Cms-p-0015a Mcbs

Post-Statement Charge (PSQ)
Variable Name
MR Screen Name

BOX PS1

Question type

Question text/description

routing

IF THE SP STILL EXPECTS CHARGES FOR AT LEAST ONE RENTAL ITEM ENTERED IN A PREVIOUS
ROUND THAT IS NOT ALREADY INCLUDED IN A CURRENT ROUND CHARGE BUNDLE, GO TO PS1A HADPYMNT.
ELSE GO TO BOX PSEND.
(Now/Next), let’s look at the costs for the (OME ITEM TYPE) [you/(SP)] [rented and then
bought/stopped renting/stopped renting on (EVENT END DATE)].

HADPYMNT

EXPPYMNT

PS1A

yes/no

Since (REFERENCE DATE), were any payments made for the (OME ITEM TYPE)?

Code list

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

PS2

yes/no

BOX PS3

routing

THIS INCLUDES PAYMENTS MADE BY SP, MEDICARE, INSURANCE, TRICARE, OR ANY OTHER SOURCE
OF PAYMENT.
[Do you/Does (SP)] expect any more rental or installment payments to be made for the (OME ITEM
(01) YES
TYPE)?
(02) NO
(-8) Don't Know
THIS INCLUDES PAYMENTS MADE BY SP, MEDICARE, INSURANCE, TRICARE, OR ANY OTHER SOURCE
(-9) Refused
OF PAYMENT.
IF THE SP STILL EXPECTS CHARGES FOR ANOTHER RENTAL ITEM ENTERED IN A PREVIOUS ROUND
THAT IS NOT ALREADY INCLUDED IN A CURRENT ROUND CHARGE BUNDLE, GO TO PS1A HADPYMNT.

routing

ELSE GO TO BOX PSEND.
GO TO NEXT SECTION

BOX PSEND