Cms-p-0015a Mcbs

No-Statement Charge (NSQ)
Variable Name

MR Screen Name
BOX NSBEG

Question type

NAVIGATOR

NS1_IN

instance navigator

NSINT

NS1

no entry

Question text/description
CREATE LIST OF EVENTS ENTERED IN THE CURRENT ROUND THAT ARE NOT ASSOCIATED WITH CHARGE
DATA ALREADY ENTERED
IF AT LEAST ONE EVENT ENTERED IN THE CURRENT ROUND IS NOT ASSOCIATED WITH CHARGE DATA
ALREADY ENTERED, GO TO NS1_IN - NAVIGATOR.
ELSE GO TO NS81 - NSTATEMENT.

Code list

(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
[Now that we're done with [your/(SP's)] statements, let's/Let's] talk about the medical services and costs for
which [you/(SP)] did not have a statement.]
THERE ARE (TOTAL NUMBER OF NS EVENTS) EVENTS (REMAINING) TO ASK ABOUT.
(Let's start with/Next let's look at) (the/[your/(SP's)]) costs for the (EVENT).

BOX NS1

routing

NSEXMCMAIL

NS2

code one

EVERRVB

NS3

verbatim text

IF (ST1 - MHMOSTMT = 3/Never AND ((SP HAS A MEDICARE MANAGED CARE PLAN THAT DOES NOT HAVE
RX COVERAGE ANYTIME IN THE CURRENT ROUND) OR (SP HAS A PRIVATE PLAN THAT IS A MANAGED CARE
PLAN ANYTIME IN THE CURRENT ROUND) OR (SP IS IN THE EXIT SAMPLE) OR (EVENT IS ASSOCIATED WITH A
MANAGED CARE PLAN))) OR (EVENT TYPE = 'OM' AND EVENT IS A RENTAL ITEM AND PS1 - HADPYMNT =
1/Yes) OR ((EVNTTYPE = 'DU' OR 'PM') AND SP DOES NOT HAVE ANY OTHER HEALTH INSURANCE PLAN
BESIDES MEDICARE IN THE CURRENT ROUND) , GO TO BOX NS4.
ELSE IF (SP IS IN THE EXIT SAMPLE AND ROUND IS NOT 71), GO TO NS4 - NSRECDSTAT.
ELSE GO TO NS2 - NSEXMCMAIL.
As far as you know, is anything expected in the mail from (Medicare, Insurance, and Tricare/Medicare and (01) YES
Tricare/Medicare and Insurance/Medicare) about [READ EVENT ABOVE]?
(02) NO
(03) EVENT ENTERED IN ERROR
(04) HAVE STATEMENT FOR EVENT
(09) FLAG COST FOR CPS DO NOT DISPLAY.
(-8) DON'T KNOW
(-9) REFUSED
REMINDER: "EVENT ENTERED IN ERROR" INSTRUCTS THE HOME OFFICE TO DELETE THIS EVENT.
(01) CONTINUOUS ANSWER

NS4

code one

IF YOU HAVE ENTERED THIS CODE IN ERROR, SELECT PREVIOUS PAGE AND ENTER THE CORRECT CODE AT
NS2. OTHERWISE, EXPLAIN WHY YOU SELECTED "EVENT ENTERED IN ERROR" FOR THIS EVENT.
[Have you/Has (SP)] received a statement for the [READ EVENT ABOVE]?

BOX NS4

routing

BOX NS4A

routing

NS5

dollar

NSRECDSTAT

TOTALCHG

(01) STATEMENT RECEIVED AND AVAILABLE
(02) STATEMENT RECEIVED, NOT AVAILABLE
(03) STATEMENT NOT RECEIVED
(-8) DON'T KNOW
(-9) REFUSED

CREATE A NEW CHARGE BUNDLE FOR THIS EVENT
IF NS2 - NSEXMCMAIL = 1/Yes or 3/EventEnteredInError, GO TO BOX NS80.
ELSE GO TO BOX NS4A.
IF (EVENT TYPE IS NOT AN OTHER MEDICAL EXPENSE) AND (EVENT IS ASSOCIATED WITH A MANAGED CARE
PLAN), GO TO NS6 - TOTALCHG.
ELSE GO TO NS5 - TOTALCHG.
Including any amounts that may be paid by Medicare or anyone else, what [was the charge for the (OME
(01) CONTINUOUS ANSWER
ITEM TYPE) rented (with the option to buy) for the time period between (REFERENCE DATE/UTILDATE) and (-8) DON'T KNOW
(TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)/was the total charge (that is, the total amount (-9) REFUSED
billed)]?
IF CHARGE REPORTED AS HOURLY RATE, CALCULATE AND ENTER THE TOTAL CHARGE FOR THE ENTIRE
ROUND.
[PROBE FOR TOTAL BILLED AMOUNT, REGARDLESS OF WHO PAID (OR WILL PAY) ANY PORTION OF THE
CHARGE. IF THE RESPONDENT RECEIVES A DISCOUNT, RECORD THE TOTAL CHARGE BEFORE THE DISCOUNT
IS APPLIED.]

No-Statement Charge (NSQ)
Variable Name

TOTALCHG

MR Screen Name
BOX NS5

Question type
routing

NS6

dollar

Question text/description
IF TOTALCHG = 0 AND SP CURRENTLY COVERED BY MEDICAID, GO TO BOX NS80.
ELSE IF EVENT TYPE = 'OM' AND EVENT IS A RENTAL ITEM, GO TO NS7 - MONTHCOV.
ELSE IF (EVENT TYPE = 'PM' OR 'OM') AND NUMBER OF PURCHASES BEING ASKED ABOUT IN NS IS > 1, GO
TO NS8 - NUMLINKS.
ELSE IF (EVENT WAS ENTERED AS A REPEAT VISIT), GO TO NS9 - RVLINKS.
ELSE GO TO BOX NS9.
What was the copayment amount for the [READ EVENT ABOVE]?

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

[EXPLAIN IF NECESSARY: Managed care plans commonly charge a fixed amount, or copayment, each time
health services are provided. For example, the person may pay $20 for each office visit and $10 for each
drug prescription.]
ENTER 0 IF NO COPAYMENT FOR THE EVENT.
IF TOTALCHG = 0 AND SP CURRENTLY COVERED BY MEDICAID, GO TO BOX NS80.
IF EVENT TYPE = 'PM' AND THE TOTAL OF NUMBER OF PURCHASES BEING ASKED ABOUT IN NS IS > 1, GO TO
NS8 - NUMLINKS.
ELSE IF (EVENT WAS ENTERED AS A REPEAT VISIT), GO TO NS9 - RVLINKS.
ELSE GO TO BOX NS9.
How many months are covered by the charge for the period of time [since (REFERENCE
(01) CONTINUOUS ANSWER
DATE/UTILDATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?
(-7) EMPTY
(-8) DON'T KNOW
[IF THE RESPONDENT DOES NOT REPORT THE NUMBER OF MONTHS AS A WHOLE NUMBER, ROUND UP.
(-9) REFUSED
(E.G., FOR 2 ½ MONTHS, ENTER “3”.)]
(01) LESS THAN 1 MONTH
(-7) EMPTY
How many of the times [you/(SP)] obtained [READ EVENT ABOVE] since (REFERENCE DATE/UTILDATE) [were (01) CONTINUOUS ANSWER
covered by the total charge/was there no charge/were covered by the (TOTAL CHARGE)/were covered by
(-8) DON'T KNOW
the copayment/was there no copayment/were covered by the (COPAYMENT)]?
(-9) REFUSED
How many of the (NUMBER OF VISITS) (visits to the OPD at/lab services provided by/visits to) (PROVIDER
(01) CONTINUOUS ANSWER
NAME) during the month of (EVENT MONTH) [were covered by the total charge/was there no charge/were (-8) DON'T KNOW
covered by the (TOTAL CHARGE)/were covered by the copayment/was there no copayment/were covered (-9) REFUSED
by the (COPAYMENT)]?
IF (COPAYMENT WAS COLLECTED FOR CHARGE BUNDLE INSTEAD OF A TOTAL CHARGE), GO TO BOX NS45.
ELSE GO TO NS10 - INCOTHER.

BOX NS6

routing

MONTHCOV

NS7

numeric

MONCOV96

NS7

code one

NUMLINKS

NS8

numeric

RVLINKS

NS9

numeric

BOX NS9

routing

INCOTHER

NS10

code one

[READ IF NECESSARY: Does [the total charge/TOTAL CHARGE)] cover this (medicine/item/event) only or
does it include other (medicine/item/event)s.]

INCTYPE

NS12

code all

What else was included?
CHECK ALL THAT APPLY.

BOX NS12

routing

NS13

roster

IF THE RESPONSE TO NS12 - INCTYPE INCLUDES 1/ProvDates, GO TO NS13 - PROVIDER_NSDATE.
ELSE GO TO BOX NS26.
WHICH MEDICAL PROVIDER IS IN THIS CHARGE BUNDLE?
SELECT OR ADD ONLY ONE PROVIDER.

PROVIDER_NSDATE

Code list

(01) ONLY THIS EVENT/ITEM/MEDICINE
(02) OTHER EVENTS/ITEMS/MEDICINES
(03) CAN'T TELL
(01) PROVIDER SERVICE DATES
(02) HOME HEALTH VISITS
(03) OTHER MEDICAL EXPENSES
(04) PRESCRIBED MEDICINES

[DISPLAY PROVIDER ROSTER AS RESPONSE OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
…
N. [PROVIDER N]
N+1. ADD ANOTHER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP NAME
FOR ALL PROVIDERS WHERE PROVNUM>02.

No-Statement Charge (NSQ)
Variable Name
PROVNAME

MR Screen Name
NS13

Question type
verbatim

Question text/description
[PROVIDER LOOKUP CALLED FROM THIS SCREEN]

Code list

ENTER THE NAME OF THE PROVIDER AND THE BILLING/GROUP OR PRACTICE NAME BELOW.

GROUPNAM
NSDATEUPD

NS13
NS14

verbatim
code one

EVENT_NSDATEDIT
VISITYPE

NS15

roster
select one

EVENT

NS16

verbatim

NSDATEINTRO

BOX NS16A

routing

BOX NS16B
NS17

routing
no entry

BOX NS17

routing

NAME:
GROUP:
THE FOLLOWING EVENT DATES HAVE BEEN ENTERED FOR THIS PROVIDER.
DO YOU NEED TO ADD OR EDIT AN EVENT DATE FOR THIS CHARGE BUNDLE?

(01) NO, DO NOT NEED TO ADD OR EDIT EVENT
DATES
(02) YES, NEED TO ADD EVENT DATE
(03) YES, NEED TO EDIT EVENT DATE
SELECT AND EDIT THE EVENT DATE THAT NEEDS CORRECTION.
(01) CONTINUOUS ANSWER
SELECT TYPE OF VISIT TO ADD:
(01) Separately Billing Lab (SL)
(02) Separately Billing Doctor (SD)
(03) Dental (DU)
(04) Hospital Emergency Room (ER)
(05) Hospital Inpatient Saty (IP)
(06) Hospital Outpatient Visit (OP)
(07) Institutional Stay (IU)
(08) All other visits to Medical Provider (MP)
[When did [you/(SP)] see (PROVIDER NAME)?/When [were you/was (SP)] admitted to and discharged from MM:
(HOSPITAL NAME)?] Please tell me all the dates [since (REFERENCE DATE/UTILDATE)/between (REFERENCE DD:
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)].
YYYY:
ENTER ALL DATES.
REPEAT VISIT: YES/NO
# OF VISITS
ADD THE MISSING EVENT DATE(S) IN THIS CHARGE BUNDLE.
ADD ALL EVENT DATES FOR THIS PROVIDER.
[IF R HAD 5 OR MORE VISITS TO THIS PROVIDER DURING THIS REFERENCE PERIOD, SELECT "REPEAT VISITS"
AND LEAVE THE DAY FIELD BLANK. ENTER EACH MONTH SEPARATELY.]
IF AT LEAST ONE EVENT DATE ADDED AT NS16 IS NOT OUTSIDE THE SURVEY REFERENCE PERIOD, GO TO BOX
NS16B.
ELSE GO TO NS14 - NSDATEUPD.
GO TO BOX NS17.
Before we continue with this statement, I would like to ask you a few questions about the visit(s) I just
added.
IF AT LEAST ONE EVENT ADDED AT NS16 IS AN 'MP' EVENT TYPE AND THE PROVIDER SPECIALTY HAS NOT
BEEN COLLECTED, GO TO NS18 - PROVSPEC.
ELSE IF AT LEAST ONE EVENT ADDED AT NS16 IS A 'DU' EVENT TYPE AND THE PROVIDER SPECIALTY HAS NOT
BEEN COLLECTED, GO TO ST18A - PROVSPEC.
ELSE GO TO BOX NS18.

No-Statement Charge (NSQ)
Variable Name
PROVSPEC

MR Screen Name
NS18

Question type
code one

Question text/description
What kind of medical person is (PROVIDER NAME)?
[SELECT THE CATEGORY FOR A GIVEN SPECIALTY ONLY IF THE RESPONDENT SPECIFICALLY NAMES THE
LISTED SPECIALTY OR MENTIONS THE WORDS OR INITIALS IN PARENTHESES FOLLOWING THAT PROVIDER
SPECIALTY. IF THE RESPONDENT NAMES A MEDICAL SPECIALTY NOT LISTED BELOW, BUT LISTED ON
SHOWCARD AC1, SUCH AS ‘CARDIOLOGY,’ SELECT 'MEDICAL DOCTOR.']

PROVSPOS
PROVSPEC
PROVSPECOTH
PROVSPECOTH

NS18
NS18A
NS18A
NS18A
BOX NS18

text
code one
code one
verbatim text
routing

OTHER MEDICAL PROVIDER (SPECIFY)
What kind of dental provider is [PROVNAME]?
What kind of dental provider is [PROVNAME]?
OTHER MEDICAL PROVIDER (SPECIFY)
IF (AT LEAST ONE EVENT ADDED AT NS16 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 NS19 - VAPLACE.
ELSE GO TO BOX NS19.

VAPLACE

NS19

yes/no

Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A. facility?

HMOASSOC

BOX NS19
NS20

routing
yes/no

GO TO NS22A_IN - NAVIGATOR.
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?

HMOREFER

NS21

yes/no

[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?
[INCLUDE REFERRALS BY THE RESPONDENT’S PRIMARY CARE PHYSICIAN (PCP).]

NAVIGATOR

NS22A_IN

instance navigator

BOX NS22A

routing

BOX NS22B

routing

IF TYPE OF EVENT = 'MP', GO TO BOX NS22B.
ELSE GO TO BOX NS23B.
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 NS23 - MPSDVIS.
ELSE GO TO BOX NS23A

Code list
(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
(01) CONTINUOUS ANSWER

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED

No-Statement Charge (NSQ)
Variable Name
MPSDVIS

EVENT_NSDATE

RVLINKS

MR Screen Name
NS23

Question type
yes/no

Question text/description
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]?

BOX NS23A
BOX NS23B
NS24
BOX NS24

routing
routing
check all
routing

NS24A

numeric

GO TO BOX NS23B.
GO TO NS22A_IN - NAVIGATOR.
SELECT THE EVENT DATE(S) THAT ARE INCLUDED IN THIS CHARGE BUNDLE.
IF AT LEAST ONE EVENT SELECTED AT NS24 IS A REPEAT VISIT, GO TO NS24A - RVLINKS.
ELSE GO TO NS25 - NSDATEMTCH.
ENTER THE NUMBER OF (EVENT TYPE) VISITS IN (EVENT MONTH, YEAR) THAT ARE COVERED BY THIS
CHARGE.
[A REPEAT VISIT MEANS THAT THE RESPONDENT HAD AT LEAST 5 VISITS TO THE PROVIDER DURING THE
CURRENT ROUND REFERENCE PERIOD.]
IF ANOTHER EVENT SELECTED AT NS24 IS A REPEAT VISIT, GO TO NS24A - RVLINKS.
ELSE GO TO NS25 - NSDATEMTCH.
ARE ALL THE PROVIDER EVENTS FROM THE CHARGE BUNDLE SHOWN BELOW?

BOX NS24A

routing

NSDATEMTCH

NS25

code one

EVENT_NSDATEDEL

NS26
BOX NS26

roster
routing

PROVIDER_HH

NS27

roster

BOX NS28A

routing

HHEVNTTYPE

NS30

code one

NSHHINTRO

NS31

no entry

BOX NS31A

routing

BOX NS31B

routing

NS32

no entry

BOX NS33

routing

NSOMUPD

NS34

code one

EVENT_NSOMEDIT
NSOMADD

NS35
NS36

roster
code one

SELECT AND EDIT THE OTHER MEDICAL EXPENSE EVENT THAT NEEDS CORRECTION.
WHAT TYPE OF OTHER MEDICAL EXPENSE NEEDS TO BE ADDED?

EVENT_NSOM

BOX NS36
NS37

routing
roster

GO TO NS34 - NSOMUPD.
SELECT OTHER MEDICAL EXPENSES THAT ARE IN THIS CHARGE BUNDLE.

NSHHMTCH

SELECT THE EVENT(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE BUNDLE.
IF NS12 – INCTYPE INCLUDES 2/HHVisits, GO TO NS27 - PROVIDER_HH.
ELSE GO TO BOX NS33.
WHICH HOME HEALTH PROVIDER IS IN THIS CHARGE BUNDLE?
SELECT OR ADD ONLY ONE PROVIDER.
IF (HOME HEALTH PROVIDER WAS ADDED AT NS27) OR (AN EXISTING PROVIDER WAS SELECTED AT NS27
THAT WAS NOT ASSOCIATED WITH A HOME HEALTH EVENT), GO TO NS30 - HHEVNTTYPE.
ELSE GO TO BOX NS31B.
IS THE PROVIDER A HOME HEALTH PROFESSIONAL OR SOME OTHER TYPE OF HOME HEALTH PROVIDER
(HOME HEALTH AIDE, HOMEMAKER, ETC.)?
Before we continue with this statement, I would like to ask you a few questions about the home health
provider I just added.
IF NS30 - HHEVNTTYPE = 1/HP, GO TO HH3 - PROVSPEC.
ELSE GO TO HH20 - HHFTYPE.
LINK HOME HEALTH PROVIDER TO CHARGE BUNDLE
GO TO NS32 - NSHHMTCH.
THE FOLLOWING HOME HEALTH PROVIDER EVENT HAS BEEN ADDED TO THIS CHARGE BUNDLE.
IF NS12 – INCTYPE INCLUDES 3/OMExpenses, GO TO NS34 - NSOMUPD.
ELSE GO TO BOX NS40.
THE FOLLOWING OME EVENTS HAVE BEEN ENTERED.
DO YOU NEED TO ADD OR EDIT AN OME EVENT FOR THIS CHARGE BUNDLE?

Code list
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

(01) CONTINUOUS ANSWER

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

(01) YES
(02) NO, NEED TO ADD A PROVIDER EVENT
(03) NO, NEED TO REMOVE A PROVIDER EVENT
(01) CONTINUOUS ANSWER

(01) CONTINUOUS ANSWER

(01) HOME HEALTH PROFESSIONAL
(02) OTHER HOME HEALTH PROVIDER

(01) CONTINUE
(-7) EMPTY

(01) NO, DO NOT NEED TO ADD OR EDIT OM EVENT
(02) YES, NEED TO ADD AN OME EVENT
(03) YES, NEED TO EDIT AN OME EVENT
(01) CONTINUOUS ANSWER
(01) GLASSES/CONTACTS
(02) HEARING/SPEECH DEVICE
(03) ORTHOPEDIC ITEM
(04) DIABETIC SUPPLIES
(05) AMBULANCE/RESCUE
(06 PROSTHESIS
(07) ALTERATIONS (HOME/CAR)
(08) OXYGEN
(09) KIDNEY DIALYSIS
(10) ALL OTHER MEDICAL SUPPLIES

(01) CONTINUOUS ANSWER

No-Statement Charge (NSQ)
Variable Name

MONTHCOV

MR Screen Name
BOX NS37

Question type
routing

NS38

numeric

Question text/description
IF AT LEAST ONE OTHER MEDICAL EXPENSE SELECTED AT NS37 IS RENTED, GO TO NS38 - MONTHCOV.
ELSE GO TO BOX NS38B.
HOW MANY MONTHS ARE COVERED BY THIS CHARGE BUNDLE?
[IF THE RESPONDENT DOES NOT REPORT THE NUMBER OF MONTHS AS A WHOLE NUMBER, ROUND UP.
(E.G., FOR 2 ½ MONTHS, ENTER “3”.)]

MONCOV96

NS38

code one

BOX NS38A

routing

BOX NS38B

routing

NS38A

numeric

BOX NS38AA

routing

NSOMMTCH

NS39

code one

EVENT_NSOMDEL

NS40
BOX NS40

roster
routing

EVENT_NSPM
NUMLINKS

NS41
NS42

roster
grid

NSPMINTRO

BOX NS42
NS43

routing
no entry

NSPMMTCH

BOX NS43
NS44

routing
code one

GO TO NS44 - NSPMMTCH.
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).]
GO TO NS44 - NSPMMTCH.
ARE ALL THE PRESCRIBED MEDICINES FROM THE CHARGE BUNDLE SHOWN BELOW?

EVENT_NSPMDEL

NS45

roster

SELECT THE PRESCRIBED MEDICINE(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE BUNDLE.

BOX NS45

routing

NS64

code one

IF TOTAL CHARGE OR COPAY COLLECTED > 0, DK OR RF, GO TO NS64 - NSTCHGPAID.
ELSE GO TO BOX NS64B.
[[Have you/Has (SP)] or any other source [, such as (an insurance plan/TRICARE/TRICARE or an insurance
plan),] already paid any of [the charge/the total charge/the copayment amount/this (TOTAL CHARGE)]?

BOX NS64A

routing

BOX NS64B

routing

NSADDSOP1

NS65

yes/no

SOP_NS1

NS66

roster

NUMLINKS

NSTCHGPAID

IF ANOTHER OTHER MEDICAL EXPENSE SELECTED AT NS37 IS RENTED, GO TO NS38 - MONTHCOV.
ELSE GO TO BOX NS38B.
IF AT LEAST ONE OTHER MEDICAL EXPENSE SELECTED AT NS37 IS OSTOMY SUPPLIES, INCONTINENCE
SUPPLIES OR BANDAGES, GO TO NS38A - NUMLINKS.
ELSE GO TO NS39 - NSOMMTCH.
HOW MANY PURCHASES OF (NAME OF OME ITEM) ARE COVERED BY THIS CHARGE BUNDLE?

IF ANOTHER OTHER MEDICAL EXPENSE SELECTED AT NS37 IS OSTOMY SUPPLIES, INCONTINENCE SUPPLIES
OR BANDAGES, GO TO NS38A - NUMLINKS.
ELSE GO TO NS39 - NSOMMTCH.
ARE ALL THE OTHER MEDICAL EXPENSES FROM THE CHARGE BUNDLE SHOWN BELOW?

SELECT THE EVENT(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE BUNDLE.
IF NS12 – INCTYPE INCLUDES 4/PMS, GO TO NS41 - EVENT_NSPM.
ELSE GO TO BOX NS45.
SELECT OR ADD ALL PRESCRIPTION MEDICINES THAT ARE IN THIS CHARGE BUNDLE.
HOW MANY PURCHASES OF EACH MEDICINE SHOWN BELOW ARE COVERED BY THIS CHARGE BUNDLE?

IF SP OR ANY SOURCE HAS PAID, GO TO BOX NS64B.
ELSE IF (NOTHING HAS BEEN PAID) OR (RESPONDENT DOES NOT KNOW IF ANYTHING HAS BEEN PAID), GO
TO BOX NS78B.
ELSE GO TO BOX NS80.
CREATE SOURCE OF PAYMENT ROSTER
GO TO NS65 - NSADDSOP1.
ARE ALL OF THE SOURCES OF PAYMENT FOR THIS CHARGE BUNDLE LISTED BELOW?
SELECT "NO" TO ADD A SOURCE OF PAYMENT.
ADD ALL ADDITIONAL SOURCES OF PAYMENT FOR THIS CHARGE BUNDLE.

Code list

(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
(-9) REFUSED
(01) LESS THAN 1 MONTH
(-7) EMPTY

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

(01) YES
(02) NO, NEED TO ADD AN OME EVENT
(03) NO, NEED TO REMOVE AN OME EVENT
(01) CONTINUOUS ANSWER

(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

(01) YES
(02) NO, NEED TO ADD A MEDICINE NAME
(03) NO, NEED TO REMOVE A MEDICINE NAME
(01) CONTINUOUS ANSWER

(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(-8) DON'T KNOW
(-9) REFUSED

(01) YES
(02) NO
(01) CONTINUOUS ANSWER

No-Statement Charge (NSQ)
Variable Name
TSOPAMT

PAYMHE

MR Screen Name
NS67

Question type
grid

Question text/description
Who (else) paid? How much did (SOURCE) pay?
ENTER ALL PAYMENT AMOUNTS. CORRECT PAYMENT AMOUNTS AS NECESSARY.

BOX NS67HE

routing

NS67HE

no entry

IF AT LEAST ONE TSOPAMT = DK OR RF OR THE SUM OF ALL TSOPAMT VALUES FOR THIS COST > 0.00, GO TO
BOX NS67A.
ELSE GO TO NS67HE - PAYMHE.
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.
IF AT LEAST ONE SOURCE OF PAYMENT WAS ADDED AT NS66, GO TO BOX NS67B.
ELSE GO TO BOX NS69F.
GO TO BOX NS69E.
Before we continue, I would like to ask you a few questions about the health insurance plan(s) you just
added.

BOX NS67A

routing

PLANINTRO_NS

BOX NS67B
NS67BINT

routing
no entry

NAVIGATOR

NS67B_IN

instance navigator

NSMHMOCHNG1

BOX NS67C
NS68

routing
yes/no

GO TO BOX NS69A
I recorded previously that (CURRENT MEDICARE MANAGED CARE PLAN NAME) was [your/(SP's)] current
Medicare Managed Care Plan. Has this information changed?

NSSOPCURR1

NS69

yes/no

[Are you/Is (SP)/Was (SP)] [currently] covered or enrolled in (NS66 SOP MEDICARE MANAGED CARE PLAN
NAME) [on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?

NSMPDPCHNG

NS69A

yes/no

I recorded previously that (CURRENT MEDICARE PRESCRIPTION
DRUG PLAN) was [your/(SP's)] current Medicare Prescription Drug
Care Plan.

NSSOPCURR2

NS69B

yes/no

BOX NS69A
BOX NS69E

routing
routing

BOX NS69F

routing

NS70

code one

AMTSCORR

Code list
(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
(-9) REFUSED

(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED

Has this information changed?
[Are you/Is (SP)/Was (SP)] (currently) covered or enrolled in (NS66 SOP MEDICARE PRESCRIPTION DRUG
PLAN) [on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

GO TO NS67B_IN - NAVIGATOR.
IF AN "OTHER SOURCE OF PAYMENT" ADDED AT NS66, CREATE AN OSOP FOR EACH SOURCE OF PAYMENT
ADDED AT NS66 THAT IS AN "OTHER SOURCE OF PAYMENT" .
GO TO BOX NS69F.
IF (TOTAL CHARGE ^= DK AND TOTAL CHARGE ^= RF) AND (AT LEAST ONE PAYMENT ENTERED AT NS67 = DK
OR RF) AND (AT LEAST ONE PAYMENT ENTERED AT NS67 ^= DK AND ^= RF AND ^= 0) AND (TOTAL OF ALL
NON-MISSING PAYMENTS ENTERED AT NS67 >= TOTAL CHARGE), GO TO NS71 - AMTSCORR.
ELSE IF (TOTAL CHARGE ^= DK AND TOTAL CHARGE ^= RF) AND (ALL PAYMENTS ENTERED AT NS67 ^= DK
AND ^= RF) AND (THE ABSOLUTE VALUE OF THE DIFFERENCE BETWEEN THE TOTAL PAYMENTS ENTERED AT
NS67 AND TOTAL CHARGE IS > $1.00), GO TO NS70 - AMTSCORR.
ELSE GO TO BOX NS77C.
There seems to be [some amount still unpaid/more payments than the charge].
(01) ENTRIES ABOVE ARE CORRECT
(02) NO, SOP NEEDS ADDITION OR CORRECTION
[REVIEW WITH RESPONDENT.] The total of all payments is $(TOTAL PAYMENTS). The amount
(03) AMOUNT REMAINING SEEMS INCORRECT
[unpaid/overpaid] is $(DIFFERENCE BETWEEN PAYMENTS AND TOTAL CHARGE). Is that correct?
(-8) DON'T KNOW
IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION,
(-9) REFUSED
USE "PREVIOUS PAGE" TO RETURN TO THE SOP GRID.

No-Statement Charge (NSQ)
Variable Name
AMTSCORR

ENTERCOM

MR Screen Name
NS71

NS72

Question type
code one

no entry

Question text/description
THE AMOUNTS ENTERED FOR THE SOURCES OF PAYMENT EQUAL OR EXCEED THE [TOTAL
CHARGE/COPAYMENT], 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.
[THE TOTAL OF PAYMENTS IS $(TOTAL PAYMENTS). THE AMOUNT [UNPAID/OVERPAID] IS $(DIFFERENCE
BETWEEN PAYMENTS AND TOTAL CHARGE).]
USE THE BOX BELOW TO EXPLAIN WHY THE AMOUNT REMAINING SEEMS INCORRECT.
CREATE PAYMENTS FOR AMOUNTS ENTERED AT NS67
GO TO BOX NS77D.
IF THE SP OR FAMILY MADE A PAYMENT AND PAYMENT IS GREATER THAN $5.00, GO TO NS78 - EXPPAYBK.
ELSE GO TO BOX NS80.

BOX NS77C

routing

BOX NS77D

routing

NS78

yes/no

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?

BOX NS78A

routing

IF NS78 - 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 NS80 - EXPAYUNT.
ELSE GO TO BOX NS80.

BOX NS78B

routing

EXPAYOUT

NS79

yes/no

IF (CURRENTLY ADMINISTERING CPS AND CHARGES WERE FIRST COLLECTED 2 ROUNDS PREVIOUS TO
CURRENT ROUND) OR (SP IS IN THE EXIT SAMPLE), GO TO NS79 - EXPAYOUT.
ELSE GO TO BOX NS80.
Do you expect anyone to pay any of this amount?

EXPAYUNT

NS80

quantity unit

How much do you expect will be paid?

EXPAYPCT
EXPAYAMT

NS80
NS80
BOX NS80

numeric
numeric
routing

EXPPAYBK

Code list
(01) ENTRIES ABOVE ARE CORRECT
(02) NO, SOP NEEDS ADDITION OR CORRECTION
(03) AMOUNT REMAINING SEEMS INCORRECT
(-8) DON'T KNOW
(-9) REFUSED

IF CURRENTLY ADMINISTERING CPS, GO TO BOX CPSBEG.
ELSE GO TO BOX NSL1.
GO TO BOX NSBEG

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) PERCENTAGE NS80 - EXPAYPCT
(02) DOLLARS NS80 - EXPAYAMT
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER

No-Statement Charge (NSQ)
Variable Name

MR Screen Name
BOX NSL1

Question type
routing

Question text/description
IF (CHARGE DATA WAS COLLECTED IN NS FOR THIS NS CHARGE BUNDLE) AND (NS CHARGE BUNDLE IS
LINKED TO ONLY ONE EVENT) AND (SP OR ANY OTHER SOURCE HAS PAID) AND

Code list

((EVENT LINKED TO NS CHARGE BUNDLE HAS EVNT.EVNTTYPE = 'PM' AND (THE TOTAL CHARGE ^= RF) AND
(PM WAS PURCHASED THROUGH AN HMO) AND (THERE ARE OTHER CURRENT ROUND PRESCRIPTION
MEDICINE EVENTS NOT LINKED TO A CURRENT ROUND CHARGE BUNDLE THAT WERE PURCHASED
THROUGH AN HMO))
OR
(EVENT LINKED TO NS CHARGE BUNDLE HAS EVNT.EVNTTYPE = 'PM' AND (TOTAL CHARGE ^= RF) AND (PM
WAS NOT PURCHASED THROUGH AN HMO OR HAD AN UNKNOWN PURCHASE LOCATION) AND (THERE ARE
OTHER CURRENT ROUND PRESCRIPTION MEDICINE EVENTS NOT LINKED TO A CURRENT ROUND CHARGE
BUNDLE THAT WERE NOT PURCHASED THROUGH AN HMO OR HAD AN UNKNOWN PURCHASE LOCATION))
OR
(EVENT LINKED TO NS CHARGE BUNDLE HAS EVNT.EVNTTYPE = 'DU', 'ER', 'OP', 'MP', 'SD', OR 'SL' AND (THE
TOTAL CHARGE ^= DK AND TOTAL CHARGE ^= RF) AND (SP REFERRED TO PROVIDER BY HMO FOR THIS
EVENT) AND (THERE ARE OTHER CURRENT ROUND EVENTS WITH THE SAME EVENT TYPE FOR THIS
PROVIDER WHERE THE SP WAS REFERRED TO THE PROVIDER BY THE HIMO THAT ARE NOT LINKED TO A
CURRENT ROUND CHARGE BUNDLE))
OR
(EVENT LINKED TO NS CHARGE BUNDLE HAS EVNT.EVNTTYPE = 'DU', 'ER', 'OP', 'MP', 'SD', OR 'SL' AND (THE
TOTAL CHARGE ^= DK AND TOTAL CHARGE ^= RF) AND (SP WAS NOT REFERRED TO PROVIDER BY HMO OR
REFERRAL IS UNKNOWN FOR THE EVENT) AND (THERE ARE OTHER CURRENT ROUND EVENTS WITH THE
SAME EVENT TYPE FOR THIS PROVIDER WHERE THE SP WAS NOT REFERRED TO PROVIDER BY HMO OR
REFERRAL IS UNKNOWN FOR THE EVENT THAT ARE NOT LINKED TO A CURRENT ROUND CHARGE BUNDLE)),
), GO TO NSL1 - NSEVSAME.
ELSE GO TO BOX NSBEG.

NSEVSAME

NSL1

code one

You told me earlier that [you/(SP)] had other [visits to (PROVIDER NAME)/prescribed medicine purchases].
Are any other [visits to (PROVIDER NAME)/prescribed medicine purchases] the same -- where the [total
charge was (TOTAL CHARGE TEXT)/copayment was (TOTAL CHARGE TEXT)] per (visit/purchase) and
payments were: [READ PAYMENTS LISTED ABOVE]?

BOX NSL2

routing

NSL3

roster

BOX NSL3

routing

NUMLINKS

NSL4

grid

EVENT_VISITSAME

NSL5

roster

BOX NSL5

routing

IF EVENT LINKED TO NS CHARGE BUNDLE HAS EVNT.EVNTTYPE = 'PM', GO TO NSL3 - EVENT_PMSAME.
ELSE GO TO NSL5 - EVENT_VISITSAME.
Which ones are the same?
REVIEW LIST WITH RESPONDENT AND SELECT ALL PRESCRIPTION MEDICINES WHERE THE COSTS AND
PAYMENTS ARE THE SAME.

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

(01) CONTINUOUS ANSWER

IF NO PRESCRIPTION MEDICINES HAD THE SAME COST AND PAYMENTS, PRESS ENTER WITHOUT SELECTING
ANY MEDICINES.
IF AT LEAST ONE PRESCRIBED MEDICINE SELECTED AT NSL3 HAS NUMBER OF PURCHASES BEING ASKED
ABOUT IN NS > 1, GO TO NSL4 - NUMLINKS.
ELSE GO TO BOX NSBEG.
How many times are the same?
(01) CONTINUOUS ANSWER
ENTER THE NUMBER OF PURCHASES OF EACH MEDICINE SHOWN BELOW THAT ARE THE SAME.
(-8) DON'T KNOW
(-9) REFUSED
Which ones are the same?
(01) CONTINUOUS ANSWER
REVIEW LIST WITH THE RESPONDENT AND SELECT ALL PROVIDER EVENTS WHERE THE COST AND PAYMENTS
ARE THE SAME.
IF NO PROVIDER EVENTS HAD THE SAME COST AND PAYMENTS, PRESS ENTER WITHOUT SELECTING ANY
EVENTS.
IF AT LEAST ONE EVENT SELECTED AT NSL5 IS A REPEAT VISIT, GO TO NSL6 - RVLINKS.
ELSE GO TO BOX NSBEG.

No-Statement Charge (NSQ)
Variable Name
RVLINKS

NSTATEMENT

MR Screen Name
NSL6

Question type
numeric

BOX NSL6

routing

NS81

yes/no

Question text/description
How many times are the same for (EVENT)?
ENTER THE NUMBER OF (EVENT TYPE) VISITS IN (EVENT
MONTH, YEAR) THAT ARE THE SAME.
IF ANOTHER EVENT SELECTED AT NSL5 IS A REPEAT VISIT, GO TO NSL6 - RVLINKS.
ELSE GO TO BOX NSBEG.
YOU HAVE ENTERED ALL CHARGE/PAYMENT DATA FOR ALL EVENTS REPORTED.

routing

DO YOU HAVE ANY MSN, INSURANCE, TRICARE, OR MEDICARE PRESCRIPTION DRUG BENEFIT STATEMENTS
THAT YOU HAVE NOT YET ENTERED?
GO TO NEXT SECTION

BOX NSEND

Code list
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

(01) YES
(02) NO