Cms-p-0015a Mcbs

Charge Payment Summary (CPS)
Variable Name

MR Screen Name

Question type

Question text/description
Code list
CPS REASON HAS ALREADY BEEN ASSIGNED TO ALL CHARGE BUNDLES ENTERED IN THE PAST 2 ROUNDS THAT
HAVE MISSING CHARGE DATA.
CPS REASON 1 = NO STATEMENT CHARGE BUNDLE, SP EXPECTED TO RECEIVE A STATEMENT
CPS REASON 2 = NO STATEMENT CHARGE BUNDLE, NO PAYMENTS HAVE BEEN MADE.
CPS REASON 3 = STATEMENT CHARGE BUNDLE, NO PAYMENTS HAVE BEEN MADE.
CPS REASON 4 = NO STATEMENT CHARGE BUNDLE, TOTAL PAYMENTS LESS THAN TOTAL CHARGE. - NO
EVENTS FLAGGED AS REASON 4 IN ROUND 71.
CPS REASON 5 = STATEMENT CHARGE BUNDLE, TOTAL PAYMENTS LESS THAN AMOUNT REMAINING. - NO
EVENTS FLAGGED AS REASON 5 IN ROUND 71.

BOX CPSBEG

routing
CPS REASON 6 = SP MADE PAYMENT AND EXPECTED REIMBURSEMENT. - NO EVENTS FLAGGED AS REASON 6
IN ROUND 71.
CPS REASON 7 = SP MADE PAYMENT AND DID NOT KNOW IF REIMBURSEMENT EXPECTED. - NO EVENTS
FLAGGED AS REASON 7 IN ROUND 71.
CPS REASON 8 = NO STATEMENT CHARGE BUNDLE ENTERED AT HOME OFFICE, SP EXPECTED TO RECEIVE A
STATEMENT. - NO EVENTS FLAGGED AS REASON 8 IN ROUND 71.
CPS REASON 9 = R70 CHARGE BUNDLE, NO STATEMENT ENTERED, FOLLOW CPS REASON 1 PATH
IN CPS, WE WILL REVIEW THIS LIST OF CHARGE BUNDLES AND WILL EXCLUDE ANY CHARGE BUNDLE WITH AN
EVENT THAT HAS BEEN DELETED, HAS BEEN LINKED TO A STATEMENT CHARGE BUNDLE IN THE CURRENT
ROUND, OR WAS ASKED ABOUT IN THE CURRENT ROUND NO STATEMENT SECTION AND THE SP IS NOT

NAVIGATOR

CPS1_IN

instance navigator

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

[Next, I will ask about some medical care that we talked about in a previous interview.]
CPSINT

CPS1

no entry

BOX CPS1A

routing

BOX CPS1B

routing

THERE ARE (TOTAL NUMBER OF CPS EVENTS) EVENTS OR BUNDLES [REMAINING] FOR SUMMARY.
[First/Next], I want to ask about [READ EVENT(S) ABOVE].
IF CPS REASON = 1 OR 8 OR 9, GO TO CPS2 - RECDSTAT.
ELSE GO TO BOX CPS1B.
CREATE SOURCE OF PAYMENT ROSTER
IF CPS REASON = 2, 6 OR 7, GO TO BOX CPS2.
ELSE IF CPS REASON = 3, GO TO CPS11 - CPTCHGPAID2.
ELSE IF CPS REASON = 4, GO TO CPS13 - CPTCHGPAID3.
ELSE IF CPS REASON = 5, GO TO CPS15 - CPTCHGPAID4.
[IF CPS REASON=9 THEN DISPLAY IN BOLD: "EVENT REPORTED IN ROUND 70"]
[At the last interview, [you were/(SP) was] expecting to receive a statement or paper from [Medicare,
Insurance, and TRICARE/Medicare and TRICARE/Medicare and Insurance/Medicare).]

RECDSTAT

CPS2

code one

[At the last interview, [you/(SP)] reported [READ EVENT(S) ABOVE].
[Have you/Has (SP)] received a statement for the [READ EVENT(S) ABOVE] (since then/since the last
interview)?
[PROBE IF NECESSARY: Please include any statements received about (your/(SP's)] Medicare prescription drug
benefit.]

(01) STATEMENT RECEIVED AND AVAILABLE
(02) STATEMENT RECEIVED, NOT AVAILABLE
(03) STATEMENT NOT RECEIVED
(-8) Don't Know
(-9) Refused

Charge Payment Summary (CPS)
Variable Name

KNOWTOTL

TOTALCHG

TOTALCHG

MR Screen Name

Question type

BOX CPS2

routing

CPS3

yes/no

BOX CPS3

routing

CPS4

numeric

CPS5

numeric

BOX CPS5A

routing

BOX CPS5B

routing

MONTHCOV

CPS6

numeric

NUMLINKS

CPS7

numeric

RVLINKS

CPS8

numeric

BOX CPS8A

routing

BOX CPS8B

routing

Question text/description
Code list
IF TOTAL CHARGE = DK OR RF AND ((ASKING ABOUT A NO STATEMENT CHARGE BUNDLE) OR (ASKING ABOUT
A STATEMENT CHARGE BUNDLE AND TYPE OF STATEMENT IS NOT A MEDICARE PRESCRIPTION DRUG BENEFIT
STATEMENT)), GO TO CPS3 - KNOWTOTL.
ELSE IF CPS REASON = 2, GO TO CPS9 - CPTCHGPAID1.
(01) YES
Do you happen to know the (total charge/copayment amount) for the [READ EVENT(S) ABOVE]?
(02) NO
(-9) Refused
IF CPS3 - KNOWTOTL = 1/Yes AND (TOTAL CHARGE WAS COLLECTED FOR CHARGE BUNDLE), GO TO CPS4 TOTALCHG.
ELSE IF CPS3 - KNOWTOTL = 1/Yes AND (COPAYMENT WAS COLLECTED FOR CHARGE BUNDLE), GO TO CPS5 TOTALCHG.
ELSE IF (CPS3 - KNOWTOTL = 2/No OR RF) AND (CPS REASON = 2), GO TO CPS9 - CPTCHGPAID1.
Including any amounts that may be paid by Medicare or anyone else, what was the total charge (that is, the
amount billed)?
(01) continuous answer
ENTER 0 IF NO CHARGE FOR THE EVENT.
(-8) Don't Know
[PROBE FOR TOTAL BILLED AMOUNT, REGARDLESS OF WHO PAID (OR WILL PAY) ANY PORTION OF THE
(-9) Refused
CHARGE. IF THE RESPONDENT RECEIVES A DISCOUNT, RECORD THE TOTAL CHARGE BEFORE THE DISCOUNT IS
APPLIED.]
What was the copayment amount for the [READ EVENT(S) ABOVE]?
[EXPLAIN IF NECESSARY: Managed care plans commonly charge a fixed amount, or copayment, each time
(01) continuous answer
health services are provided. For example, the person may pay $20 for each office visit and $10 for each drug (-8) Don't Know
prescription.]
(-9) Refused
ENTER 0 IF NO COPAYMENT FOR THE EVENT.
IF (CPS REASON = 2) AND (TOTAL CHARGE = 0) AND (SP IS CURRENTLY COVERED BY MEDICAID), GO TO BOX
CPS32.
ELSE GO TO BOX CPS5B.
FOR THE FIRST/NEXT EVENT INCLUDED IN THE CHARGE BUNDLE, IF EVENT TYPE = 'OM' AND EVENT IS A
RENTAL ITEM, GO TO CPS6 - MONTHCOV.
ELSE FOR THE FIRST/NEXT EVENT INCLUDED IN THE CHARGE BUNDLE, IF (EVENT TYPE = 'PM') OR (EVENT TYPE
= 'OM' AND (OTHER MEDICAL EXPENSE IS OSTOMY SUPPLIES, INCONTINENCE SUPPLIES OR BANDAGES)), GO
TO CPS7 - NUMLINKS.
ELSE FOR THE FIRST/NEXT EVENT INCLUDED IN THE CHARGE BUNDLE, IF (EVENT WAS ENTERED AS A REPEAT
VISIT), GO TO CPS8 - RVLINKS.
ELSE GO TO BOX CPS8A.
For the [READ OME ITEM ABOVE], how many months are covered by the charge for the period of time
between (CHARGE BUNDLE REFERENCE PERIOD)?
[IF THE RESPONDENT DOES NOT REPORT THE NUMBER OF MONTHS AS A WHOLE NUMBER, ROUND UP. (E.G.,
FOR 2 ½ MONTHS, ENTER “3”.)]
How many of the times [you/(SP)] obtained (MEDICINE NAME/OME ITEM TYPE) for the period between
(CHARGE BUNDLE REFERENCE PERIOD) [were covered by the total charge/were covered by the (CPS4 - TOTAL
CHARGE)/was there no charge/were covered by the copayment/were covered by the (CPS5 COPAYMENT)/was there no copayment]?
How many of the [READ EVENT ABOVE] [were covered by the total charge/were covered by the (CPS4 - TOTAL
CHARGE)/was there no charge/were covered by the copayment/were covered by the (CPS5 COPAYMENT)/was there no copayment]?
IF ANOTHER EVENT IS INCLUDED IN THE CHARGE BUNDLE, GO TO BOX CPS5B.
ELSE GO TO BOX CPS8B.
IF CPS REASON = 2 AND TOTAL CHARGE ^= 0, GO TO CPS9 - CPTCHGPAID1.
ELSE IF CPS REASON = 2 AND TOTAL CHARGE = 0, GO TO BOX CPS10.

(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused

Charge Payment Summary (CPS)
Variable Name

MR Screen Name

Question type

CPTCHGPAID1

CPS9

code one

TCHGWRONG

CPS10

no entry

BOX CPS10

routing

CPTCHGPAID2

CPS11

code one

TCHGWRONG

CPS12

no entry

BOX CPS12

routing

CPTCHGPAID3

CPS13

code one

TCHGWRONG

CPS14

no entry

BOX CPS14

routing

CPTCHGPAID4

CPS15

code one

TCHGWRONG

CPS16

no entry

BOX CPS16

routing

CPS17

yes/no

EXPAYOUT

Question text/description

Code list
(01) SP OR ANY SOURCE PAID
[Last time, we recorded that the (total charge/copayment amount) for the [READ EVENT(S) ABOVE] was
(02) NOTHING HAS BEEN PAID
(TOTAL CHARGE)), and that no payment had been made.] [Have you/Has (SP)] or any other source[, such as (03) (TOTAL CHARGE/COPAYMENT AMOUNT) IS
(an insurance plan/TRICARE/TRICARE or an insurance plan),] now paid any of [the total charge/the copayment WRONG
amount/this (TOTAL CHARGE)]?
(-8) Don't Know
(-9) Refused
YOU CANNOT CORRECT THE TOTAL CHARGE HERE. THE ERROR HAS BEEN NOTED. ANSWER “YES” OR “NO”
AS APPROPRIATE AS TO WHETHER ANY SOURCE HAS PAID ANY PORTION OF THE CHARGE.
IF (CPS9 - CPTCHGPAID1 = 1/SomeonePaid) OR (TOTAL CHARGE = 0), GO TO NS65 - NSADDSOP1.
ELSE IF (CPS9 - CPTCHGPAID1 = 2/NothingPaid), GO TO CPS17 - EXPAYOUT.
ELSE GO TO BOX CPS32.
Last time, we recorded that [Medicare had paid [nothing and/(MEDICARE PAYMENT AMOUNT) and after
(01) SP OR ANY SOURCE PAID
Medicare paid,]] there was an amount remaining of (CPS AMOUNT REMAINING) for the [READ EVENT(S)
(02) NOTHING HAS BEEN PAID
ABOVE.]
(03) AMOUNT REMAINING SEEMS WRONG
(-8) Don't Know
[Have you/Has (SP)] or any other source [, such as (an insurance plan/TRICARE/TRICARE or an insurance
(-9) Refused
plan),] now paid any of this (AMOUNT REMAINING)?
YOU CANNOT CORRECT THE AMOUNT REMAINING HERE. THE ERROR HAS BEEN NOTED. ANSWER “YES” OR
“NO” AS APPROPRIATE AS TO WHETHER ANY SOURCE HAS PAID.
IF (CPS11 - CPTCHGPAID2 = 1/SomeonePaid), GO TO ST65 - STADDSOP1.
ELSE IF (CPS11 - CPTCHGPAID2 = 2/NothingPaid), GO TO CPS17 - EXPAYOUT.
ELSE IF (CPS11 - CPTCHGPAID2 = DK), GO TO CPS23 - RRDETAIL.
ELSE GO TO BOX CPS32.
Let me review what we recorded last time.
(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
[REVIEW WITH RESPONDENT.] The total of all payments is $(TOTAL PAYMENTS). The amount unpaid is
(03) TOTAL CHARGE SEEMS WRONG
$(DIFFERENCE BETWEEN PAYMENTS AND TOTAL CHARGE).
(04) PAYMENT AMOUNTS WRONG
(-8) Don't Know
[Have you/Has (SP)] or any other source [, such as (an insurance plan/TRICARE/TRICARE or an insurance
(-9) Refused
plan),] paid any additional amount?
YOU CANNOT CORRECT THE TOTAL CHARGE HERE. THE ERROR HAS BEEN NOTED. ANSWER “YES” OR “NO”
AS APPROPRIATE AS TO WHETHER ANY SOURCE HAS PAID ANY ADDITIONAL AMOUNT.
IF CPS13 - CPTCHGPAID3 = 1/Yes OR 4/PaymentsWrong, GO TO NS65 - NSADDSOP1.
ELSE IF CPS13 - CPTCHGPAID3 = 2/NothingPaid, GO TO CPS17 - EXPAYOUT.
ELSE IF (CPS13 - CPTCHGPAID3 = DK), GO TO CPS23 - RRDETAIL.
ELSE GO TO BOX CPS32.
Let me review what we recorded last time.
(01) SP OR ANY SOURCE PAID
[REVIEW ABOVE WITH RESPONDENT.] There seems to be some amount still unpaid. The total of non(02) NOTHING HAS BEEN PAID
Medicare payments is $(TOTAL PAYMENTS). The amount unpaid is $(DIFFERENCE BETWEEN PAYMENTS AND (03) AMOUNT REMAINING SEEMS WRONG
CPS AMOUNT REMAINING).
(04) PAYMENT AMOUNTS WRONG
(-8) Don't Know
[Have you/Has (SP)] or any other source [, such as (an insurance plan/TRICARE/TRICARE or an insurance
(-9) Refused
plan),] paid any additional amount?
YOU CANNOT CORRECT THE AMOUNT REMAINING HERE. THE ERROR HAS BEEN NOTED. ANSWER “YES” OR
“NO” AS APPROPRIATE AS TO WHETHER ANY SOURCE HAS PAID ANY ADDITIONAL AMOUNT.
IF CPS15 - CPTCHGPAID4 = 1/Yes OR 4/PaymentsWrong, GO TO ST65 - STADDSOP1.
ELSE IF CPS15 - CPTCHGPAID4 = 2/NothingPaid, GO TO CPS17 - EXPAYOUT.
ELSE IF (CPS15 - CPTCHGPAID4 = DK), GO TO CPS23 - RRDETAIL.
ELSE GO TO BOX CPS32.
(01) YES
Do you expect that [you/(SP)] or any other source will pay any [of this amount/additional amount for [READ (02) NO
EVENT(S) ABOVE]]?
(-8) Don't Know
(-9) Refused

Charge Payment Summary (CPS)
Variable Name

MR Screen Name

Question type

BOX CPS17

routing

EXPAYUNT

CPS18

code one

EXPAYPCT
EXPAYAMT

CPS18
CPS18

numeric
numeric

RRDETAIL

CPS23

yes/no

RRADD

CPS24

yes/no

CPADDSOP

CPS25

yes/no

SOP_CP

CPS26

roster

TSOPREIM_NAME

CPS27

grid

TSOPREIM_AMT

CPS27

grid

BOX CPS27A

routing

BOX CPS27B

routing

PLANINTRO_CPS

CPS27BINT

no entry

NAVIGATOR

CPS27B_IN

instance navigator

BOX CPS27C

Question text/description
IF (CHARGES WERE FIRST COLLECTED 2 ROUNDS PREVIOUS TO CURRENT ROUND) OR (SP IS IN THE EXIT
SAMPLE), GO TO CPS18 - EXPAYUNT.
ELSE GO TO BOX CPS32.

Code list

(91) PERCENTAGE
(02) DOLLARS
How much do you expect will be paid?
(-8) Don't Know
(-9) Refused
How much do you expect will be paid?
(01) continuous answer
How much do you expect will be paid?
(01) continuous answer
DID RESPONDENT MENTION (AN INSURANCE/A) REFUND OR REIMBURSEMENT ABOUT WHICH HE/SHE IS NOT (01) YES
SURE OF THE DETAILS?
(02) NO
[DO NOT ENTER A COMMENT HERE TO EXPLAIN THE SITUATION.]
(-8) Don't Know
DO YOU WANT TO ADD A REFUND OR REIMBURSEMENT?
(01) YES
[DO NOT SELECT “YES” IF THE RESPONDENT KNOWS A REIMBURSEMENT AMOUNT, BUT DOES NOT KNOW
(02) NO
WHO PAID IT.]
ARE ALL OF THE SOURCES OF PAYMENT FOR THIS CHARGE BUNDLE LISTED BELOW?
(01) YES
SELECT "NO" TO ADD A SOURCE OF PAYMENT.
(02) NO
ADD ALL ADDITIONAL SOURCES OF PAYMENT FOR THIS CHARGE BUNDLE.
(01) continuous answer
(01) continuous answer
(-7) Empty
Who (else) paid (besides Medicare)? How much did (SOURCE) pay?
(-8) Don't Know
(-9) Refused
How much did (SOURCE) pay?
(01) continuous answer
(-7) Empty
REIMBURSEMENT AMOUNT: (REIMBURSEMENT AMOUNT)
(-8) Don't Know
ENTER ALL REIMBURESMENT AMOUNTS.
(-9) Refused
IF AT LEAST ONE SOURCE OF PAYMENT WAS ADDED AT CPS26, GO TO BOX CPS27B.
ELSE GO TO BOX CPS29F.
IF AT LEAST ONE SOURCE OF PAYMENT ADDED AT CPS26 IS A HEALTH INSURANCE PLAN AND CPREASON=3,
GO TO CPS27BINT - PLANINTRO_CPS.
ELSE GO TO BOX CPS29E.
Before we continue, I would like to ask you a few questions about the health insurance plan(s) you just added.
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED

routing

CREATE A NEW HEALTH INSURANCE PLAN FOR FIRST/NEXT SOURCE OF PAYMENT ADDED AT CPS26
IF SOURCE OF PAYMENT IS A MEDICARE MANAGED CARE PLAN AND SP HAS A MEDICARE MANAGED CARE
PLAN THAT IS CURRENT, GO TO CPS28 - CPMHMOCHNG.
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 CPS29 - CPSOPCURR.
ELSE IF SOURCE OF PAYMENT IS A MEDICARE PRESCRIPTION DRUG PLAN AND SP HAS A MEDICARE
PRESCRIPTION DRUG PLAN THAT IS CURRENT, GO TO CPS29A - CPMPDPCHNG.
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 CPS29B - CPSOPCURR2.
ELSE IF SOURCE OF PAYMENT IS MEDICAID, GO TO HI6 - COVTIME.
ELSE IF SOURCE OF PAYMENT IS A PUBLIC PLAN, GO TO HI13 - COVTIME.
ELSE IF SOURCE OF PAYMENT IS A PRIVATE PLAN, GO TO HI21 - COVTIME.
ELSE GO TO HIT2 - COVTIME.

CPMHMOCHNG

CPS28

yes/no

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

CPSOPCURR

CPS29

yes/no

[Are you/Is (SP)/Was (SP)] (currently) covered or enrolled in (CPS26 SOP MEDICARE MANAGED CARE PLAN
NAME) [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

Charge Payment Summary (CPS)
Variable Name

MR Screen Name

Question type

CPMPDPCHNG

CPS29A

yes/no

Question text/description
I recorded previously that (CURRENT MEDICARE PRESCRIPTION DRUG PLAN) was [your/(SP's)] current
Medicare Prescription Drug Care Plan.
Has this information changed?

CPSOPCURR2

CPS29B

yes/no

BOX CPS29A

routing

BOX CPS29E

routing

BOX CPS29F

routing

[Are you/Is (SP)/Was (SP)] (currently) covered or enrolled in (CPS26 SOP MEDICARE PRESCRIPTION DRUG
PLAN) [on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?

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

GO TO CPS27B_IN - NAVIGATOR.
IF AN "OTHER SOURCE OF PAYMENT" ADDED AT CPS26, CREATE AN OSOP FOR EACH SOURCE OF PAYMENT
ADDED AT CPS26 THAT IS AN "OTHER SOURCE OF PAYMENT"
GO TO BOX CPS29F.
CREATE REIMBURSEMENTS FOR AMOUNTS ENTERED AT CPS27.
GO TO CPS30 - REIMBCOV.

REIMBCOV

CPS30

yes/no

DOES THIS REIMBURSEMENT AMOUNT COVER ANY OTHER EVENTS BESIDES THOSE SHOWN ABOVE?

REIMCODE

CPS31

code all

WHAT OTHER TYPE(S) OF EVENT(S) ARE COVERD BY THIS REIMBURSEMENT?
CHECK ALL THAT APPLY.

REIMCOMMENT

CPS32

no entry

BOX CPS32
BOX CPSEND

routing
routing

PLEASE ENTER A COMMENT TO RECORD ANYTHING ELSE YOU KNOW ABOUT THIS REFUND (PROVIDER(S),
DATE(S), ETC.)
GO TO BOX CPSBEG.
GO TO NEXT SECTION.

(01) YES
(02) NO
(-8) Don't Know
(01) SEPARATELY BILLING LAB (SL)
(02) SEPARATELY BILLING DOCTOR (SD)
(03) DENTAL (DU)
(04) HOSPITAL EMERGENCY ROOM (ER)
(05) HOSPITAL INPATIENT STAY (IP)
(06) HOSPITAL OUTPATIENT VISIT (OP)
(07) INSTITUTIONAL STAY (IU)
(08) HOME HEALTH PROFESSIONAL (HP)
(09) OTHER HOME HEALTH (HF)
(10) OTHER VISITS TO MEDICAL PROVIDERS (MP)
(11) OTHER MEDICAL EXPENSES (OM)
(12) PRESCRIBED MEDICINES (PM)
(-8) Don't Know