BOX STEND
BOX STEND
Page Order # :
1340
BOX INSTRUCTIONS
( STQ3010 )
GO TO NEXT SECTION. .
ASSIGNMENTS
TECHNICAL NOTES
DESIGN NOTES
1:48:56 PM Monday, April 06, 2009
Page 368 of 368
| File Type | application/pdf |
| File Title | rptMCBSSpecs_Main |
| Author | Sweeney_l |
| File Modified | 2010-04-02 |
| File Created | 2009-04-06 |