CMS-P0015A English Section by Section

BOX STBEG

BOX STBEG

9:21:12 AM Wednesday, March 27, 2013

Page Order # :

5

Page 1 of 365

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 COVERED BY A
MEDICARE PRESCRIPTION DRUG PLAN ANYTIME DURING THE
CURRENT ROUND) 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

MHMOAnytimeWithoutR
x

SP covered by Medicare Managed Care (Medicare

Advantage Plan) without RX during curr. rnd=

There is a PLAN where PLANTYPE=5/MHMO & PLRO

where (PLROPLAN=PLANNUM & PLRORND=curr.round

& COVANYTM=1/Yes & MHMORX^=1/Yes)).

Exclude Deleted Plans. See T.N. 52.

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.

9:21:12 AM Wednesday, March 27, 2013

Page 2 of 365

BOX STBEG
DESIGN NOTES

9:21:12 AM Wednesday, March 27, 2013

Page 3 of 365

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:

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).

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:
9:21:13 AM Wednesday, March 27, 2013

Page 4 of 365

ST1

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

MAPLAN: (MANAGED CARE PLAN NAME)

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

9:21:14 AM Wednesday, March 27, 2013

Page 5 of 365

ST1

Field1:

MHMOSTMT

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

9:21:16 AM Wednesday, March 27, 2013

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 365

ST1
65

MHMOCurrent

SP has a current Medicare Managed Care plan
(Medicare Advantage 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

9:21:16 AM Wednesday, March 27, 2013

Page 7 of 365

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" (MHMO, TRICARE, or Medicare Prescription
Drug plan) or there was a (MHMO, TRICARE, or Medicare
Prescription Drug plan) "current" at the time of the previous round
interview, then display "Please include…]".
Else do not display.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

9:21:17 AM Wednesday, March 27, 2013

Page 8 of 365

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:

[PROBE IF NECESSARY: Do you have any statements or paper
from Medicare, insurance, or TRICARE [that [you/(SP)] received
since the last interview]? (Please include any statements received
about [your/(SP's)] prescription drug benefit.)]
Int. Instr II:

INPUT FIELDS / ROUTING

MCSAVAIL

Field1:
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
9:21:18 AM Wednesday, March 27, 2013

Page 9 of 365

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.

355

TricareCurrent

There is a "current" Tricare plan =

There is a PLAN where PLAN.PLANTYPE = 6/Tricare &

PLRO where (PLRO.PLROPLAN = PLAN.PLANNUM &

PLRORND = current round & (PLRO.COVTIME =

1/WholeTime or PLRO.COVNOW = 1/Yes)).

Exclude Deleted Plans. See T.N. 52.

29

CurrMedManageCarePl
an - Change to 65.

SP currently in Medicare Managed Care Plan (Medicare

Advantage 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.

349

ThisMPDPCurrentPrevR
nd

This MPDP Plan was "current" at the time of the previous

round interview =

For this PLAN, there is a PLRO where

(PLRO.PLROPLAN=PLAN.PLANNUM &

PLRO.PLRORND=previous round &

PLRO.COVCURNT=1/Yes).

Exclude Deleted Plans. See T.N. 52.

72

TricareCurrentPrevRnd

Tricare "current" at the time of the previous round

interview =

There is a PLAN where PLAN.PLANTYPE=6/Tricare &

PLRO where (PLROPLAN=PLAN.PLANNUM &

PLRORND=previous round and

(COVTIME=1/WholeTime or COVNOW=1/Yes)).

Exclude Deleted Plans. See T.N. 52.

Exclude plans stopped in HIS. See T.N. 476.

51

MHMOCurrPrevRnd

Medicare Managed Care plan (Medicare Advantage plan)

"current" at time of previous round interview =

There is a PLAN where PLANTYPE=5/MHMO & PLRO

where (PLROPLAN=PLANNUM & PLRORND=previous

round & COVCURNT=1/Yes)).

Exclude Deleted Plans. See T.N. 52.

Exclude plans stopped in HIS. See T.N. 476.

476

HISStoppedPlans

Plans stopped in HIS that are not valid for displays or

checks =

Any PLAN where PLAN.PLANSFLG=1/Yes is a PLAN

stopped in HIS.

DESIGN NOTES
9:21:19 AM Wednesday, March 27, 2013

Page 10 of 365

ST2

9:21:19 AM Wednesday, March 27, 2013

Page 11 of 365

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:

9:21:19 AM Wednesday, March 27, 2013

Page 12 of 365

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

Field1:

STHIREP

( 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

Route

Empty

ST4 - MATCHST ( STQ1110 )

BACKGROUND VARIABLE ASSIGNMENTS

9:21:21 AM Wednesday, March 27, 2013

Page 13 of 365

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

9:21:21 AM Wednesday, March 27, 2013

Page 14 of 365

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 has a "current" (MHMO, TRICARE, or Medicare Prescription
Drug plan) or there was a (MHMO, TRICARE, or Medicare
Prescription Drug plan) "current" at the time of the previous round
interview, then display "SELECT.." for Interviewer Instruction 2.
Else do not display.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
9:21:21 AM Wednesday, March 27, 2013

SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
Page 15 of 365

ST4
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)
[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 "MPDP STATEMENT OR MA/TRICARE PRESCRIPTION
DRUG BUNDLE" AT THE NEXT SCREEN FOR ALL STATEMENTS
FROM THE SP’S "(MPDP)" PLAN, "(MHMO)" PLAN OR TRICARE
PLAN THAT REPORTS 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

Route

Empty

ST5 - ST_CHARGEBUNDLE ( STQ1120 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

9:21:23 AM Wednesday, March 27, 2013

Page 16 of 365

ST4
355

TricareCurrent

There is a "current" Tricare plan =

There is a PLAN where PLAN.PLANTYPE = 6/Tricare &

PLRO where (PLRO.PLROPLAN = PLAN.PLANNUM &

PLRORND = current round & (PLRO.COVTIME =

1/WholeTime or PLRO.COVNOW = 1/Yes)).

Exclude Deleted Plans. See T.N. 52.

29

CurrMedManageCarePl
an - Change to 65.

SP currently in Medicare Managed Care Plan (Medicare

Advantage 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.

349

ThisMPDPCurrentPrevR
nd

This MPDP Plan was "current" at the time of the previous

round interview =

For this PLAN, there is a PLRO where

(PLRO.PLROPLAN=PLAN.PLANNUM &

PLRO.PLRORND=previous round &

PLRO.COVCURNT=1/Yes).

Exclude Deleted Plans. See T.N. 52.

72

TricareCurrentPrevRnd

Tricare "current" at the time of the previous round

interview =

There is a PLAN where PLAN.PLANTYPE=6/Tricare &

PLRO where (PLROPLAN=PLAN.PLANNUM &

PLRORND=previous round and

(COVTIME=1/WholeTime or COVNOW=1/Yes)).

Exclude Deleted Plans. See T.N. 52.

Exclude plans stopped in HIS. See T.N. 476.

51

MHMOCurrPrevRnd

Medicare Managed Care plan (Medicare Advantage plan)

"current" at time of previous round interview =

There is a PLAN where PLANTYPE=5/MHMO & PLRO

where (PLROPLAN=PLANNUM & PLRORND=previous

round & COVCURNT=1/Yes)).

Exclude Deleted Plans. See T.N. 52.

Exclude plans stopped in HIS. See T.N. 476.

476

HISStoppedPlans

Plans stopped in HIS that are not valid for displays or

checks =

Any PLAN where PLAN.PLANSFLG=1/Yes is a PLAN

stopped in HIS.

DESIGN NOTES

9:21:23 AM Wednesday, March 27, 2013

Page 17 of 365

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:

COL #

9:21:23 AM Wednesday, March 27, 2013

HEADER

INSTRUCTIONS

1

Bundle #

Display COST.COSTNUM.

2

Statement
Source(s)

Display COST.STTYPE response text.

Page 18 of 365

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".
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

RX 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

9:21:24 AM Wednesday, March 27, 2013

Page 19 of 365

ST5

Field1:
Cheshire Name:
Item Text display:

ST_CHARGEBUNDLE

( STQ1120 )

TEMP

Display "AND" in all response options in BOLD.

Item Text:

Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:

Drop Down List:
Lookup File:
Lookup File Name:

String

TCOSTPICK135
1
No

No

Number Label
1 [Continuous answer.]

FieldSize:
Min Value:

Max Value:

Mask:

135

Route
BOX ST5A - (STQ1121 )

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.STTYPE
COST.MCARTYPE
CORO.COROCOST
CORO.CORORND
CORO.COROTYPE
BASE.LASTCOST

Charge Bundle COST Number
Current Round
1/ST
0
Statement Type Reported at ST5.
MSN Type
Charge Bundle COST number
Current Round
1/ST
Highest COST.COSTNUM.

NOTE: COST.STATTYPE is set at BOX ST5B based on ST5 - COST.STTYPE and ST5A ­
COST.PDPTYPE.

SOFT EDIT CHECKS

HARD EDIT CHECKS

9:21:24 AM Wednesday, March 27, 2013

Page 20 of 365

ST5
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.

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.

468

TypeOfStatement

Type of Statement = COST.STATTYPE.

DESIGN NOTES
ST5 is called from NS and CPS when SP reports having a statement.

9:21:24 AM Wednesday, March 27, 2013

Page 21 of 365

BOX ST5A

BOX ST5A

Page Order # :

130

BOX INSTRUCTIONS
( STQ1121 )

IF ST5 – STTYPE = 8/MPDPorMAorTricare THEN GO TO ST5A - PDPTYPE (
STQ1122 ).
ELSE GO TO BOX ST5B - (STQ1123 ).

ASSIGNMENTS

TECHNICAL NOTES

DESIGN NOTES

9:21:24 AM Wednesday, March 27, 2013

Page 22 of 365

ST5A

ST5A

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

PDPTYPE

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

135

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:

SELECT THE TYPE OF PRESCRIPTION DRUG STATEMENT FOR
THIS BUNDLE.

Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING

9:21:25 AM Wednesday, March 27, 2013

Page 23 of 365

ST5A

Field1:

PDPTYPE

Cheshire Name:

( STQ1122 )

COST.PDPTYPE

Item Text display:

Item Text:

Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated

TPDPType
1
No
No

Number Label
1 MPDP

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX ST5B - (STQ1123 )

2

English text: MEDICARE PRESCRIPTION DRUG BENEFIT STATEMENT
MedAdvantage
BOX ST5B - (STQ1123 )

3

English text: MEDICARE ADVANTAGE STATEMENT
Tricare
BOX ST5B - (STQ1123 )
English text: TRICARE STATEMENT

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

9:21:25 AM Wednesday, March 27, 2013

Page 24 of 365

BOX ST5B

BOX ST5B

Page Order # :

138

BOX INSTRUCTIONS
( STQ1123 )

SET STATEMENT TYPE. .
GO TO BOX ST5 - (STQ1125 ).

ASSIGNMENTS
STATTYPE

If ST5A-PDPTYPE asked in the current round and
(ST5-STTYPE = 8/MPDPorMAorTricare and (ST5APDPTYPE = 1/MPDP or 2/MedAdvantage))), set
COST.STATTYPE = 8/MPDPBenefit.
Else If ST5A-PDPTYPE asked in the current round
and (ST5-STTYPE = 8/MPDPorMAorTricare and
ST5A- PDPTYPE = 3/Tricare), set COST.STATTYPE
= 4/Tricare.
Else if ST5-STTYPE = 1/Medicare, set
COST.STATTYPE = 1/Medicare.
Else if ST5-STTYPE = 2/Insurance, set
COST.STATTYPE = 2/Insurance.
Else if ST5-STTYPE = 3MedicareAndInsurance, set
COST.STATTYPE = 3/MedicareAndInsurance.
Else if ST5-STTYPE = 4/Tricare, set
COST.STATTYPE = 4/Tricare.
Else if ST5-STTYPE = 5/MedicareAndTricare, set
COST.STATTYPE = 5/MedicareAndTricare.
Else if ST5-STTYPE = 6/TricareAndInsurance, set
COST.STATTYPE = 6/TricareAndInsurance.
Else if ST5-STTYPE =
7/MedicareAndTricareAndInsurance, set
COST.STATTYPE =
7/MedicareAndTricareAndInsurance.

TECHNICAL NOTES

DESIGN NOTES

9:21:26 AM Wednesday, March 27, 2013

Page 25 of 365

BOX ST5

BOX ST5

Page Order # :

140

BOX INSTRUCTIONS
( STQ1125 )

IF TYPE OF STATEMENT = 1/Medicare, 3/MedicareAndInsurance,
5/MedicareAndTricare, OR 7/MedicareAndTricareAndInsurance, GO TO ST7 ­
MSNCLNUM ( STQ1190 ).
ELSE IF TYPE OF STATEMENT = 2/Insurance OR 6/TricareAndInsurance,
GO TO ST10 - INSCLNUM ( STQ1330 ).
ELSE IF TYPE OF STATEMENT = 4/Tricare AND ST5 - STTYPE = 4/Tricare,
GO TO ST11 - TRICLNUM ( STQ1350 ).
ELSE GO TO ST11B - PDPBEGMM ( STQ1354 ).

ASSIGNMENTS

TECHNICAL NOTES
468

TypeOfStatement

Type of Statement = COST.STATTYPE.

DESIGN NOTES
BOX ST5 routes all statements where ST5 - STTYPE =
8/MPDPorMAorTricare to ST11B, including charge bundles where
COST.STATTYPE = 4/Tricare.

9:21:26 AM Wednesday, March 27, 2013

Page 26 of 365

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

9:21:27 AM Wednesday, March 27, 2013

Page 27 of 365

ST7
KNOW".
Question Text:
DO NOT ENTER ANY CLAIM CONTROL NUMBERS IN
COMMENTS.

Int. Instr II:

INPUT FIELDS / ROUTING

Field1:

MSNCLNUM

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 )

9:21:29 AM Wednesday, March 27, 2013

Page 28 of 365

ST7

Field2:

MSNCLNM2

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

Route

Empty

BOX ST7 - (STQ1240 )

Don't know

ST7 - MSNCLNM3 ( STQ1210 )

9:21:32 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

63

Route
ST7 - MSNCLNM3 ( STQ1210 )

Page 29 of 365

ST7

Field3:

MSNCLNM3

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

Route

Empty

BOX ST7 - (STQ1240 )

Don't know

ST7 - MSNCLNM4 ( STQ1220 )

9:21:34 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

63

Route
ST7 - MSNCLNM4 ( STQ1220 )

Page 30 of 365

ST7

Field4:

MSNCLNM4

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

Route

Empty

BOX ST7 - (STQ1240 )

Don't know

ST7 - MSNCLNM5 ( STQ1230 )

9:21:37 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

63

Route
ST7 - MSNCLNM5 ( STQ1230 )

Page 31 of 365

ST7

Field5:

MSNCLNM5

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

Route

Empty

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.

9:21:38 AM Wednesday, March 27, 2013

Page 32 of 365

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.

9:21:38 AM Wednesday, March 27, 2013

Page 33 of 365

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

9:21:38 AM Wednesday, March 27, 2013

Page 34 of 365

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

9:21:38 AM Wednesday, March 27, 2013

Page 35 of 365

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

9:21:39 AM Wednesday, March 27, 2013

Page 36 of 365

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

9:21:39 AM Wednesday, March 27, 2013

Page 37 of 365

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)

9:21:40 AM Wednesday, March 27, 2013

Page 38 of 365

ST9
SECOND TIME: (SECOND MSN CLAIM CONTROL NUMBER)
WHICH IS CORRECT?

Int. Instr II:
INPUT FIELDS / ROUTING

Field1:

WHICHNUM

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

9:21:42 AM Wednesday, March 27, 2013

Page 39 of 365

ST9

Field2:

NEWCLNUM

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

Route

Don't know

BOX ST9 - (STQ1320 )

FieldSize:
Min Value:

Max Value:

Mask:

63

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
9:21:43 AM Wednesday, March 27, 2013

Page 40 of 365

ST9

DESIGN NOTES

9:21:43 AM Wednesday, March 27, 2013

Page 41 of 365

BOX ST9

BOX ST9

Page Order # :

220

BOX INSTRUCTIONS
( STQ1320 )

IF TYPE OF STATEMENT = 3/MedicareAndInsurance OR
7/MedicareAndTricareAndInsurance, GO TO ST10 - INSCLNUM ( STQ1330 ).
ELSE IF TYPE OF STATEMENT = 5/MedicareAndTricare, GO TO ST11 TRICLNUM ( STQ1350 ).
ELSE GO TO ST12 - INCTYPE ( STQ1390 ).

ASSIGNMENTS

TECHNICAL NOTES
468

TypeOfStatement

Type of Statement = COST.STATTYPE.

DESIGN NOTES

9:21:43 AM Wednesday, March 27, 2013

Page 42 of 365

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

9:21:44 AM Wednesday, March 27, 2013

Page 43 of 365

ST10

Field1:

INSCLNUM

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

Route

Don't know

BOX ST10 - (STQ1340 )

FieldSize:
Min Value:
Max Value:
Mask:

15

Route
BOX ST10 - (STQ1340 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

9:21:45 AM Wednesday, March 27, 2013

Page 44 of 365

BOX ST10

BOX ST10

Page Order # :

240

BOX INSTRUCTIONS
( STQ1340 )

IF TYPE OF STATEMENT = 6/TricareAndInsurance OR
7/MedicareAndTricareAndInsurance, GO TO ST11 - TRICLNUM ( STQ1350 ).
ELSE GO TO ST12 - INCTYPE ( STQ1390 ).

ASSIGNMENTS

TECHNICAL NOTES
468

TypeOfStatement

Type of Statement = COST.STATTYPE.

DESIGN NOTES

9:21:45 AM Wednesday, March 27, 2013

Page 45 of 365

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

9:21:46 AM Wednesday, March 27, 2013

Page 46 of 365

ST11

Field1:

TRICLNUM

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

Route

Don't know

ST12 - INCTYPE ( STQ1390 )

FieldSize:
Min Value:
Max Value:
Mask:

15

Route
ST12 - INCTYPE ( STQ1390 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

9:21:47 AM Wednesday, March 27, 2013

Page 47 of 365

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:

9:21:48 AM Wednesday, March 27, 2013

Page 48 of 365

ST11B
Context Header:

SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)
TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)

Int. Instr I:

ENTER THE BEGINNING AND ENDING DATES OF SERVICE
FROM THE PRESCRIPTION DRUG BENEFIT STATEMENT.

Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING
PDPBEGMM

Field1:
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

Route

Don't know

ST11B - PDPBEGDD ( STQ1356 )

Refusal

ST11B - PDPBEGDD ( STQ1356 )

9:21:50 AM Wednesday, March 27, 2013

FieldSize:

Min Value:
Max Value:
Mask:

01

12

Route
ST11B - PDPBEGDD ( STQ1356 )

Page 49 of 365

ST11B

Field2:

PDPBEGDD

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

Route

Don't know

ST11B - PDPBEGYY ( STQ1358 )

Refusal

ST11B - PDPBEGYY ( STQ1358 )

9:21:53 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

2
1
31

Route
ST11B - PDPBEGYY ( STQ1358 )

Page 50 of 365

ST11B

Field3:

PDPBEGYY

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

Route

Don't know

ST11B - PDPENDMM ( STQ1362 )

Refusal

ST11B - PDPENDMM ( STQ1362 )

9:21:56 AM Wednesday, March 27, 2013

FieldSize:

Min Value:
Max Value:
Mask:

0

99

Route
ST11B - PDPENDMM ( STQ1362 )

Page 51 of 365

ST11B

Field4:

PDPENDMM

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

Route

Don't know

ST11B - PDPENDDD ( STQ1364 )

Refusal

ST11B - PDPENDDD ( STQ1364 )

9:21:58 AM Wednesday, March 27, 2013

FieldSize:

Min Value:
Max Value:
Mask:

01

12

Route
ST11B - PDPENDDD ( STQ1364 )

Page 52 of 365

ST11B

Field5:

PDPENDDD

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

Route

Don't know

ST11B - PDPENDYY ( STQ1366 )

Refusal

ST11B - PDPENDYY ( STQ1366 )

9:22:01 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

2
1
31

Route
ST11B - PDPENDYY ( STQ1366 )

Page 53 of 365

ST11B

Field6:

PDPENDYY

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

Route

Don't know

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
9:22:02 AM Wednesday, March 27, 2013

Page 54 of 365

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

9:22:02 AM Wednesday, March 27, 2013

Page 55 of 365

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

9:22:02 AM Wednesday, March 27, 2013

Page 56 of 365

ST12

Field1:

INCTYPE

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 ((TYPE OF STATEMENT = 8/MPDPBenefit) or (TYPE OF

STATEMENT = 4/Tricare and ST5 - STTYPE =

8/MPDPorMAorTRICARE)), 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 ((TYPE OF STATEMENT = 8/MPDPBenefit) or (TYPE OF

9:22:04 AM Wednesday, March 27, 2013

Page 57 of 365

ST12
STATEMENT = 4/Tricare and ST5 - STTYPE =

8/MPDPorMAorTRICARE)), response to ST12 - INCTYPE should not

include 2/HHVisits.

If not true, display message "PLEASE VERIFY THAT HOME

HEALTH VISITS ARE INCLUDED IN CHARGE BUNDLE."

Edit # 3:

If ((TYPE OF STATEMENT = 8/MPDPBenefit) or (TYPE OF

STATEMENT = 4/Tricare and ST5 - STTYPE =

8/MPDPorMAorTRICARE)), 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
468

TypeOfStatement

Type of Statement = COST.STATTYPE.

DESIGN NOTES

9:22:04 AM Wednesday, March 27, 2013

Page 58 of 365

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

9:22:04 AM Wednesday, March 27, 2013

Page 59 of 365

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 alphabetical order by PROV.PROVNAME.

Roster/Grid display:

COL #

HEADER

INSTRUCTIONS

1

Provider Name

Display PROV.PROVNAME.

2

Billing/Group
Practice Name

Display PROV.GROUPNAM.

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?

9:22:04 AM Wednesday, March 27, 2013

Page 60 of 365

ST13
Question Text:

SELECT OR ADD ONLY ONE PROVIDER.

Int. Instr II:
INPUT FIELDS / ROUTING

Field1:
Cheshire Name:

PROVIDER_STDATE

( STQ1410 )

TEMP

Item Text display:

Item Text:

Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:

Drop Down List:
Lookup File:
Lookup File Name:

String

TProvPick135
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

See additional instructions below.

COSTPROV

Set COST.COSTPROV = PROV.PROVNUM of
provider selected at ST13.

PRVROSTR

If Provider added, set PROV.PRVROSTR =
15/STProviderServiceDates.

SOFT EDIT CHECKS

HARD EDIT CHECKS

9:22:05 AM Wednesday, March 27, 2013

Page 61 of 365

ST13

TECHNICAL NOTES

DESIGN NOTES
Interviewer can add or select Provider at this roster.

9:22:05 AM Wednesday, March 27, 2013

Page 62 of 365

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, (PROVIDER NAME), 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.

9:22:05 AM Wednesday, March 27, 2013

Page 63 of 365

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

9:22:06 AM Wednesday, March 27, 2013

Page 64 of 365

ST14

Field1:

STDATEUPD

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

9:22:07 AM Wednesday, March 27, 2013

Page 65 of 365

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, (PROVIDER NAME), 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:

9:22:07 AM Wednesday, March 27, 2013

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 365

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

9:22:08 AM Wednesday, March 27, 2013

Page 67 of 365

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

9:22:08 AM Wednesday, March 27, 2013

Page 68 of 365

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

9:22:08 AM Wednesday, March 27, 2013

Page 69 of 365

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.

9:22:08 AM Wednesday, March 27, 2013

Page 70 of 365

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, (PROVIDER NAME), 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:

9:22:09 AM Wednesday, March 27, 2013

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 71 of 365

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

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:

ADD THE MISSING EVENT DATE(S) IN THIS CHARGE BUNDLE.

Question Text:
Int. Instr II:

ADD ALL EVENT DATES FOR THIS PROVIDER.

INPUT FIELDS / ROUTING

9:22:10 AM Wednesday, March 27, 2013

Page 72 of 365

ST16

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.]

FieldSize:
Min Value:
Max Value:
Mask:

135

Route
BOX ST16A - (STQ1450 )

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.

EVCHGLOC

If Event added, set EVNT.EVCHGLOC = 'ST'.

SOFT EDIT CHECKS

9:22:10 AM Wednesday, March 27, 2013

Page 73 of 365

ST16
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

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.

9:22:10 AM Wednesday, March 27, 2013

Page 74 of 365

ST16
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.

DESIGN NOTES
Interviewer can only add events at this roster.

9:22:10 AM Wednesday, March 27, 2013

Page 75 of 365

BOX ST16A

BOX ST16A

Page Order # :

370

BOX INSTRUCTIONS
( STQ1450 )

IF AT LEAST ONE EVENT DATE ADDED AT ST16 IS 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.

DESIGN NOTES

9:22:10 AM Wednesday, March 27, 2013

Page 76 of 365

BOX ST16B

BOX ST16B

Page Order # :

375

BOX INSTRUCTIONS
( STQ1555 )

IF AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU', 'IP', 'OP', OR 'MP'
EVENT TYPE, GO TO ST17 - STDATEINTRO ( STQ1560 ).
ELSE GO TO BOX ST17 - (STQ1570 ).

ASSIGNMENTS

TECHNICAL NOTES
241

TypeOfEvent

Type of Event =
EVNT.EVNTTYPE.

DESIGN NOTES
We do not display ST17 Introduction if EVNT.EVNTTYPE = 'ER', 'IU', 'SD',
or 'SL' since we do not collect event details for these types of events.

9:22:10 AM Wednesday, March 27, 2013

Page 77 of 365

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

9:22:11 AM Wednesday, March 27, 2013

Page 78 of 365

ST17

Field1:

STDATEINTRO

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

Route

Empty

BOX ST17 - (STQ1570 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

9:22:12 AM Wednesday, March 27, 2013

Page 79 of 365

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
We do not collect ST18 - PROVSPEC if EVNT.EVNTTYPE = 'ER', 'IP',
'OP', 'IU', 'SD', or 'SL'.

9:22:12 AM Wednesday, March 27, 2013

Page 80 of 365

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:

Display name of Provider, (PROVIDER NAME), selected at ST13.

Question display:

Display name of Provider, (PROVIDER NAME), selected at ST13.

Multi Field display:

Vertical Alignment

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

PROVIDER NAME: (PROVIDER NAME)

Int. Instr I:

Question Text:

What kind of medical person is (PROVIDER NAME)?

Int. Instr II:

INPUT FIELDS / ROUTING

9:22:14 AM Wednesday, March 27, 2013

Page 81 of 365

ST18

9:22:16 AM Wednesday, March 27, 2013

Page 82 of 365

ST18

Field1:

PROVSPEC

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
9:22:20 AM Wednesday, March 27, 2013

Page 83 of 365

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

9:22:25 AM Wednesday, March 27, 2013

Page 84 of 365

ST18

91

Other

ST18 - PROVSPOS ( STQ1610 )

English text: OTHER MEDICAL PROVIDER SPECIALTY
Attribute

Route

Don't know

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

9:22:26 AM Wednesday, March 27, 2013

Page 85 of 365

BOX ST18

BOX ST18

Page Order # :

430

BOX INSTRUCTIONS
( STQ1620 )

IF (AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU', 'ER', 'IP', 'OP', 'IU',
OR 'MP' EVENT TYPE) AND (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.

241

TypeOfEvent

Type of Event =
EVNT.EVNTTYPE.

DESIGN NOTES
We do not collect ST19 - VAPLACE if EVNT.EVNTTYPE = 'SD' or 'SL'.

9:22:27 AM Wednesday, March 27, 2013

Page 86 of 365

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:

Display name of Provider, (PROVIDER NAME), selected at ST13.

Question display:

Display name of Provider, (PROVIDER NAME), selected at ST13.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

PROVIDER NAME: (PROVIDER NAME)

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

9:22:27 AM Wednesday, March 27, 2013

Page 87 of 365

ST19

Field1:

VAPLACE

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

Route

Don't know

BOX ST19 - (STQ1650 )

Refusal

BOX ST19 - (STQ1650 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

9:22:28 AM Wednesday, March 27, 2013

Page 88 of 365

BOX ST19

BOX ST19

Page Order # :

460

BOX INSTRUCTIONS
( STQ1650 )

IF (AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU', 'ER', 'IP', 'OP', OR
'MP' EVENT TYPE) AND (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 (AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU', 'ER', 'IP', 'OP',
OR 'MP' EVENT TYPE) AND (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 ST20-HMOASSOC or ST21-HMOREFER if
EVNT.EVNTTYPE = 'IU', 'SD' or 'SL'.

9:22:28 AM Wednesday, March 27, 2013

Page 89 of 365

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:

Display name of Provider, (PROVIDER NAME), selected at ST13.

Question display:

Display name of Provider, (PROVIDER NAME), 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:

PROVIDER NAME: (PROVIDER NAME)

9:22:29 AM Wednesday, March 27, 2013

Page 90 of 365

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

Field1:

HMOASSOC

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

9:22:31 AM Wednesday, March 27, 2013

Deleted plans that are not valid for displays or checks =
Page 91 of 365

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
(Medicare Advantage plan) during the current round =
There is a PLAN where PLANTYPE=5/MHMO & PLRO
where (PLROPLAN=PLANNUM & PLRORND=current
round & 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

9:22:31 AM Wednesday, March 27, 2013

Page 92 of 365

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:

Display name of Provider, (PROVIDER NAME), selected at ST13.

Question display:

Display name of Provider, (PROVIDER NAME), 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:

PROVIDER NAME: (PROVIDER NAME)

9:22:31 AM Wednesday, March 27, 2013

Page 93 of 365

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

Field1:

HMOREFER

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_IN - NAVIGATOR ( STQ1675 )

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

9:22:33 AM Wednesday, March 27, 2013

Page 94 of 365

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

(Medicare Advantage plan) during the current round =

There is a PLAN where PLANTYPE=5/MHMO & PLRO

where (PLROPLAN=PLANNUM & PLRORND=current

round & 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

9:22:33 AM Wednesday, March 27, 2013

Page 95 of 365

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 IP, OP, MP events added at ST16.
In addition, display all other events added for this provider in the
current round as "DONE".
Display all DU, ER, 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:

9:22:33 AM Wednesday, March 27, 2013

Page 96 of 365

ST22A_IN
INPUT FIELDS / ROUTING
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
Roster details will be collected on EVNT:

EVNT key = EVNT.EVNTBASE + EVNT.EVNTNUM

EVNT.EVNTNUM = Number of event selected at ST16.

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
241

TypeOfEvent

Type of Event =
EVNT.EVNTTYPE.

DESIGN NOTES

9:22:34 AM Wednesday, March 27, 2013

Page 97 of 365

BOX ST22A

BOX ST22A

Page Order # :

490

BOX INSTRUCTIONS
( STQ1680 )

FOR THIS EVENT ADDED AT ST16,
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 IP, OP Utilization sections, depending on

EVNTTYPE of event added at ST16.

MP events are handled by BOX ST23A.

DU, ER, IU, SD, SL events do not collect event details.

IP and OP returns to ST at BOX ST23B.

9:22:34 AM Wednesday, March 27, 2013

Page 98 of 365

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

9:22:34 AM Wednesday, March 27, 2013

Page 99 of 365

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:

EVENT MONTH = Display Month of the MP event added at ST16.
Display name of medical provider, (PROVIDER NAME), 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, (PROVIDER NAME), 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:

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

9:22:35 AM Wednesday, March 27, 2013

Page 100 of 365

ST23
Column 1, header = "EVENT TYPE".
Column 1, display =
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:

EVENT MONTH: (EVENT MONTH)
PROVIDER NAME: (PROVIDER NAME)

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

9:22:36 AM Wednesday, March 27, 2013

Page 101 of 365

ST23

Field1:

( STQ1691 )

MPSDVIS

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

Route

Don't know

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
9:22:38 AM Wednesday, March 27, 2013

Page 102 of 365

ST23

9:22:38 AM Wednesday, March 27, 2013

Page 103 of 365

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.

9:22:38 AM Wednesday, March 27, 2013

Page 104 of 365

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.

9:22:38 AM Wednesday, March 27, 2013

Page 105 of 365

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, (PROVIDER NAME), 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:

COL #

9:22:38 AM Wednesday, March 27, 2013

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 106 of 365

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

9:22:39 AM Wednesday, March 27, 2013

Page 107 of 365

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

9:22:40 AM Wednesday, March 27, 2013

Page 108 of 365

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.

9:22:40 AM Wednesday, March 27, 2013

Page 109 of 365

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

9:22:40 AM Wednesday, March 27, 2013

Page 110 of 365

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, (PROVIDER NAME), 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:

9:22:40 AM Wednesday, March 27, 2013

ENTER THE NUMBER OF (EVENT TYPE) VISITS IN (EVENT
MONTH, YEAR) THAT ARE COVERED BY THIS CHARGE.
Page 111 of 365

ST24A
INPUT FIELDS / ROUTING
RVLINKS

Field1:

( 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

Route

Don't know

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

9:22:41 AM Wednesday, March 27, 2013

Page 112 of 365

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

9:22:41 AM Wednesday, March 27, 2013

Page 113 of 365

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

9:22:42 AM Wednesday, March 27, 2013

Page 114 of 365

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),

9:22:42 AM Wednesday, March 27, 2013

Page 115 of 365

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

9:22:43 AM Wednesday, March 27, 2013

Page 116 of 365

ST25

Field1:

STDATEMTCH

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

9:22:44 AM Wednesday, March 27, 2013

Page 117 of 365

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:

If more than one provider linked to charge bundle, display the name
of the most recent provider, (PROVIDER NAME), linked to charge
bundle.

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 Name of Provider, PROV.PROVNAME, for each Provider

Service event.

Display in order of entry.

Roster/Grid display:

COL #

9:22:44 AM Wednesday, March 27, 2013

HEADER

INSTRUCTIONS

1

Type

Display EVNT.EVNTTYPE.

2

Provider Name

Display PROV.PROVNAME where
PROV.PROVNUM = EVNT.EVNTPROV.

Page 118 of 365

ST26
3

Start Date

Display EVENT DATE in "Mon DD YYYY"
format.

4

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.

5

Status

If EVNT.EVNTTYPE = 'IP' and
EVNT.IPSTATUS = 1/StillInHospital,
display "ON".
Else if EVNT.VISTTYPE = 2/RepeatVisit,
display "RV".
Else do not display.

6

# 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.

7

Round

Display 'R' + EVNT.EVNTRNDC. EX:
R45

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)
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

9:22:44 AM Wednesday, March 27, 2013

Page 119 of 365

ST26

Field1:

EVENT_STDATEDEL

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.

9:22:45 AM Wednesday, March 27, 2013

Page 120 of 365

ST26
DESIGN NOTES
DISABLE PREVIOUS PAGE.

9:22:45 AM Wednesday, March 27, 2013

Page 121 of 365

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

9:22:45 AM Wednesday, March 27, 2013

Page 122 of 365

ST27

ST27

Page Order # :

Design Screen Type:

Roster

Fields:

Field 1:

PROVIDER_STHH

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Name:

Home Health 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 alphabetical order by PROV.PROVNAME.

Roster/Grid display:

COL #

HEADER

INSTRUCTIONS

1

Provider Name

Display Provider Name,
PROV.PROVNAME

2

SubProvider Name

If PROV.SUBPROV ^= empty, display
SubProvider name,
PROV.SUBPROV.
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)

9:22:45 AM Wednesday, March 27, 2013

Page 123 of 365

ST27
WHICH HOME HEALTH PROVIDER IS IN THIS CHARGE BUNDLE?

Int. Instr I:
Question Text:

SELECT OR ADD ONLY ONE PROVIDER.

Int. Instr II:
INPUT FIELDS / ROUTING

Field1:
Cheshire Name:

PROVIDER_STHH

( STQ1725 )

TEMP

Item Text display:

Item Text:

Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

String

TProvPick135
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 Home Health Provider Roster, see HOME HEALTH PROVIDER

ROSTER POP-UP specifications for pop-up window programming instructions.

Variables populated in Home Health Provider Roster Pop-Up Window:

PROV.PROVNUM
PROV.PROVRNDC
PROV.PROVNAME

Provider number

Round number

Provider name

See additional instructions below.

COSTPROV

Set COST.COSTPROV = PROV.PROVNUM of
provider selected at ST27.

PRVROSTR

If Provider added, set PROV.PRVROSTR =
16/STHomeHealthProvider.

SOFT EDIT CHECKS

9:22:46 AM Wednesday, March 27, 2013

Page 124 of 365

ST27
HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES
Interviewer can add or select Provider at this roster.

9:22:46 AM Wednesday, March 27, 2013

Page 125 of 365

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, (PROVIDER NAME), 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:

9:22:47 AM Wednesday, March 27, 2013

Page 126 of 365

ST28
(ST CLAIM HEADER)

SURVEY REFERENCE PERIOD: (SURVEY REFERENCE DATE)

TO (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)

PROVIDER: (PROVIDER NAME)

Context Header:

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 )

9:22:50 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

2
01
12

Route
ST28 - COSTBEGD ( STQ1731 )

Page 127 of 365

ST28

Field2:

COSTBEGD

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

Route

Don't know

ST28 - COSTBEGY ( STQ1732 )

Refusal

ST28 - COSTBEGY ( STQ1732 )

9:22:52 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

2
1
31

Route
ST28 - COSTBEGY ( STQ1732 )

Page 128 of 365

ST28

Field3:

COSTBEGY

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

Route

Don't know

ST28 - COSTENDM ( STQ1733 )

Refusal

ST28 - COSTENDM ( STQ1733 )

9:22:55 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

2
00
99

Route
ST28 - COSTENDM ( STQ1733 )

Page 129 of 365

ST28

Field4:

COSTENDM

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

Route

Don't know

ST28 - COSTENDD ( STQ1734 )

Refusal

ST28 - COSTENDD ( STQ1734 )

9:22:57 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

2
01
12

Route
ST28 - COSTENDD ( STQ1734 )

Page 130 of 365

ST28

Field5:

COSTENDD

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

Route

Don't know

ST28 - COSTENDY ( STQ1735 )

Refusal

ST28 - COSTENDY ( STQ1735 )

9:23:00 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

2
1
31

Route
ST28 - COSTENDY ( STQ1735 )

Page 131 of 365

ST28

Field6:

COSTENDY

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

Route

Don't know

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)."

9:23:01 AM Wednesday, March 27, 2013

Page 132 of 365

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.

9:23:01 AM Wednesday, March 27, 2013

Page 133 of 365

ST28
DESIGN NOTES

9:23:01 AM Wednesday, March 27, 2013

Page 134 of 365

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

9:23:01 AM Wednesday, March 27, 2013

Page 135 of 365

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, (PROVIDER NAME), 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
9:23:02 AM Wednesday, March 27, 2013

Page 136 of 365

ST30

Field1:

HHEVNTTYPE

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

9:23:02 AM Wednesday, March 27, 2013

Page 137 of 365

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

9:23:03 AM Wednesday, March 27, 2013

Page 138 of 365

ST31

Field1:

STHHINTRO

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

Route

Empty

BOX ST31A - (STQ1765 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

9:23:04 AM Wednesday, March 27, 2013

Page 139 of 365

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.

9:23:04 AM Wednesday, March 27, 2013

Page 140 of 365

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.

9:23:04 AM Wednesday, March 27, 2013

Page 141 of 365

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".

9:23:05 AM Wednesday, March 27, 2013

Page 142 of 365

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".

9:23:06 AM Wednesday, March 27, 2013

Page 143 of 365

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

9:23:06 AM Wednesday, March 27, 2013

Page 144 of 365

ST32

Field1:

( STQ1775 )

STHHMTCH

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

Route

Empty

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

9:23:07 AM Wednesday, March 27, 2013

Page 145 of 365

BOX ST33

BOX ST33

Page Order # :

585

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

9:23:07 AM Wednesday, March 27, 2013

Page 146 of 365

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 =

9:23:08 AM Wednesday, March 27, 2013

Page 147 of 365

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:

9:23:08 AM Wednesday, March 27, 2013

Page 148 of 365

ST34
INPUT FIELDS / ROUTING
STOMUPD

Field1:
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

9:23:09 AM Wednesday, March 27, 2013

Page 149 of 365

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

9:23:10 AM Wednesday, March 27, 2013

HEADER

INSTRUCTIONS
If EVNT.RENTPROB=2/Rent and
((EVNT.RENT2BUY ^=
2/PurchasedRentToBuy) or
(EVNT.RENT2BUY = EMPTY)), display
"R".
Else do not display.

Page 150 of 365

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

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

9:23:10 AM Wednesday, March 27, 2013

Page 151 of 365

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 ^=

9:23:11 AM Wednesday, March 27, 2013

Page 152 of 365

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.

9:23:11 AM Wednesday, March 27, 2013

Page 153 of 365

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

9:23:12 AM Wednesday, March 27, 2013

Page 154 of 365

ST36

Field1:

STOMADD

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

9:23:14 AM Wednesday, March 27, 2013

Page 155 of 365

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.

9:23:14 AM Wednesday, March 27, 2013

Page 156 of 365

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.

9:23:14 AM Wednesday, March 27, 2013

Page 157 of 365

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 #
1

HEADER
Type

9:23:14 AM Wednesday, March 27, 2013

Display EVNT.EVNTTYPE.
If EVNT.RENTPROB=2/Rent and
((EVNT.RENT2BUY ^=
2/PurchasedRentToBuy) or
(EVNT.RENT2BUY = EMPTY)), display
"R".
Else do not display.

2

3

INSTRUCTIONS

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 158 of 365

ST37
4

Purchase or
Repair/Rental

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.

5

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.

6

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.

7

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.

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:
Question Text:
Int. Instr II:

SELECT OTHER MEDICAL EXPENSES THAT ARE IN THIS
CHARGE BUNDLE ON THE (TYPE OF STATEMENT).

INPUT FIELDS / ROUTING

9:23:14 AM Wednesday, March 27, 2013

Page 159 of 365

ST37

Field1:

EVENT_STOM

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

9:23:15 AM Wednesday, March 27, 2013

Existing Event Date is outside survery reference period =
EVNT.EVORPFLAG = 1/ORP.

Page 160 of 365

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.

9:23:15 AM Wednesday, March 27, 2013

Page 161 of 365

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

9:23:15 AM Wednesday, March 27, 2013

Page 162 of 365

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
9:23:16 AM Wednesday, March 27, 2013

Page 163 of 365

ST38

Field1:

MONTHCOV

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

Route

Empty

ST38 - MONCOV96 ( STQ1816 )

Don't know

ST38 - MONCOV96 ( STQ1816 )

Refusal

ST38 - MONCOV96 ( STQ1816 )

9:23:19 AM Wednesday, March 27, 2013

FieldSize:

Min Value:
Max Value:
Mask:

1

72

Route
ST38 - MONCOV96 ( STQ1816 )

Page 164 of 365

ST38

Field2:

MONCOV96

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

Route

Empty

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
9:23:20 AM Wednesday, March 27, 2013

Page 165 of 365

ST38
NUMBER OF MONTHS OR SELECT "LESS THAN 1 MONTH".
TECHNICAL NOTES

DESIGN NOTES

9:23:20 AM Wednesday, March 27, 2013

Page 166 of 365

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

9:23:20 AM Wednesday, March 27, 2013

Page 167 of 365

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

9:23:20 AM Wednesday, March 27, 2013

Page 168 of 365

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

9:23:21 AM Wednesday, March 27, 2013

Page 169 of 365

ST38A

Field1:

NUMLINKS

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

Route

Don't know

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

9:23:22 AM Wednesday, March 27, 2013

Page 170 of 365

ST38A
HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

9:23:22 AM Wednesday, March 27, 2013

Page 171 of 365

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

9:23:22 AM Wednesday, March 27, 2013

Page 172 of 365

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

9:23:23 AM Wednesday, March 27, 2013

Page 173 of 365

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),

9:23:23 AM Wednesday, March 27, 2013

Page 174 of 365

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

9:23:24 AM Wednesday, March 27, 2013

Page 175 of 365

ST39

Field1:

STOMMTCH

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

9:23:24 AM Wednesday, March 27, 2013

Page 176 of 365

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

9:23:25 AM Wednesday, March 27, 2013

HEADER

INSTRUCTIONS
If EVNT.RENTPROB=2/Rent and
EVNT.RENT2BUY ^=
2/PurchasedRentToBuy, display "R".
Else do not display.

Page 177 of 365

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

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:

9:23:25 AM Wednesday, March 27, 2013

Page 178 of 365

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
9:23:26 AM Wednesday, March 27, 2013

Page 179 of 365

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
DISABLE PREVIOUS PAGE.

9:23:26 AM Wednesday, March 27, 2013

Page 180 of 365

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

9:23:26 AM Wednesday, March 27, 2013

Page 181 of 365

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 Name

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)

9:23:26 AM Wednesday, March 27, 2013

Page 182 of 365

ST41
Int. Instr I:
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

Field1:
Cheshire Name:

EVENT_STPM

( STQ1850 )

TEMP

Item Text display:

Item Text:

Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

String

TEvntPick200
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.
9:23:27 AM Wednesday, March 27, 2013

Page 183 of 365

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.

EVCHGLOC

If Event added, set EVNT.EVCHGLOC = 'ST'.

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.

9:23:27 AM Wednesday, March 27, 2013

Page 184 of 365

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:
9:23:28 AM Wednesday, March 27, 2013

Page 185 of 365

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
NUMLINKS

Field1:
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

Route

Don't know

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

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.

9:23:29 AM Wednesday, March 27, 2013

Page 186 of 365

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

9:23:29 AM Wednesday, March 27, 2013

Page 187 of 365

BOX ST42

BOX ST42

Page Order # :

670

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.

9:23:29 AM Wednesday, March 27, 2013

Page 188 of 365

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

9:23:29 AM Wednesday, March 27, 2013

Page 189 of 365

ST43

Field1:

STPMINTRO

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 ( PMQ1183 )

English text: CONTINUE
Attribute

Route

Empty

PM6A_IN - NAVIGATOR ( PMQ1183 )

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.

9:23:30 AM Wednesday, March 27, 2013

Page 190 of 365

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.

9:23:31 AM Wednesday, March 27, 2013

Page 191 of 365

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

9:23:31 AM Wednesday, March 27, 2013

Page 192 of 365

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),

9:23:31 AM Wednesday, March 27, 2013

Page 193 of 365

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

9:23:32 AM Wednesday, March 27, 2013

Page 194 of 365

ST44

Field1:

STPMMTCH

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
1
No
No

Number Label
1 Yes

FieldSize:
Min Value:
Max Value:
Mask:

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

9:23:33 AM Wednesday, March 27, 2013

Page 195 of 365

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 #

9:23:33 AM Wednesday, March 27, 2013

HEADER

INSTRUCTIONS

1

Medicine Name

Display name of PM, EVNT.PMEDNAME.

2

Strength

Display prescription medicine strength
text field, EVNT.PMSTRUNI.

3

# Purchases

Display XCEV.NUMLINKS on XCEV
where XCEV.XCEVEVNT = this
EVNT.EVNTNUM and XCEV.XCEVCOST
= COST.COSTNUM for this charge
bundle.

Page 196 of 365

ST45
Report display:

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

9:23:34 AM Wednesday, March 27, 2013

Page 197 of 365

ST45
XCEV.XCEVEVNT = EVNT.EVNTNUM of event
selected.
SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES
DISABLE PREVIOUS PAGE.

9:23:34 AM Wednesday, March 27, 2013

Page 198 of 365

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

9:23:34 AM Wednesday, March 27, 2013

Page 199 of 365

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

9:23:35 AM Wednesday, March 27, 2013

Page 200 of 365

ST46

Field1:

ORPMESSAGE

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

Route

Empty

BOX ST80 - (STQ2930 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

9:23:36 AM Wednesday, March 27, 2013

Page 201 of 365

BOX ST46

BOX ST46

Page Order # :

800

BOX INSTRUCTIONS
( STQ2010 )

IF (TYPE OF STATEMENT = 2/Insurance OR 6/TricareAndInsurance) OR
(TYPE OF STATEMENT = 4/Tricare AND ST5 – STTTYPE = 4/Tricare) OR
(ST5 - MCARTYPE = 4/MSNPartB), GO TO ST47 - ASGNTAKE ( STQ2020 ).
ELSE GO TO BOX ST47 - (STQ2050 ).

ASSIGNMENTS

TECHNICAL NOTES
468

TypeOfStatement

Type of Statement = COST.STATTYPE.

DESIGN NOTES

9:23:36 AM Wednesday, March 27, 2013

Page 202 of 365

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

9:23:36 AM Wednesday, March 27, 2013

Page 203 of 365

ST47

Field1:

ASGNTAKE

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 ST5 - 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

9:23:37 AM Wednesday, March 27, 2013

Page 204 of 365

BOX ST47

BOX ST47

Page Order # :

840

BOX INSTRUCTIONS
( STQ2050 )

IF ((TYPE OF STATEMENT = 8/MPDPBenefit) or (TYPE OF STATEMENT =
4/Tricare and ST5 - STTYPE = 8/MPDPorMAorTricare)), GO TO ST47A ­
TOTALCHG ( STQ2055 ).
ELSE IF (TYPE OF STATEMENT = 2/Insurance) OR (TYPE OF STATEMENT
= 4/Tricare AND ST5 - STTYPE = 4/Tricare) OR (TYPE OF STATEMENT =
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
TOTALTYP

If ST5 -MCARTYPE ^= 6/MSNPartAInpatient, set
CORO.TOTALTYP = 1/TotalCharge on CORO where
CORO.CORORND = current round and
CORO.COROCOST = this ST charge bundle
COST.COSTNUM.

TECHNICAL NOTES
468

TypeOfStatement

Type of Statement = COST.STATTYPE.

DESIGN NOTES

9:23:37 AM Wednesday, March 27, 2013

Page 205 of 365

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
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:

9:23:38 AM Wednesday, March 27, 2013

Page 206 of 365

ST47A
INPUT FIELDS / ROUTING
TOTALCHG

Field1:
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

Route

Don't know

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.

TOTALAMT

COST.TOTALAMT = ST47A - TOTALCHG.

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

9:23:39 AM Wednesday, March 27, 2013

Page 207 of 365

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:

9:23:41 AM Wednesday, March 27, 2013

Page 208 of 365

ST48
Int. Instr II:

INPUT FIELDS / ROUTING

TOTALCHG

Field1:
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

Route

Don't know

ST48 - MCAPPAMT ( STQ2061 )

Refusal

ST48 - MCAPPAMT ( STQ2061 )

9:23:43 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

0
999999.99
Dollars

Route
ST48 - MCAPPAMT ( STQ2061 )

Page 209 of 365

ST48

Field2:

MCAPPAMT

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

Route

Don't know

ST48 - MCPAYAMT ( STQ2062 )

Refusal

ST48 - MCPAYAMT ( STQ2062 )

9:23:46 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

0
999999.99
Dollars

Route
ST48 - MCPAYAMT ( STQ2062 )

Page 210 of 365

ST48

Field3:

MCPAYAMT

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

Route

Don't know

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.

9:23:47 AM Wednesday, March 27, 2013

Page 211 of 365

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

9:23:47 AM Wednesday, March 27, 2013

Page 212 of 365

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

9:23:47 AM Wednesday, March 27, 2013

Page 213 of 365

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:

9:23:48 AM Wednesday, March 27, 2013

(ST CLAIM HEADER) AMOUNT REMAINING: (AMOUNT
REMAINING)
EVENT: (CHARGE BUNDLE EVENT)
Page 214 of 365

ST49
(CHARGE BUNDLE EVENT) (etc.)
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

If ST49 - STTCHGPAID1 =

3/AmountRemaingWrong, set COST.ARWRONG =

9:23:50 AM Wednesday, March 27, 2013

Page 215 of 365

ST49
1/Yes.
TCHGPAID

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.

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

9:23:50 AM Wednesday, March 27, 2013

Page 216 of 365

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

9:23:50 AM Wednesday, March 27, 2013

Page 217 of 365

ST50
REMAINING)
DO YOU WANT TO MAKE ANY CHANGES?

Int. Instr II:
INPUT FIELDS / ROUTING

Field1:

CHANGAMT

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
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

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

9:23:51 AM Wednesday, March 27, 2013

Page 218 of 365

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:

9:23:52 AM Wednesday, March 27, 2013

Page 219 of 365

ST51
INPUT FIELDS / ROUTING
TOTALCHG

Field1:
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

Route

Don't know

ST51 - MCAPPAMT ( STQ2069 )

Refusal

ST51 - MCAPPAMT ( STQ2069 )

9:23:54 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

0
999999.99
Dollars

Route
ST51 - MCAPPAMT ( STQ2069 )

Page 220 of 365

ST51

Field2:

MCAPPAMT

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

Route

Don't know

ST51 - MCPAYAMT ( STQ2070 )

Refusal

ST51 - MCPAYAMT ( STQ2070 )

9:23:57 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

0
999999.99
Dollars

Route
ST51 - MCPAYAMT ( STQ2070 )

Page 221 of 365

ST51

Field3:

MCPAYAMT

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

Route

Don't know

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."

9:23:58 AM Wednesday, March 27, 2013

Page 222 of 365

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

9:23:58 AM Wednesday, March 27, 2013

Page 223 of 365

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

9:23:58 AM Wednesday, March 27, 2013

Page 224 of 365

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:

9:23:59 AM Wednesday, March 27, 2013

Page 225 of 365

ST52
INPUT FIELDS / ROUTING
TOTALCHG

Field1:
Cheshire Name:

( STQ2080 )

CORO.TOTALCHG

Item Text display:
Item Text:
Label:

Label Position:

AMOUNT PROVIDER 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

Route

Don't know

ST52 - MCAPPAMT ( STQ2081 )

Refusal

ST52 - MCAPPAMT ( STQ2081 )

9:24:02 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

0
999999.99
Dollars

Route
ST52 - MCAPPAMT ( STQ2081 )

Page 226 of 365

ST52

Field2:

MCAPPAMT

Cheshire Name:

( STQ2081 )

COST.MCAPPAMT

Item Text display:
Item Text:
Label:
Label Position:

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

Route

Don't know

ST52 - MCPAYAMT ( STQ2082 )

Refusal

ST52 - MCPAYAMT ( STQ2082 )

9:24:04 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

0
999999.99
Dollars

Route
ST52 - MCPAYAMT ( STQ2082 )

Page 227 of 365

ST52

Field3:

MCPAYAMT

Cheshire Name:
Item Text display:

( STQ2082 )

COST.MCPAYAMT
Always display (PROVIDER/YOU) in label in parenthesis.

Item Text:
Label:
Label Position:

AMOUNT 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

Route

Don't know

ST52 - MAYBBILL ( STQ2083 )

Refusal

ST52 - MAYBBILL ( STQ2083 )

9:24:06 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

0
999999.99
Dollars

Route
ST52 - MAYBBILL ( STQ2083 )

Page 228 of 365

ST52

Field4:

MAYBBILL

Cheshire Name:

( STQ2083 )

COST.MAYBBILL

Item Text display:
Item Text:
Label:
Label Position:

MAXIMUM 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

Route

Don't know

BOX ST52 - (STQ2085 )

FieldSize:
Min Value:
Max Value:
Mask:

0
999999.99
Dollars

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.

9:24:08 AM Wednesday, March 27, 2013

Page 229 of 365

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

9:24:08 AM Wednesday, March 27, 2013

Page 230 of 365

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

9:24:08 AM Wednesday, March 27, 2013

Page 231 of 365

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:

9:24:08 AM Wednesday, March 27, 2013

(ST CLAIM HEADER) AMOUNT REMAINING: (AMOUNT
REMAINING)
EVENT: (CHARGE BUNDLE EVENT)
Page 232 of 365

ST53
(CHARGE BUNDLE EVENT) (etc.)
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

If ST53 - STTCHGPAID1 =

3/AmountRemaingWrong, set COST.ARWRONG =

9:24:10 AM Wednesday, March 27, 2013

Page 233 of 365

ST53
1/Yes.
TCHGPAID

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.

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

9:24:10 AM Wednesday, March 27, 2013

Page 234 of 365

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)

9:24:11 AM Wednesday, March 27, 2013

Page 235 of 365

ST54
DO YOU WANT TO MAKE ANY CHANGES?

Int. Instr II:
INPUT FIELDS / ROUTING

CHANGAMT

Field1:
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

9:24:12 AM Wednesday, March 27, 2013

Page 236 of 365

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:
9:24:13 AM Wednesday, March 27, 2013

Page 237 of 365

ST55
INPUT FIELDS / ROUTING
TOTALCHG

Field1:
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

Route

Don't know

ST55 - MCAPPAMT ( STQ2089 )

Refusal

ST55 - MCAPPAMT ( STQ2089 )

9:24:16 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

0
999999.99
Dollars

Route
ST55 - MCAPPAMT ( STQ2089 )

Page 238 of 365

ST55

Field2:

MCAPPAMT

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

Route

Don't know

ST55 - MCPAYAMT ( STQ2090 )

Refusal

ST55 - MCPAYAMT ( STQ2090 )

9:24:19 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

0
999999.99
Dollars

Route
ST55 - MCPAYAMT ( STQ2090 )

Page 239 of 365

ST55

Field3:

MCPAYAMT

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

Route

Don't know

ST55 - MAYBBILL ( STQ2091 )

Refusal

ST55 - MAYBBILL ( STQ2091 )

9:24:22 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

0
999999.99
Dollars

Route
ST55 - MAYBBILL ( STQ2091 )

Page 240 of 365

ST55

Field4:

MAYBBILL

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

Route

Don't know

BOX ST55 - (STQ2095 )

FieldSize:
Min Value:
Max Value:
Mask:

0
999999.99
Dollars

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."

9:24:24 AM Wednesday, March 27, 2013

Page 241 of 365

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

9:24:24 AM Wednesday, March 27, 2013

Page 242 of 365

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

9:24:24 AM Wednesday, March 27, 2013

Page 243 of 365

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:

9:24:25 AM Wednesday, March 27, 2013

DISREGARD "AMOUNT CHARGED" IF IT APPEARS ON THE
STATEMENT.
Page 244 of 365

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.]

9:24:27 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

0
120

Route
ST56 - NONCOVRD ( STQ2101 )

Page 245 of 365

ST56

Field2:

NONCOVRD

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

Route

Don't know

ST56 - COINSUR ( STQ2102 )

Refusal

ST56 - COINSUR ( STQ2102 )

9:24:30 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

0
999999.99
Dollars

Route
ST56 - COINSUR ( STQ2102 )

Page 246 of 365

ST56

Field3:

COINSUR

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

Route

Don't know

ST56 - MAYBBILL ( STQ2103 )

Refusal

ST56 - MAYBBILL ( STQ2103 )

9:24:32 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

0
999999.99
Dollars

Route
ST56 - MAYBBILL ( STQ2103 )

Page 247 of 365

ST56

Field4:

MAYBBILL

Cheshire Name:

( STQ2103 )

COST.MAYBBILL

Item Text display:
Item Text:
Label:
Label Position:

MAXIMUM 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

Route

Don't know

BOX ST56 - (STQ2105 )

FieldSize:
Min Value:
Max Value:
Mask:

0
999999.99
Dollars

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

9:24:33 AM Wednesday, March 27, 2013

Page 248 of 365

ST56
TECHNICAL NOTES

DESIGN NOTES

9:24:33 AM Wednesday, March 27, 2013

Page 249 of 365

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

9:24:33 AM Wednesday, March 27, 2013

Page 250 of 365

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:

9:24:34 AM Wednesday, March 27, 2013

(ST CLAIM HEADER) AMOUNT REMAINING: (AMOUNT
REMAINING)
EVENT: (CHARGE BUNDLE EVENT)
Page 251 of 365

ST57
(CHARGE BUNDLE EVENT) (etc.)
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

If ST57 - STTCHGPAID1 =

3/AmountRemaingWrong, set COST.ARWRONG =

9:24:36 AM Wednesday, March 27, 2013

Page 252 of 365

ST57
1/Yes.
TCHGPAID

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.

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

9:24:36 AM Wednesday, March 27, 2013

Page 253 of 365

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:
9:24:37 AM Wednesday, March 27, 2013

DO YOU WANT TO MAKE ANY CHANGES?
Page 254 of 365

ST58
INPUT FIELDS / ROUTING
CHANGAMT

Field1:
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
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

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

9:24:37 AM Wednesday, March 27, 2013

Page 255 of 365

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:
9:24:39 AM Wednesday, March 27, 2013

Page 256 of 365

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.]

9:24:41 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

0
120

Route
ST59 - NONCOVRD ( STQ2109 )

Page 257 of 365

ST59

Field2:

NONCOVRD

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

Route

Don't know

ST59 - COINSUR ( STQ2110 )

Refusal

ST59 - COINSUR ( STQ2110 )

9:24:44 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

0
999999.99
Dollars

Route
ST59 - COINSUR ( STQ2110 )

Page 258 of 365

ST59

Field3:

COINSUR

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

Route

Don't know

ST59 - MAYBBILL ( STQ2111 )

Refusal

ST59 - MAYBBILL ( STQ2111 )

9:24:46 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

0
999999.99
Dollars

Route
ST59 - MAYBBILL ( STQ2111 )

Page 259 of 365

ST59

Field4:

MAYBBILL

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

Route

Don't know

BOX ST59 - (STQ2115 )

FieldSize:
Min Value:
Max Value:
Mask:

0
999999.99
Dollars

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

9:24:47 AM Wednesday, March 27, 2013

Page 260 of 365

ST59
TECHNICAL NOTES

DESIGN NOTES

9:24:47 AM Wednesday, March 27, 2013

Page 261 of 365

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

9:24:48 AM Wednesday, March 27, 2013

Page 262 of 365

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:

9:24:49 AM Wednesday, March 27, 2013

Page 263 of 365

ST60
INPUT FIELDS / ROUTING
TOTALCHG

Field1:
Cheshire Name:
Item Text display:

( STQ2120 )

CORO.TOTALCHG
Always display (PROVIDER/FACILITY) in label in
parenthesis.

Item Text:
Label:

Label Position:

AMOUNT (PROVIDER/FACILITY) 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

Route

Don't know

ST60 - NONCOVRD ( STQ2121 )

Refusal

ST60 - NONCOVRD ( STQ2121 )

9:24:51 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

0
999999.99
Dollars

Route
ST60 - NONCOVRD ( STQ2121 )

Page 264 of 365

ST60

Field2:

NONCOVRD

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

Route

Don't know

ST60 - COINSUR ( STQ2122 )

Refusal

ST60 - COINSUR ( STQ2122 )

9:24:54 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

0
999999.99
Dollars

Route
ST60 - COINSUR ( STQ2122 )

Page 265 of 365

ST60

Field3:

COINSUR

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

Route

Don't know

ST60 - MAYBBILL ( STQ2123 )

Refusal

ST60 - MAYBBILL ( STQ2123 )

9:24:57 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

0
999999.99
Dollars

Route
ST60 - MAYBBILL ( STQ2123 )

Page 266 of 365

ST60

Field4:

MAYBBILL

Cheshire Name:

( STQ2123 )

COST.MAYBBILL

Item Text display:
Item Text:
Label:
Label Position:

MAXIMUM 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

Route

Don't know

BOX ST60 - (STQ2125 )

FieldSize:
Min Value:
Max Value:
Mask:

0
999999.99
Dollars

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

9:24:58 AM Wednesday, March 27, 2013

Page 267 of 365

ST60
If (NONCOVRD ^= DK and NONCOVRD ^= RF) and (TOTALCHG ^=

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

9:24:58 AM Wednesday, March 27, 2013

Page 268 of 365

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

9:24:58 AM Wednesday, March 27, 2013

Page 269 of 365

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:

9:24:59 AM Wednesday, March 27, 2013

(ST CLAIM HEADER) AMOUNT REMAINING: (AMOUNT
REMAINING)
EVENT: (CHARGE BUNDLE EVENT)
Page 270 of 365

ST61
(CHARGE BUNDLE EVENT) (etc.)
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

If ST61 - STTCHGPAID1 =

3/AmountRemaingWrong, set COST.ARWRONG =

9:25:01 AM Wednesday, March 27, 2013

Page 271 of 365

ST61
1/Yes.
TCHGPAID

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.

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

9:25:01 AM Wednesday, March 27, 2013

Page 272 of 365

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:
9:25:01 AM Wednesday, March 27, 2013

DO YOU WANT TO MAKE ANY CHANGES?
Page 273 of 365

ST62
INPUT FIELDS / ROUTING
CHANGAMT

Field1:
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
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

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

9:25:02 AM Wednesday, March 27, 2013

Page 274 of 365

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:
9:25:04 AM Wednesday, March 27, 2013

Page 275 of 365

ST63
INPUT FIELDS / ROUTING
TOTALCHG

Field1:
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

Route

Don't know

ST63 - NONCOVRD ( STQ2129 )

Refusal

ST63 - NONCOVRD ( STQ2129 )

9:25:06 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

0
999999.99
Dollars

Route
ST63 - NONCOVRD ( STQ2129 )

Page 276 of 365

ST63

Field2:

NONCOVRD

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

Route

Don't know

ST63 - COINSUR ( STQ2130 )

Refusal

ST63 - COINSUR ( STQ2130 )

9:25:09 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

0
999999.99
Dollars

Route
ST63 - COINSUR ( STQ2130 )

Page 277 of 365

ST63

Field3:

COINSUR

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 )

9:25:12 AM Wednesday, March 27, 2013

FieldSize:
Min Value:
Max Value:
Mask:

0
999999.99
Dollars

Route
ST63 - MAYBBILL ( STQ2131 )

Page 278 of 365

ST63

Field4:

MAYBBILL

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

Route

Don't know

BOX ST63 - (STQ2135 )

FieldSize:
Min Value:
Max Value:
Mask:

0
999999.99
Dollars

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 ^=

9:25:13 AM Wednesday, March 27, 2013

Page 279 of 365

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

9:25:13 AM Wednesday, March 27, 2013

Page 280 of 365

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

9:25:13 AM Wednesday, March 27, 2013

Page 281 of 365

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 - STTYPE ^= 8/MPDPorMAorTricare, 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 - STTYPE ^= 8/MPDPorMAorTricare, display "PROVIDER

NAME".

Else do not display.

If ST5 - STTYPE ^= 8/MPDPorMAorTricare, display "THEN ASK:"

Else display "SELECT…".

Question Text:

If ST5 - STTYPE = 8/MPDPorMAorTricare, display "The total cost of

prescriptions…".

Else do not display.

If ST5 - STTYPE = 8/MPDPorMAorTricare, 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".

9:25:14 AM Wednesday, March 27, 2013

Page 282 of 365

ST64
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.
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 TEXT).] [[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

9:25:15 AM Wednesday, March 27, 2013

Page 283 of 365

ST64

Field1:

STTCHGPAID2

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
1
No
No

Number Label
1 SomeonePaid
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX ST64A - (STQ2700 )

English text: SP OR ANY SOURCE PAID
NothingPaid

BOX ST64A - (STQ2700 )

English text: NOTHING HAS BEEN PAID
Attribute

Route

Don't know

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

9:25:16 AM Wednesday, March 27, 2013

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 284 of 365

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.

468

TypeOfStatement

Type of Statement = COST.STATTYPE.

DESIGN NOTES

9:25:16 AM Wednesday, March 27, 2013

Page 285 of 365

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

9:25:16 AM Wednesday, March 27, 2013

Page 286 of 365

BOX ST64B

BOX ST64B

9:25:16 AM Wednesday, March 27, 2013

Page Order # :

1093

Page 287 of 365

BOX ST64B
BOX INSTRUCTIONS
( STQ2701 )

CREATE SOURCE OF PAYMENT ROSTER .
IF ADMINISTERING ST AND (ONE OR MORE CHARGE BUNDLES
ENTERED IN ST SECTION) AND (ST65 – STADDSOP1 HAS BEEN ASKED
IN THE CURRENT ROUND) AND (PAYMENTS HAVE BEEN COLLECTED AT
ST67), GO TO ST67 - TSOPAMT ( STQ2720 ).
ELSE 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.
9:25:17 AM Wednesday, March 27, 2013

Page 288 of 365

BOX ST64B
Next, store EXTRA HELP:
TSOP.TSOPTEXT = "EXTRA HELP"
TSOP.TSOPTYPE = 12/ExtraHelp.
Next, store COVERAGE GAP DISCOUNT:
TSOP.TSOPTEXT = "COVERAGE GAP DISCOUNT"
TSOP.TSOPTYPE = 13/CoverageGapDiscount.
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

TSOP.TSOPDISP = "(DM)"

Repeat for all DMEMs.
Next, store all Other Sources of Payments (not flagged as deleted) on OSOP:
Store OSOP:
TSOP.TSOPTEXT = OSOP.OSOPTEXT
TSOP.TSOPTYPE = 4/OSOP
TSOP.TSOPOSOP = OSOP.OSOPNUM
IF (OSOP.OSOPISHI ^= NULL & (OSOP.OSOPISHI = DK or RF)), TSOP.TSOPDISP =
"(UNKNOWN)".
ELSE TSOP.TSOPDISP = "(OSOP)".
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.

9:25:17 AM Wednesday, March 27, 2013

Page 289 of 365

BOX ST64B
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

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.

53

PlanTypes

Medicare: PLANTYPE=1/Medicare.

Medicaid: PLANTYPE=2/Medicaid.

Medicare Advantage: 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.

457

ChgBundlePaymEntere
d

One or more charge bundles entered in ST section and

ST65 – STADDSOP1 has been asked in the current

round =

HRND.EVERSTMT = 1/Yes on HRND where

HRND.HRNDRND = current round and (ST65­
STADDSOP1 = 1/YES or 2/NO)

464

STPaymCollected

Payments collected at ST67 =

HRND.STSOPFLG = 1/Yes on HRND where

HRND.HRNDRND = current round. HRND.STSOPFLG

is set to 1/Yes at BOX ST67A after 1st ST charge bundle

where payments collected.

DESIGN NOTES
When administering ST, we will stop probing for new SOP's at ST65 once

we collect an ST charge bundle and payments have been collected. A

flag is set at BOX ST67A, HRND.STSOPFLG = 1/Yes, which flags that we

should no longer probe for new SOP's in ST.

However, if administering NS or CPS and SP reports a statement and NS

or CPS routes to CPS, we will always probe for new SOP's at ST65.

9:25:17 AM Wednesday, March 27, 2013

Page 290 of 365

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:
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:
Do not display TSOP.TSOPTYPE = 11/MedicareSubsidy.
Display all remaining Sources of Payments in the following order
based on TSOP.TSOPTYPE:
= 1/SPFamily
= 2/ProvDiscount
= 12/ExtraHelp
= 13/CoverageGapDiscount
= 6/Medicare
= 8/MHMO
= 10/MedicarePartD
= 5/VA
= 3/PlanNotMHMO
= 4/OSOP

9:25:17 AM Wednesday, March 27, 2013

Page 291 of 365

ST65
= 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:
ARE ALL OF THE SOURCES OF PAYMENT NECESSARY FOR
COMPLETING THE STATEMENT SECTION LISTED BELOW?

Int. Instr I:
Question Text:

SELECT "NO" TO ADD A SOURCE OF PAYMENT.

Int. Instr II:
INPUT FIELDS / ROUTING

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
9:25:18 AM Wednesday, March 27, 2013

Page 292 of 365

ST65

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.

9:25:18 AM Wednesday, March 27, 2013

Page 293 of 365

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:
Question display:
Multi Field display:

Roster/Grid Instructions:

Display all eligible Source of Payments stored on TSOP based on
the following logic:
Do not display TSOP.TSOPTYPE = 9/DM or TSOP.TSOPTYPE =
11/MedicareSubsidy.
Display all remaining Sources of Payments in the following order
based on TSOP.TSOPTYPE:
= 1/SPFamily
= 2/ProvDisount
= 12/ExtraHelp
= 13/CoverageGapDiscount
= 6/Medicare
= 8/MHMO
= 10/MedicarePartD
= 5/VA
= 3/PlanNotMHMO
= 4/OSOP
If there is more than Source of Payment per Source of Payment
Type, display in order of entry in TSOP.

9:25:19 AM Wednesday, March 27, 2013

Page 294 of 365

ST66
Display all loaded Source of Payments as protected rows.
COL #

Roster/Grid display:

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:

ADD ALL ADDITIONAL SOURCES OF PAYMENT.

Int. Instr I:
Question Text:

Int. Instr II:

INPUT FIELDS / ROUTING

Field1:
Cheshire Name:

SOP_ST1

( STQ2703 )

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
1
No
No

Number Label
1 [Continuous answer.]

FieldSize:
Min Value:
Max Value:
Mask:

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.

9:25:20 AM Wednesday, March 27, 2013

Page 295 of 365

ST66
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

Medicaid already on SOP roster =
There is a TSOP where TSOP.TSOPPTYP=2/Medicaid.

264

TricareSOP

Tricare already on SOP roster =
There is a TSOP where TSOP.TSOPPTYP = 6/Tricare.

DESIGN NOTES

9:25:20 AM Wednesday, March 27, 2013

Page 296 of 365

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 - STTYPE ^= 8/MPDPorMAorTricare, 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 - STTYPE = 3/MedicareAndInsurance, display "REFER
TO INSURANCE STATEMENT."
Else if ST5 - STTYPE = 5/MedicareAndTricare, display "REFER
TO TRICARE STATEMENT."
Else if ST5 - STTYPE = 6/TricareAndInsurance or
7/MedicareAndTricareAndInsurance, display "REFER TO
INSURANCE AND TRICARE STATEMENTS."
Else if ST5 - STTYPE = 8/MPDPorMAorTricare and TYPE OF
STATEMENT = 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 - STTYPE = 8/MPDPorMAorTricare and TYPE OF

9:25:20 AM Wednesday, March 27, 2013

Page 297 of 365

ST67
STATEMENT = 8/MPDPBenefit, THEN:

Do not display TSOP.TSOPTYPE = 2/ProvDisount, 6/Medicare, and

11/MedicareSubsidy.

Display all remaining Sources of Payments in the following order

based on TSOP.TSOPTYPE:

= 1/SPFamily

= 12/ExtraHelp

=13/CoverageGapDiscount

= 8/MHMO

= 10/MedicarePartD

= 5/VA

= 3/PlanNotMHMO

= 4/OSOP

= 9/DM

ELSE THEN:

Do not display TSOP.TSOPTYPE = 11/MedicareSubsidy,

12/ExtraHelp, 13/CoverageGapDiscount, 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 - STTYPE = 8/MPDPorMAorTricare, 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 - STTYPE = 8/MPDPorMAorTricare, 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:

COL #
1

9:25:21 AM Wednesday, March 27, 2013

HEADER
SOP Name

INSTRUCTIONS
Display TSOP.TSOPTEXT. Display Only.

Page 298 of 365

ST67
2

SOP Type

If TSOP.TSOPDISP ^= empty, display
TSOP.TSOPDISP.
Else do not display.
Display only.

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

9:25:22 AM Wednesday, March 27, 2013

Page 299 of 365

ST67

Field1:

( STQ2720 )

TSOPAMT

Cheshire Name:

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

FieldSize:
Min Value:
Max Value:
Mask:

1
No
No

Number Label
1 [Continuous answer.]

0.01
999999.99
Dollars

Route
BOX ST67HE - (STQ2740 )

Attribute

Route

Empty

BOX ST67HE - (STQ2740 )

Don't know

BOX ST67HE - (STQ2740 )

Refusal

BOX ST67HE - (STQ2740 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
468

TypeOfStatement

Type of Statement = COST.STATTYPE.

DESIGN NOTES

9:25:24 AM Wednesday, March 27, 2013

Page 300 of 365

BOX ST67HE

BOX ST67HE

Page Order # :

1115

BOX INSTRUCTIONS
( STQ2740 )

IF AT LEAST ONE TSOPAMT = DK OR RF OR THE SUM OF ALL TSOPAMT
VALUES FOR THIS COST > 0.00, GO TO BOX ST67A - (STQ2780 ).
ELSE GO TO ST67HE - PAYMHE ( STQ2760 ).

ASSIGNMENTS

TECHNICAL NOTES

DESIGN NOTES

9:25:24 AM Wednesday, March 27, 2013

Page 301 of 365

ST67HE

ST67HE

Page Order # :

Design Screen Type:

No Entry

Fields:

Field 1:

PAYMHE

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

1117

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:

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'.
USE "PREVIOUS PAGE" TO RETURN TO THE SOP GRID AND
MAKE CORRECTIONS.

Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING
9:25:26 AM Wednesday, March 27, 2013

Page 302 of 365

ST67HE

Field1:

PAYMHE

Cheshire Name:

( STQ2760 )

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
ST67HE-PAYMHE

English text: CONTINUE
Attribute

Route

Empty
ST67HE-PAYMHE
BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES
DISABLE NEXT PAGE.
ST67HE-PAYMHE routes back to ST67HE-PAYMHE to enforce the
intended hard edit. To route past this edit screen, corrections must be
made at the SOP Grid by using Previous Page.

9:25:27 AM Wednesday, March 27, 2013

Page 303 of 365

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
At BOX ST67A, flag that there has been at least one ST charge bundle added where
payments have been collected. The flag, HRND.STSOPFLG, is checked at BOX ST64B
when additional ST charge bundles are added and if set to 1/Yes, BOX ST64B will skip
probing for new SOP's at ST65.
STSOPFLG

If HRND.STSOPFLG = NULL on HRND where
HRND.HRNDRND = current round, set
HRND.STSOPFLG = 1/Yes.

TECHNICAL NOTES

DESIGN NOTES

9:25:27 AM Wednesday, March 27, 2013

Page 304 of 365

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 ST69E - (STQ2840 ).

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

9:25:27 AM Wednesday, March 27, 2013

Page 305 of 365

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

9:25:28 AM Wednesday, March 27, 2013

Page 306 of 365

ST67BINT

Field1:

PLANINTRO

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

Route

Empty

ST67B_IN - NAVIGATOR ( STQ2815 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

9:25:29 AM Wednesday, March 27, 2013

Page 307 of 365

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

9:25:30 AM Wednesday, March 27, 2013

Page 308 of 365

ST67B_IN

Field1:

NAVIGATOR

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 ST69E - (STQ2840 )
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

9:25:30 AM Wednesday, March 27, 2013

Page 309 of 365

BOX ST67C

BOX ST67C

9:25:30 AM Wednesday, March 27, 2013

Page Order # :

1131

Page 310 of 365

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 or tblPLAN.wvsDeleteFlag = Yes, this
stopped Medicaid plan will be restarted. Update existing PLAN flags = empty or No 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 or tblPLAN.wvsDeleteFlag = Yes, this
stopped Tricare plan will be restarted. Update existing PLAN flags = empty or No 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
9:25:31 AM Wednesday, March 27, 2013

Page 311 of 365

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. In addition, if
tblPLAN.wvsDeleteFlag = Yes, update to
tblPLAN.wvsDeleteFlag = No.

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

9:25:31 AM Wednesday, March 27, 2013

Source of Payment is a HI Plan =
Medicaid: TSOP.TSOPISHI=1/Medicaid
Public: TSOP.TSOPISHI=2/PublicPlan
Page 312 of 365

BOX ST67C
Private: TSOP.TSOPISHI=3/PrivatePlan
MHMO: TSOP.TSOPISHI=7/MHMO
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
(Medicare Advantage 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.

9:25:31 AM Wednesday, March 27, 2013

Page 313 of 365

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:

Display name of current Medicare Managed Care Plan,
PLAN.PLNAME.

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:

MA PLAN: (CURRENT MEDICARE MANAGED CARE PLAN NAME)

Int. Instr I:
Question Text:

9:25:32 AM Wednesday, March 27, 2013

I recorded previously that (CURRENT MEDICARE MANAGED CARE
PLAN NAME) was [your/(SP's)] current Medicare Managed Care
Plan. Has this information changed?

Page 314 of 365

ST68
Int. Instr II:
INPUT FIELDS / ROUTING
STMHMOCHNG1

Field1:
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

Route

Don't know

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

9:25:34 AM Wednesday, March 27, 2013

Page 315 of 365

ST68
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
(Medicare Advantage 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

9:25:34 AM Wednesday, March 27, 2013

Page 316 of 365

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:

Display name of Medicare Managed Care Plan Name,
PLAN.PLNAME, added at ST66 Source of Payment Roster.

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:

MPDP: (ST66 SOP MEDICARE PRESCRIPTION DRUG PLAN)

Int. Instr I:
Question Text:

9:25:35 AM Wednesday, March 27, 2013

[Are you/Is (SP)/Was (SP)] (currently) covered or enrolled in (ST66
SOP MEDICARE MANAGED CARE PLAN NAME) [on (DATE OF
Page 317 of 365

ST69
DEATH/DATE OF INSTITUTIONALIZATION)]?
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
HIMC6A - MHMORXTM ( HIQ4020 )
VERIFY IN HI.

English text: YES
No

BOX ST69A - (STQ2825 )

English text: NO
Attribute

Route

Don't know

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.

9:25:36 AM Wednesday, March 27, 2013

Page 318 of 365

ST69
COVCURNT

If ST68 - STMHMOCHNG1 = 1/Yes and ST69 ­
STSOPCURR1 = 1/Yes, update
PLRO.PLROCOVURNT = 2/No on PLRO where
PLRO.PLROPLAN = PLAN.PLANNUM of pre­
existing current MHMO and PLRO.PLRORNDC =
current round.

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.

9:25:36 AM Wednesday, March 27, 2013

Page 319 of 365

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:

9:25:37 AM Wednesday, March 27, 2013

Page 320 of 365

ST69A
INPUT FIELDS / ROUTING
STMPDPCHNG

Field1:
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

9:25:39 AM Wednesday, March 27, 2013

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 321 of 365

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

9:25:39 AM Wednesday, March 27, 2013

Page 322 of 365

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:

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.

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:

MPDP: (ST66 SOP MEDICARE PRESCRIPTION DRUG PLAN)

9:25:40 AM Wednesday, March 27, 2013

Page 323 of 365

ST69B
Int. Instr I:
[Are you/Is (SP)/Was (SP)] (currently) covered or enrolled in (ST66
SOP MEDICARE PRESCRIPTION DRUG PLAN) [on (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)]?

Question Text:

Int. Instr II:
INPUT FIELDS / ROUTING
STSOPCURR2

Field1:
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.

9:25:41 AM Wednesday, March 27, 2013

Page 324 of 365

ST69B
COVCURNT

If ST69A - STMPDPCHNG = 1/Yes and ST69B ­
STSOPCURR2 = 1/Yes, update
PLRO.PLROCOVURNT = 2/No on PLRO where
PLRO.PLROPLAN = PLAN.PLANNUM of pre­
existing current MPDP and PLRO.PLRORNDC =
current round.

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

9:25:41 AM Wednesday, March 27, 2013

Page 325 of 365

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.

9:25:41 AM Wednesday, March 27, 2013

Page 326 of 365

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 and TSOP fields as specified below.

OSOPNUM

OSOP.OSOPNUM = highest OSOP.OSOPNUM + 01.

OSOPRNDC

OSOP.OSOPRNDC = current round.

OSOPTEXT

OSOP.OSOPTEXT = TSOP.TSOPTEXT.

OSOPISHI

OSOP.OSOPISHI = TSOP.TSOPISHI.

TSOPTYPE

TSOP.TSOPTYPE = 4/OSOP.

TSOPOSOP

TSOP.TSOPOSOP = OSOP.OSOPNUM.

TSOPDISP

IF (OSOP.OSOPISHI ^= NULL & (OSOP.OSOPISHI

= DK or RF)), TSOP.TSOPDISP = "(UNKNOWN)".
ELSE TSOP.TSOPDISP = "(OSOP)".

TECHNICAL NOTES
339

SOPIsOSOP

Source of Payment is an "Other Source of Payment" =
TSOP.TSOPISHI = 4/NotHIPlanVA, 5/MilitaryPlanNotVA,
6/NotSPsPlan, 8/DM, DK, or RF.

DESIGN NOTES

9:25:41 AM Wednesday, March 27, 2013

Page 327 of 365

BOX ST69F

BOX ST69F

Page Order # :

1168

BOX INSTRUCTIONS
( STQ2842 )

IF ((TYPE OF STATEMENT = 8/MPDPBenefit) or (TYPE OF STATEMENT =
4/Tricare and ST5 - STTYPE = 8/MPDPorMAorTricare)) 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.

468

TypeOfStatement

Type of Statement = COST.STATTYPE.

DESIGN NOTES

9:25:41 AM Wednesday, March 27, 2013

Page 328 of 365

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:

Display report above question text.
Display all Source of Payments where TSOP.TSOPAMT ^= empty in

9:25:42 AM Wednesday, March 27, 2013

Page 329 of 365

ST70
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:

IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION,

USE "PREVIOUS PAGE" TO RETURN TO THE SOP GRID.

INPUT FIELDS / ROUTING

9:25:43 AM Wednesday, March 27, 2013

Page 330 of 365

ST70

Field1:

AMTSCORR

Cheshire Name:
Item Text display:

( STQ2850 )

CORO.AMTSCORR

Do not display response option 2/NoAddCorrectSOP

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
BOX ST77C - (STQ2910 )

English text: ENTRIES ABOVE ARE CORRECT
NoAddCorrectSOP
DO NOT DISPLAY.
English text: NO, SOP NEEDS ADDITION OR CORRECTION
AmountRemainingIncorrect
ST72 - ENTERCOM ( STQ2870 )
English text: AMOUNT REMAINING SEEMS INCORRECT

Attribute

Route

Don't know

BOX ST77C - (STQ2910 )

Refusal

BOX ST77C - (STQ2910 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
230

AmountRemaining

9:25:45 AM Wednesday, March 27, 2013

Amount Remaining =
COST.AREMAING.

Page 331 of 365

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

9:25:45 AM Wednesday, March 27, 2013

Page 332 of 365

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
= 9/DM

9:25:46 AM Wednesday, March 27, 2013

Page 333 of 365

ST71
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.

IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION,

USE "PREVIOUS PAGE" TO RETURN TO THE SOP GRID.

INPUT FIELDS / ROUTING

9:25:48 AM Wednesday, March 27, 2013

Page 334 of 365

ST71

Field1:

AMTSCORR

Cheshire Name:
Item Text display:

( STQ2860 )

CORO.AMTSCORR

Do not display response option 2/NoAddCorrectSOP

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
BOX ST77C - (STQ2910 )

English text: ENTRIES ABOVE ARE CORRECT
NoAddCorrectSOP
DO NOT DISPLAY.
English text: NO, SOP NEEDS ADDITION OR CORRECTION
AmountRemainingIncorrect
ST72 - ENTERCOM ( STQ2870 )
English text: AMOUNT REMAINING SEEMS INCORRECT

Attribute

Route

Don't know

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

9:25:49 AM Wednesday, March 27, 2013

Page 335 of 365

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:

Display report above question text.

9:25:50 AM Wednesday, March 27, 2013

Page 336 of 365

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

9:25:50 AM Wednesday, March 27, 2013

Page 337 of 365

ST72

Field1:

ENTERCOM

Cheshire Name:

( STQ2870 )

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

Route

Empty

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

9:25:51 AM Wednesday, March 27, 2013

Page 338 of 365

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:

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:

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

9:25:52 AM Wednesday, March 27, 2013

Page 339 of 365

ST73
= 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 PAYMENTS: (TOTAL PAYMENTS)

AMOUNT REMAINING: (DIFFERENCE BETWEEN PAYMENTS

AND 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:

IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION,

USE "PREVIOUS PAGE" TO RETURN TO THE SOP GRID.

INPUT FIELDS / ROUTING

9:25:53 AM Wednesday, March 27, 2013

Page 340 of 365

ST73

Field1:

AMTSCORR

CORO.AMTSCORR

Cheshire Name:
Item Text display:

( STQ2875 )

Do not display response options 2/NoAddCorrectSOP or
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
DO NOT DISPLAY.
English text: NO, SOP NEEDS ADDITION OR CORRECTION
AmountRemainingIncorrect
DO NOT DISPLAY.
English text: AMOUNT REMAINING SEEMS INCORRECT

Attribute

Route

Don't know

BOX ST77C - (STQ2910 )

Refusal

BOX ST77C - (STQ2910 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

9:25:54 AM Wednesday, March 27, 2013

Page 341 of 365

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:

IS THERE ADDITIONAL INFORMATION ON THE DRUG BENEFIT

STATEMENT THAT EXPLAINS THE AMOUNT STILL UNPAID?

9:25:55 AM Wednesday, March 27, 2013

Page 342 of 365

ST74
INPUT FIELDS / ROUTING
INFOEXPLAIN

Field1:
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

9:25:56 AM Wednesday, March 27, 2013

Page 343 of 365

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:

USE COMMENTS TO ENTER ANY INFORMATION THAT

EXPLAINS THE AMOUNT STILL UNPAID.

9:25:56 AM Wednesday, March 27, 2013

Page 344 of 365

ST75
INPUT FIELDS / ROUTING
ENTERCOM2

Field1:
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

Route

Empty

BOX ST77C - (STQ2910 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

9:25:57 AM Wednesday, March 27, 2013

Page 345 of 365

BOX ST77C

BOX ST77C

9:25:57 AM Wednesday, March 27, 2013

Page Order # :

1240

Page 346 of 365

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.
PAYMCOST

If creating a new PAYM record, create PAYM where

9:25:57 AM Wednesday, March 27, 2013

Page 347 of 365

BOX ST77C
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

9:25:57 AM Wednesday, March 27, 2013

Page 348 of 365

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

9:25:57 AM Wednesday, March 27, 2013

Page 349 of 365

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:

Display SP/Family payment.

Question display:

Display SP/Family payment.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

(ST CLAIM HEADER) SP/FAMILY PAYMENT: (SP/FAMILY

PAYMENT)

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:

9:25:58 AM Wednesday, March 27, 2013

Page 350 of 365

ST78
INPUT FIELDS / ROUTING
( 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

9:25:59 AM Wednesday, March 27, 2013

Page 351 of 365

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/ExitInterviewSkipPre) 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

9:25:59 AM Wednesday, March 27, 2013

Page 352 of 365

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/ExitInterviewSkipPre) 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

9:25:59 AM Wednesday, March 27, 2013

Page 353 of 365

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

9:26:00 AM Wednesday, March 27, 2013

Page 354 of 365

ST79

Field1:

EXPAYOUT

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

Route

Don't know

BOX ST80 - (STQ2930 )

Refusal

BOX ST80 - (STQ2930 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

9:26:01 AM Wednesday, March 27, 2013

Page 355 of 365

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:

9:26:02 AM Wednesday, March 27, 2013

Page 356 of 365

ST80
INPUT FIELDS / ROUTING
EXPAYUNT

Field1:
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 )

9:26:04 AM Wednesday, March 27, 2013

Page 357 of 365

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.EXPAYAMT

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
9:26:05 AM Wednesday, March 27, 2013

Page 358 of 365

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

9:26:05 AM Wednesday, March 27, 2013

Page 359 of 365

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 ((TYPE OF STATEMENT = 8/MPDPBenefit) or (TYPE OF
STATEMENT = 4/Tricare and ST5 - STTYPE = 8/MPDPorMAorTricare)), 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
468

TypeOfStatement

Type of Statement = COST.STATTYPE.

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.

9:26:05 AM Wednesday, March 27, 2013

Page 360 of 365

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

9:26:06 AM Wednesday, March 27, 2013

Page 361 of 365

ST81

Field1:

ABUNDLE

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

9:26:06 AM Wednesday, March 27, 2013

Page 362 of 365

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

9:26:07 AM Wednesday, March 27, 2013

Page 363 of 365

ST82

Field1:

ASTATEMENT

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
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BOX STEND - (STQ3010 )

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BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

9:26:08 AM Wednesday, March 27, 2013

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BOX STEND

BOX STEND

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1340

BOX INSTRUCTIONS
( STQ3010 )

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ASSIGNMENTS

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