CMS-R-262 CY 2016 PBP Data Entry System Screens (section B)

The Plan Benefit Package (PBP) and Formulary Submission for Advantage (MA) Plans and Prescription Drug Plans (PDPs) (CMS-R-262)

Appendix_C_PBP_2016_ screenshots_section_b_2014_12_05

CY2016 Plan Benefit Package (PBP) Software and Formulary Submission (CMS-R-262)

OMB: 0938-0763

Document [pdf]
Download: pdf | pdf
#1a Inpatient Hospital-Acute – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 1 of 244

#1a Inpatient Hospital-Acute – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 2 of 244

#1a Inpatient Hospital-Acute – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 3 of 244

#1a Inpatient Hospital-Acute – Base 4

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 4 of 244

#1a Inpatient Hospital-Acute – Base 5

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 5 of 244

#1a Inpatient Hospital-Acute – Base 6

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 6 of 244

#1a Inpatient Hospital-Acute – Base 7

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 7 of 244

#1a Inpatient Hospital-Acute – Base 8

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 8 of 244

#1a Inpatient Hospital-Acute – Base 9

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 9 of 244

#1a Inpatient Hospital-Acute – Base 10

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 10 of 244

#1a Inpatient Hospital-Acute – Base 11

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 11 of 244

#1a Inpatient Hospital-Acute – Base 12

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 12 of 244

CY 2016 PBP Data Entry System Screens

#1a Inpatient Hospital-Acute (B Only) – Base 1

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 13 of 244

CY 2016 PBP Data Entry System Screens

#1a Inpatient Hospital-Acute (B Only) – Base 2

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 14 of 244

CY 2016 PBP Data Entry System Screens

#1a Inpatient Hospital-Acute (B Only) – Base 3

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 15 of 244

CY 2016 PBP Data Entry System Screens

#1a Inpatient Hospital-Acute (B Only) – Base 4

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 16 of 244

CY 2016 PBP Data Entry System Screens

#1b Inpatient Hospital Psychiatric – Base 1

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 17 of 244

CY 2016 PBP Data Entry System Screens

#1b Inpatient Hospital Psychiatric – Base 2

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 18 of 244

CY 2016 PBP Data Entry System Screens

#1b Inpatient Hospital Psychiatric – Base 3

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 19 of 244

CY 2016 PBP Data Entry System Screens

#1b Inpatient Hospital Psychiatric – Base 4

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 20 of 244

CY 2016 PBP Data Entry System Screens

#1b Inpatient Hospital Psychiatric – Base 5

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 21 of 244

CY 2016 PBP Data Entry System Screens

#1b Inpatient Hospital Psychiatric – Base 6

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 22 of 244

CY 2016 PBP Data Entry System Screens

#1b Inpatient Hospital Psychiatric – Base 7

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 23 of 244

CY 2016 PBP Data Entry System Screens

#1b Inpatient Hospital Psychiatric – Base 8

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 24 of 244

CY 2016 PBP Data Entry System Screens

#1b Inpatient Hospital Psychiatric – Base 9

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 25 of 244

CY 2016 PBP Data Entry System Screens

#1b Inpatient Hospital Psychiatric – Base 10

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 26 of 244

CY 2016 PBP Data Entry System Screens

#1b Inpatient Hospital Psychiatric – Base 11

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 27 of 244

CY 2016 PBP Data Entry System Screens

#1b Inpatient Hospital Psychiatric – Base 12

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 28 of 244

CY 2016 PBP Data Entry System Screens

#1b Inpatient Hospital Psychiatric (B Only) – Base 1

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 29 of 244

CY 2016 PBP Data Entry System Screens

#1b Inpatient Hospital Psychiatric (B Only) – Base 2

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 30 of 244

CY 2016 PBP Data Entry System Screens

#1b Inpatient Hospital Psychiatric (B Only) – Base 3

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 31 of 244

CY 2016 PBP Data Entry System Screens

#1b Inpatient Hospital Psychiatric (B Only) – Base 4

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 32 of 244

CY 2016 PBP Data Entry System Screens

#1b Inpatient Hospital Psychiatric (B Only) – Base 5

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 33 of 244

#2 SNF – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 34 of 244

#2 SNF – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 35 of 244

#2 SNF – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 36 of 244

#2 SNF – Base 4

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 37 of 244

#2 SNF – Base 5

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 38 of 244

#2 SNF – Base 6

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 39 of 244

#2 SNF – Base 7

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 40 of 244

#2 SNF – Base 8

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 41 of 244

#2 SNF – Base 9

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 42 of 244

#2 SNF (B Only) – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 43 of 244

#2 SNF (B Only) – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 44 of 244

#2 SNF (B Only) – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 45 of 244

#2 SNF (B Only) – Base 4

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 46 of 244

CY 2016 PBP Data Entry System Screens

#3 Cardiac and Pulmonary Rehabilitation Services – Base 1

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 47 of 244

CY 2016 PBP Data Entry System Screens

#3 Cardiac and Pulmonary Rehabilitation Services – Base 2

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 48 of 244

CY 2016 PBP Data Entry System Screens

#3 Cardiac and Pulmonary Rehabilitation Services – Base 3

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 49 of 244

CY 2016 PBP Data Entry System Screens

#3 Cardiac and Pulmonary Rehabilitation Services – Base 4

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 50 of 244

#4a Emergency Care – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 51 of 244

#4a Emergency Care – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 52 of 244

#4b Urgently Needed Services – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 53 of 244

#4b Urgently Needed Services – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 54 of 244

#4b Urgently Needed Services – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 55 of 244

CY 2016 PBP Data Entry System Screens

#4c Worldwide Emergency/Urgent Coverage – Base 1

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 56 of 244

CY 2016 PBP Data Entry System Screens

#4c Worldwide Emergency/Urgent Coverage – Base 2

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 57 of 244

CY 2016 PBP Data Entry System Screens

#4c worldwide Emergency/Urgent Coverage – Base 3

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 58 of 244

#5 Partial Hospitalization – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 59 of 244

#5 Partial Hospitalization – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 60 of 244

#6 Home Health Services – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 61 of 244

#6 Home Health Services – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 62 of 244

#6 Home Health Services – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 63 of 244

#6 Home Health Services – MMP – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 64 of 244

#6 Home Health Services – MMP – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 65 of 244

#6 Home Health Services – MMP – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 66 of 244

CY 2016 PBP Data Entry System Screens

#7a Primary Care Physician Services – Base 1

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 67 of 244

CY 2016 PBP Data Entry System Screens

#7a Primary Care Physician Services – Base 2

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 68 of 244

#7b Chiropractic Services – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 69 of 244

#7b Chiropractic Services – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 70 of 244

#7b Chiropractic Services – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 71 of 244

#7b Chiropractic Services – Base 4

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 72 of 244

CY 2016 PBP Data Entry System Screens

#7c Occupational Therapy Services – Base 1

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 73 of 244

CY 2016 PBP Data Entry System Screens

#7c Occupational Therapy Services – Base 2

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 74 of 244

CY 2016 PBP Data Entry System Screens

#7c Occupational Therapy Services – MMP – Base 1

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 75 of 244

CY 2016 PBP Data Entry System Screens

#7c Occupational Therapy Services – MMP – Base 2

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 76 of 244

#7d Physician Specialist Services – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 77 of 244

#7d Physician Specialist Services – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 78 of 244

CY 2016 PBP Data Entry System Screens

#7e Mental Health Specialty Services – Base 1

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 79 of 244

CY 2016 PBP Data Entry System Screens

#7e Mental Health Specialty Services – Base 2

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 80 of 244

CY 2016 PBP Data Entry System Screens

#7e Mental Health Specialty Services – Base 3

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 81 of 244

#7f Podiatry Services – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 82 of 244

#7f Podiatry Services – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 83 of 244

#7f Podiatry Services – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 84 of 244

CY 2016 PBP Data Entry System Screens

#7g Other Health Care Professional – Base 1

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 85 of 244

CY 2016 PBP Data Entry System Screens

#7g Other Health Care Professional – Base 2

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 86 of 244

#7h Psychiatric Services – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 87 of 244

#7h Psychiatric Services – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 88 of 244

#7h Psychiatric Services – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 89 of 244

#7i PT and SP Services – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 90 of 244

#7i PT and SP Services – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 91 of 244

#7i PT and ST – MMP – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 92 of 244

#7i PT and ST – MMP – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 93 of 244

CY 2016 PBP Data Entry System Screens

#8a Outpatient Diag Procs/Tests/Lab Services – Base 1

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 94 of 244

CY 2016 PBP Data Entry System Screens

#8a Outpatient Diag Procs/Tests/Lab Services – Base 2

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 95 of 244

CY 2016 PBP Data Entry System Screens

#8a Outpatient Diag Procs/Tests/Lab Services – Base 3

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 96 of 244

CY 2016 PBP Data Entry System Screens

#8a Outpatient Diag Procs/Tests/Lab Services – Base 4

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 97 of 244

CY 2016 PBP Data Entry System Screens

#8b Outpatient Diag/Therapeutic Rad Services – Base 1

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 98 of 244

CY 2016 PBP Data Entry System Screens

#8b Outpatient Diag/Therapeutic Rad Services – Base 2

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 99 of 244

CY 2016 PBP Data Entry System Screens

#8b Outpatient Diag/Therapeutic Rad Services – Base 3

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 100 of 244

#9a Outpatient Hospital Services – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 101 of 244

#9a Outpatient Hospital Services – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 102 of 244

#9a Outpatient Hospital Services – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 103 of 244

#9b ASC Services – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 104 of 244

#9b ASC Services – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 105 of 244

#9b ASC Services – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 106 of 244

#9c Outpatient Substance Abuse – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 107 of 244

#9c Outpatient Substance Abuse – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 108 of 244

#9c Outpatient Substance Abuse – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 109 of 244

#9d Outpatient Blood Services – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 110 of 244

#9d Outpatient Blood Services – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 111 of 244

#10a Ambulance Services – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 112 of 244

#10a Ambulance Services – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 113 of 244

#10b Transportation Services – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 114 of 244

#10b Transportation Services – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 115 of 244

#10b Transportation Services – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 116 of 244

#11a DME – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 117 of 244

#11a DME – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 118 of 244

#11a DME – MMP – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 119 of 244

#11a DME – MMP – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 120 of 244

CY 2016 PBP Data Entry System Screens

#11b Prosthetics/Medical Supplies – Base 1

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 121 of 244

CY 2016 PBP Data Entry System Screens

#11b Prosthetics/Medical Supplies – Base 2

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 122 of 244

CY 2016 PBP Data Entry System Screens

#11b Prosthetics/Medical Supplies – Base 3

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 123 of 244

CY 2016 PBP Data Entry System Screens

#11b Prosthetics/Medical Supplies – MMP – Base 1

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 124 of 244

CY 2016 PBP Data Entry System Screens

#11c Diabetic Supplies and Services – Base 1

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 125 of 244

CY 2016 PBP Data Entry System Screens

#11c Diabetic Supplies and Services – Base 2

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 126 of 244

#12 End-Stage Renal Disease – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 127 of 244

#12 End-Stage Renal Disease – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 128 of 244

#13a Acupuncture – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 129 of 244

#13a Acupuncture – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 130 of 244

#13a Acupuncture – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 131 of 244

#13b OTC Items – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 132 of 244

#13b OTC Items – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 133 of 244

#13b OTC Items – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 134 of 244

#13c Meal Benefit – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 135 of 244

#13c Meal Benefit – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 136 of 244

#13c Meal Benefit – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 137 of 244

#13d Other 1 – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 138 of 244

#13d Other 1 – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 139 of 244

#13d Other 1 – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 140 of 244

#13e Other 2 – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 141 of 244

#13e Other 2 – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 142 of 244

#13e Other 2 – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 143 of 244

#13f Other 3 – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 144 of 244

#13f Other 3 – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 145 of 244

#13f Other 3 – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 146 of 244

CY 2016 PBP Data Entry System Screens

#13g Dual Eligible SNPs with Highly Integrated Services – Base 1

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 147 of 244

CY 2016 PBP Data Entry System Screens

#13g Dual Eligible SNPs with Highly Integrated Services – Base 2

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 148 of 244

CY 2016 PBP Data Entry System Screens

#13g Dual Eligible SNPs with Highly Integrated Services – Base 3

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 149 of 244

#13h Additional Services – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 150 of 244

#13h Additional Services – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 151 of 244

#13h Additional Services – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 152 of 244

#13h Additional Services – Base 4

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 153 of 244

#13h Additional Services – Base 5

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 154 of 244

#13h Additional Services – Base 6

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 155 of 244

#13h Additional Services – Base 7

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 156 of 244

#13h Additional Services – Base 8

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 157 of 244

#13h Additional Services – Base 9

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 158 of 244

#13h Additional Services – Base 10

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 159 of 244

#13h Additional Services – Base 11

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 160 of 244

#13h Additional Services – Base 12

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 161 of 244

#13h Additional Services – Base 13

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 162 of 244

#13h Additional Services – Base 14

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 163 of 244

#13h Additional Services – Base 15

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 164 of 244

#13h Additional Services – Base 16

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 165 of 244

#13h Additional Services – Base 17

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 166 of 244

#13h Additional Services – Base 18

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 167 of 244

#13h Additional Services – Base 19

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 168 of 244

#13h Additional Services – Base 20

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 169 of 244

#13h Additional Services – Base 21

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 170 of 244

#13h Additional Services – Base 22

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 171 of 244

#13h Additional Services – Base 23

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 172 of 244

#13h Additional Services – Base 24

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 173 of 244

#13h Additional Services – Base 25

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 174 of 244

#13h Additional Services – Base 26

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 175 of 244

#13h Additional Services – Base 27

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 176 of 244

CY 2016 PBP Data Entry System Screens

#14a Medicare-covered Preventive Services

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 177 of 244

#14b Annual Physical Exam – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 178 of 244

#14b Annual Physical Exam – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 179 of 244

#14b Annual Physical Exam – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 180 of 244

CY 2016 PBP Data Entry System Screens

#14c Eligible Supplemental Benefits as Defined in Chapter 4 – Base 1

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 181 of 244

CY 2016 PBP Data Entry System Screens

#14c Eligible Supplemental Benefits as Defined in Chapter 4 – Base 2

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 182 of 244

CY 2016 PBP Data Entry System Screens

#14c Eligible Supplemental Benefits as Defined in Chapter 4 – Base 3

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 183 of 244

CY 2016 PBP Data Entry System Screens

#14c Eligible Supplemental Benefits as Defined in Chapter 4 – Base 4

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 184 of 244

CY 2016 PBP Data Entry System Screens

#14c Eligible Supplemental Benefits as Defined in Chapter 4 – Base 5

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 185 of 244

CY 2016 PBP Data Entry System Screens

#14c Eligible Supplemental Benefits as Defined in Chapter 4 – Base 6

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 186 of 244

CY 2016 PBP Data Entry System Screens

#14c Eligible Supplemental Benefits as Defined in Chapter 4 – Base 7

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 187 of 244

CY 2016 PBP Data Entry System Screens

#14c Eligible Supplemental Benefits as Defined in Chapter 4 – Base 8

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 188 of 244

CY 2016 PBP Data Entry System Screens

#14c Eligible Supplemental Benefits as Defined in Chapter 4 – Base 9

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 189 of 244

CY 2016 PBP Data Entry System Screens

#14d Kidney Disease Education Services – Base 1

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 190 of 244

CY 2016 PBP Data Entry System Screens

#14d Kidney Disease Education Services – Base 2

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 191 of 244

CY 2016 PBP Data Entry System Screens

#14d Kidney Disease Education Services – Base 3

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 192 of 244

CY 2016 PBP Data Entry System Screens

#14e Diabetes Self-management Training – Base 1

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 193 of 244

CY 2016 PBP Data Entry System Screens

#14e Diabetes Self-management Training – Base 2

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 194 of 244

CY 2016 PBP Data Entry System Screens

#14e Diabetes Self-management Training – Base 3

Fu Associates, Ltd.

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 195 of 244

#15 Medicare Part B Rx Drugs – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 196 of 244

#15 Medicare Part B Rx Drugs – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 197 of 244

#15 Medicare Part B Rx Drugs – Notes

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 198 of 244

#15 Home Infusion Bundled Services

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 199 of 244

#16a Preventive Dental – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 200 of 244

#16a Preventive Dental – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 201 of 244

#16a Preventive Dental – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 202 of 244

#16a Preventive Dental – Base 4

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 203 of 244

#16a Preventive Dental – Base 5

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 204 of 244

#16b Comprehensive Dental – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 205 of 244

#16b comprehensive Dental – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 206 of 244

#16b Comprehensive Dental – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 207 of 244

#16b Comprehensive Dental – Base 4

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 208 of 244

#16b Comprehensive Dental – Base 5

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 209 of 244

#16b Comprehensive Dental – Base 6

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 210 of 244

#17a Eye Exams – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 211 of 244

#17a Eye Exams – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 212 of 244

#17a Eye Exams – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 213 of 244

#17b Eyewear – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 214 of 244

#17b Eyewear – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 215 of 244

#17b Eyewear – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 216 of 244

#17b Eyewear – Base 4

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 217 of 244

#17b Eyewear – Base 5

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 218 of 244

#17b Eyewear – Base 6

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 219 of 244

#18a Hearing Exams – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 220 of 244

#18a Hearing Exams – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 221 of 244

#18a Hearing Exams – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 222 of 244

#18a Hearing Exams – Base 4

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 223 of 244

#18b Hearing Aids – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 224 of 244

#18b Hearing Aids – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 225 of 244

#18b Hearing Aids – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 226 of 244

#18b Hearing Aids – Base 4

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 227 of 244

#18b Hearing Aids – Base 5

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 228 of 244

#20 Outpatient Drugs – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 229 of 244

#20 Outpatient Drugs – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 230 of 244

#20 Outpatient Drugs – Base 3

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 231 of 244

#20 Outpatient Drugs – Base 4

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 232 of 244

#20 Outpatient Drugs – Notes (Optional)

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 233 of 244

#20 Outpatient Drugs – Group 1 – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 234 of 244

#20 Outpatient Drugs – Group 1 – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 235 of 244

#20 Outpatient Drugs – Group 2 – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 236 of 244

#20 Outpatient Drugs – Group 2 – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 237 of 244

#20 Outpatient Drugs – Group 3 – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 238 of 244

#20 Outpatient Drugs – Group 3 – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 239 of 244

#20 Outpatient Drugs – Group 4 – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 240 of 244

#20 Outpatient Drugs – Group 4 – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 241 of 244

#20 Outpatient Drugs – Group 5 – Base 1

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 242 of 244

#20 Outpatient Drugs – Group 5 – Base 2

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 243 of 244

#20 Home Infusion Bundled Services

Fu Associates, Ltd.

CY 2016 PBP Data Entry System Screens

CY2016 PBP – Section B
12/5/2014
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

Page 244 of 244


File Typeapplication/pdf
File TitleCY 2016 PBP Data Entry System Screens
AuthorScott Meyer
File Modified2014-12-05
File Created2014-12-05

© 2024 OMB.report | Privacy Policy