Form #1 Form #1 Institutions (non-hospital) questionnaire

Form Approved
OMB No. 0935-0118
Exp. Date 12/31/2015

Attachment 92

MEDICAL EXPENDITURE PANEL SURVEY

MEDICAL PROVIDER COMPONENT

EVENT FORM

FOR

institutional PROVIDERS

(non-hospital facilities)

FOR

REFERENCE YEAR 2014

SECTION 1 – OMB HYPERLINK ON FIRST SCREEN

DCS: READ THIS ALOUD ONLY IF REQUESTED BY RESPONDENT.

PRESS NEXT TO CONTINUE IN THIS EVENT FORM

PRESS BREAKOFF TO DISCONTINUE

(Public reporting burden for this collection of information is estimated to average 3 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0118) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.)

OMB No. 0935-0118; Exp. Date XX/XX/XXXX

SECTION 2 – MEDICAL RECORDS – EVENT DATE

[Page 1 – MEDICAL RECORDS – event date (1 of 1)]

A1. What were the admit and discharge dates of the (first/next) stay?

ADMIT: MONTH DAY YEAR DISCHARGE: MONTH DAY YEAR NOT YET DISCHARGED………………1

Not2014

YOU ENTERED DATES FOR A SINGLE STAY THAT INCLUDED ALL OF 2014.

 
IF THIS WAS AN ERROR PRESS “PREVIOUS” TO CORRECT YOUR DATE ENTRIES.

IF THIS IS CORRECT PRESS “NEXT.”

SECTION 3 – MEDICAL RECORDS – DIAGNOSES

[Page 2 – MEDICAL RECORDS - DIAGNOSES (1 of 1)]

A3. I need the diagnoses for this stay. I would prefer the ICD-9 codes (or DSM-IV codes), if they are available. IF CODES ARE NOT USED, RECORD DESCRIPTIONS. [SYSTEM WILL ALLOW FOR A MAXIMUM OF 5 ICD-9 CODES TO BE COLLECTED]

CODE DESCRIPTION CHECK HERE IF THIS IS AN ICD-10 CODE

SECTION 4 – MEDICAL RECORDS – SBD

[Page 3 – MEDICAL RECORDS - Sbd (1 of 1)]

A2. I need to record the name and specialty of each physician who provided services during the stay starting on (ADMIT DATE) and whose charges might not be included in the facility bill. We are interested in physicians with whom your facility has contractual arrangements, not the patient’s private physician. PROBE FOR MORE THAN ONE RADIOLOGIST, ANETHESIOLOGIST, ETC OR OTHER SEPARATELY BILLING MEDICAL PROFESSIONAL. IF RESPONDENT IS UNSURE WHETHER A PARTICULAR DOCTOR’S CHARGES ARE INCLUDED IN THE INSTITUTION BILL, RECORD YES HERE.

SEPARATELY BILLING DOCTORS FOR THIS EVENT………………………………1 NO SEPARATELY BILLING DOCTORS FOR THIS STAY………………………………..2 DO NOT HAVE THIS INFORMATION………..3

EF1 Can you please provide the full name of the (first/next) physician whose charges might not be included in the hospital bill?

Physician Name:

GROUP NAME/FIRSTNAME/MIDDLE/LAST/NATIONAL PROVIDER ID

EF3 What is this physician’s specialty?

Specialty:

(IF OTHER SPECIFY:)

EF2 Did this doctor provide any of the following services for this event: radiology, anesthesiology, pathology, or surgery?

1 Radiology

2 Anesthesiology

3 Pathology

4 Surgery

5 None of the above

6 DON’T KNOW

EF5 How would you describe the role of this doctor for this medical event?

Active Physician/Providing Direct Care 1

Referring Physician 2

Copied Physician 3

Follow-up Physician 4

Department Head 5

Primary Care Physician 6

Some Other Physician 7

None of the above 8

DON’T KNOW 9

(IF OTHER DESCRIBE) What other type of physician?

EF6 ENTER ANY COMMENTS ABOUT THIS SBD, INCLUDING ADDITIONAL SERVICES TO THE ONE SELECTED IN EF2.

EVENT NOTES:

SECTION 5 – MEDICAL RECORDS – SUMMARY/CONCLUSION

MEDICAL RECORDS - SUMMARY/CONCLUSION (1 of 1)]

4a

PRESS "BREAKOFF" TO CLOSE THIS MEDICAL RECORDS SECTION. CMS WILL ASK WHETHER YOUR MEDICAL RECORDS RESPONDENT HAS ADDITIONAL EVENTS FOR THIS PATIENT.

PRESS "NEXT" WHEN YOU ARE READY TO BEGIN PATIENT ACCOUNTS SECTION.

PROGRAMMER NOTES

DK/REF/RETRIEVABLE – Not Applicable here

SECTION 6 – PATIENT ACCOUNTS – INTRODUCTION

[Page 5 – PATIENT ACCOUNTS - iNTRODUCTION (1 of 1)]

I have information from Medical Records that (PATIENT NAME) received health care services (DATE).

NOTE: IF THE ONLY EVENT KNOWN BY PATIENT ACCOUNTS IS WITHIN A DAY OR TWO OF WHAT WAS REPORTED BY MEDICAL RECORDS, ANSWER YES BELOW.

YES, RECORDS FOUND FOR THIS EVENT. = 1

NO, RECORDS NOT FOUND FOR THIS EVENT. = 2

NO, OTHER RECORDS PROBLEM = 3

SECTION 7 – PATIENT ACCOUNTS – REIMBURSEMENT TYPE

[Page 6 – PATIENT ACCOUNTS - REIMBURSEMENT TYPE (1 of 1)]

Q5. Was the facility reimbursed for this stay on a fee-for-service basis or a capitated basis? EXPLAIN IF NECESSARY: Fee-for-service means that the facility was reimbursed on the basis of the services provided. Capitated basis means that the patient was enrolled in a prepaid managed care plan, such as an HMO, and reimbursement to the facility was not based on the services provided. This is also called Per Member Per Month IF IN DOUBT, CODE FEE-FOR-SERVICE.

Fee-for-service basis 1 Capitated basis 2

SECTION 8 – PATIENT ACCOUNTS – sERVICES/cHARGES

[Page 7 – PATIENT ACCOUNTS - sERVICES/cHARGES (1 of 2)]

Q6. What was the full established charge for room, board, and basic care for this stay, before any adjustments or discounts, between (ADMIT DATE) and (DISCHARGE DATE/END OF 2014)? EXPLAIN IF NECESSARY: The full established charge is the charge maintained in the facility's master fee schedule for billing private pay patients. It is the “list price” for the service, before consideration of any discounts or adjustments resulting from contractual arrangements or agreements with insurance plans. IF NO CHARGE: Some facilities that don't charge for each individual service do associate dollar amounts with services in their records for purposes of budgeting or cost analysis. This kind of information is sometimes call a "charge equivalent." Could you give me the charge equivalent for this stay? CHECKPOINT: HAVE YOU BEEN ABLE TO DETERMINE THE FULL ESTABLISHED CHARGE?

FULL ESTABLISHED CHARGE OR CHARGE EQUIVALENT: $ YES, DID PROVIDE TOTAL CHARGE………..1 nO, CANNOT PROVIDE TOTAL CHARGE …2

SECTION 9 – PATIENT ACCOUNTS – sources of payment

[Page 9 – PATIENT ACCOUNTS - sources of payment (1 of 1)]

Q7. From which of the following sources has the facility received payment for this charge and how much was paid by each source? Please include all payments that have taken place between (ADMIT DATE) and now for this stay. SELECT ALL THAT APPLY [DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO, PROBE: And is that Medicare, Medicaid, or private insurance? [SYSTEM WILL SET UP AS A LOOP, SO NO LIMIT REQUIRED] OTHER SPECIFY: PROBE FOR SOURCE OF FUNDS AND TYPE OF PLAN. IF PROVIDER VOLUNTEERS THAT PATIENT PAYS A MONTHLY PREMIUM, VERIFY: So, you receive a monthly payment rather than payment for the specific service? IF YES: GO BACK TO Q5 AND CODE AS CAPITATED BASIS Q8. [I show the total payment as TOTPAYM / I show the payment as undetermined. / I show the payment as TOTPAYM, although one or more payments are missing ] Is that correct? IF NO, CORRECT ENTRIES ABOVE AS NEEDED.

SOURCE a. Patient or Patient’s Family; b. Medicare; c. Medicaid; d. Private Insurance; e. VA/Champva; f. Tricare; g. Worker’s Comp; or h. Something else? (IF SOMETHING ELSE: What was that?) TOTAL PAYMENTS

PAYMENT AMOUNT $ $ $ $ $ $ $ $ $

SECTION 10 – PATIENT ACCOUNTS – VERIFICATION of payment

[Page 10 – PATIENT ACCOUNTS - VERIFICATION of payment (1 of 1)]

Q8a. I recorded that the payment(s) you received equal YES, FINAL PAYMENTS RECORDED IN Q7 AND Q8 =1

the charge. I would like to make sure that I have NO =2

this recorded correctly. I recorded that the total

payment is [SYSTEM WILL DISPLAY TOTAL

PAYMENT FROM Q8]. Does this total payment

include any other amounts such as adjustments or

discounts, or is this the final payment?

IF NECESSARY, READ BACK AMOUNT(S)

RECORDED IN Q7.

SECTION 11 – PAYMENTS LESS THAN CHARGES (Q9_UNDERPAYMENT)

[Page 10 – SOURCES OF PAYMENT (1 of 1)]

PLC1. It appears that the total payments were less than the total charge.  Is that because …

a. There were adjustments or discounts          YES=1 NO=2    

b. You are expecting additional payment        YES=1 NO=2    

c. This was charity care or sliding scale    YES=1 NO=2     

d. This was bad debt                                 YES=1 NO=2     

ELIGVET2.

It appears that the total payment was less than the total charges. Is that because the person is an eligible veteran?

YES=1, NO=2

DCS:  IF THE POC IS CONFUSED BY THE QUESTION, ANSWER THE QUESTION “NO”

MER NOTES

DK/REF/RET ALLOWED

SECTION 12 – PATIENT ACCOUNTS – DIFFERENCE BETWEEN payment AND CHARGES

[Page 11 – PATIENT ACCOUNTS - DIFFERENCE BETWEEN payment AND CHARGES (1 of 1)]

Are you expecting additional payment from: IF THE ONLY PAYMENT FOR THIS EVENT WAS A LUMP SUM, ANSWER “NO” TO ALL OPTIONS ADJEXTRA It appears that the total payment was more than the total charges. Is that correct? YES=1 NO=2 DCS:  IF THE ANSWER IS “NO” PLEASE GO BACK TO C5 (VERIFY TOTAL PAYMENTS) TO RECONFIRM CHARGES AND PAYMENTS AS NEEDED

Expecting additional payment i. Patient or Patient’s Family; YES=1, NO=2 j. Medicare; YES=1, NO=2 k. Medicaid; YES=1, NO=2 l. Private Insurance; YES=1, NO=2 m. VA/Champva; YES=1, NO=2 n. Tricare; YES=1, NO=2 o. Worker’s Comp; or YES=1, NO=2 p. Something else? YES=1, NO=2 (IF SOMETHING ELSE: What was that?)

SECTION 13 – PATIENT ACCOUNTS – rates/Charges

[Page 12 – PATIENT ACCOUNTS – rate/charges (1 of 3)]

Q10. Can you tell me what the facility's full established daily rate for room and board and basic care was during this stay?

$_______________ . ________ RATE PROVIDED………………………….1 rate changed during stay 2

[Page 14 – PATIENT ACCOUNTS – rates/CHARGE (3 of 3)]

Q11. This stay for [PATIENT] that we are discussing lasted [STAYDAYS.] For how many days was the patient charged during this stay? Please give only the days during 2014.

__________________ # DAYS DAYS PROVIDED 1 DAYS NOT REPORTED 2

SECTION 14 – PATIENT ACCOUNTS – Sources of payment 2

[Page 15 – PATIENT ACCOUNTS – Sources of payment 2 (1 of 1)]

Q11a. From which of the following sources has the facility received payment for these charges and how much was paid by each source? Please include all payments that have taken place between (ADMIT DATE) and now for this stay. SELECT ALL THAT APPLY [DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO, PROBE: And is that Medicare, Medicaid, or private insurance? OTHER SPECIFY: PROBE FOR SOURCE OF FUNDS AND TYPE OF PLAN. IF PROVIDER VOLUNTEERS THAT PATIENT PAYS A MONTHLY PREMIUM, VERIFY: So, you receive a monthly payment rather than payment for the specific service? IF YES: GO BACK TO Q5 AND CODE AS CAPITATED BASIS Q11b. [I show the total payment as TOTPAYM / I show the payment as undetermined. / I show the payment as TOTPAYM, although one or more payments are missing ] . Is that correct? IF NO, CORRECT ENTRIES ABOVE AS NEEDED.

SOURCE a. Patient or Patient’s Family; b. Medicare; c. Medicaid; d. Private Insurance; e. VA/Champva; f. Tricare; g. Worker’s Comp; or h. Something else? (IF SOMETHING ELSE: What was that?) TOTAL PAYMENTS

PAYMENT AMOUNT $ $ $ $ $ $ $ $ $

SECTION 15 – PATIENT ACCOUNTS – billing period information WITH PAYMENTS

[Page 16 – PATIENT ACCOUNTS – billing period information (1 of 7)]

Q12. (Perhaps it would be easier if you gave me information about payments by billing period.) What was the billing start date?

MO DY YR

Q12a. What was your billing end date?

MO DY YR

[Page 17 – PATIENT ACCOUNTS – billing period information (2 of 7)]

Q12-1. BILLING PERIOD IS BETWEEN BPBEGM#/ BPBEGD#/ BPBEGY# and BPENDM#/BPENDD#/ BPENDY# Thanks, that means there were _____ days in your billing period. Between (___and___), how many days was the patient charged for room, board and basic care?

______________# BILLED DAYS

[Page 18 – PATIENT ACCOUNTS – billing period information (2 of 7)]

Q12-1a. The number of days the patient was charged for room, board and basic care was (DAYSBILLED#) days and that is less than the number of days in the billing period, (DAYSBILLPER#). Do you know why?

_______________________________________

[Page 19 – PATIENT ACCOUNTS – billing period information (3 of 7)]

Q12-2. Between (____ and ___), what was the private pay rate for room, board and basic care (PATIENT NAME) received? If the rate changed, please give me the initial rate.

$__________.____

12-3. How many days was that rate applied during this billing period?

______________ # DAYS

[Page 20 – PATIENT ACCOUNTS – billing period information (4 of 7)]

12-Intro. I see that the rate of (BASEPAYRATE#) applied for (BASERATEDAY#) days, although your billing period was (DAYSBILLED#) long. I need to ask some questions to help account for the entire billing period.

12-2A. Between (____ and ___), what other private pay rate applied to the basic care that (PATIENT NAME) received?

$__________.____

12-3A. On what date did this rate of (_____) begin? ____/____/____

MO DY YR

12-4A. During this billing period, how many days was that rate of (OTHBASERATE#) applied?

# DAYS: ________

12-5A. Why did the rate change? CODE ONLY ONE.

LEVEL OF CARE 1

PATIENT DISCHARGED TO HOSPITAL 2

PATIENT DISCHARGED TO COMMUNITY 3

PATIENT DISCHARGED TO OTHER FACILITY 4
RATE INCREASE 5

ROOM CHANGE 6

OTHER, SPECIFY 7

_________________

[Page 21 – PATIENT ACCOUNTS – billing period information (5 of 7)]

12-7 Is (RATE IN 12-2a) the private pay rate that applied at the end of the billing period?

YES 1

NO 2

[Page 22 – PATIENT ACCOUNTS – billing period information (6 of 7)]

12-8. What was the private pay rate that applied at the end of the billing period?

$______________._____

SECTION 16 – PATIENT ACCOUNTS – SOURCES OF PAYMENT 3

[Page 24 – PATIENT ACCOUNTS – SOURCES OF PAYMENT (1 of 1)]

Q13. From which of the following sources did the facility receive payments for this billing period and how much was paid by each source? Please include all payments that have taken place between (ADMIT DATE) and now for this stay. SELECT ALL THAT APPLY [DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO, PROBE: And is that Medicare, Medicaid, or private insurance? [SYSTEM WILL SET UP AS A LOOP, SO NO LIMIT REQUIRED] OTHER SPECIFY: PROBE FOR SOURCE OF FUNDS AND TYPE OF PLAN. IF PROVIDER VOLUNTEERS THAT PATIENT PAYS A MONTHLY PREMIUM, VERIFY: So, you receive a monthly payment rather than payment for the specific service? IF YES: GO BACK TO Q5 AND CODE AS CAPITATED BASIS Q13a. [I show the total payment as TOTPAYM / I show the payment as undetermined. / I show the payment as TOTPAYM, although one or more payments are missing] IF NO, CORRECT ENTRIES ABOVE AS NEEDED.

SOURCE a. Patient or Patient’s Family; b. Medicare; c. Medicaid; d. Private Insurance; e. VA/Champva; f. Tricare; g. Worker’s Comp; or h. Something else? (IF SOMETHING ELSE: What was that?) TOTAL PAYMENTS

PAYMENT AMOUNT $ $ $ $ $ $ $ $ $

SECTION 17 – PATIENT ACCOUNTS – ANCILLARY CHARGES

[Page 25 – PATIENT ACCOUNTS – ANCILLARY CHARGES (1 of 1)]

Q14. Did (PATIENT NAME) have any health-related ancillary charges for this stay? That is, were there charges for additional services not included in the basic rate?

YES 1 NO 2

SECTION 18 – PATIENT ACCOUNTS – total ANCILLARY CHARGES

[Page 26 – PATIENT ACCOUNTS – total ANCILLARY CHARGES (1 of 1)]

Q15. What was the total of full established charges for health-related ancillary care during this stay? Please exclude charges for non-health related services such as television, beautician services, etc. EXPLAIN IF NECESSARY: Ancillaries are facility charges that are not included in the basic charge. Ancillary charges may include laboratory, radiology, drugs and therapy (physical, speech, occupational).

TOTAL CHARGES: $__________.___ YES, PROVIDED ………………………………1 CAN’T SEPARATE HEALTH AND NON-HEALTH ANCILLARY CHARGES…………2 CAN'T GIVE TOTAL HEALTH-RELATED ANCILLARY CHARGES………………………3

IF NO CHARGE Some facilities that don’t charge for each individual service do associate dollar amounts with services for purposes of budgeting or cost analysis. This is sometimes called a “charge equivalent”. Could you give me the total of the charge equivalents for health-related ancillary care during this stay?

SECTION 19 – PATIENT ACCOUNTS – SOURCES OF PAYMENT 4

[Page 27 – PATIENT ACCOUNTS – SOURCES OF PAYMENT (1 of 1)]

Q16. From which of the following sources has the facility received payment for these charges and how much was paid by each source? Please include all payments that have taken place between (ADMIT DATE) and now for this stay. SELECT ALL THAT APPLY [DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO, PROBE: And is that Medicare, Medicaid, or private insurance? [SYSTEM WILL SET UP AS A LOOP, SO NO LIMIT REQUIRED] OTHER SPECIFY: PROBE FOR SOURCE OF FUNDS AND TYPE OF PLAN. Q17. [I show the total payment as ______ / I show the payment as undetermined. / I show the payment as _____, although one or more payments are missing ] Is that correct? IF NO, CORRECT ENTRIES ABOVE AS NEEDED.

a. Patient or Patient’s Family; b. Medicare; c. Medicaid; d. Private Insurance; e. VA/Champva; f. Tricare; g. Worker’s Comp; or h. Something else? (IF SOMETHING ELSE: What was that?) _____________________ TOTAL PAYMENTS

$ $ $ $ $ $ $ $ $

SECTION 20 – PATIENT ACCOUNTS – VERIFICATION of payment 2

[Page 28 – PATIENT ACCOUNTS - VERIFICATION of payment (1 of 1)]

Q17a. I recorded that the payment(s) you received equal the charges. I would like to make sure that I have this recorded correctly. I recorded that the total payment is [TOTAL PAYMENT FROM Q17]. Does this total payment include any other amounts such as adjustments or discounts, or is this the final payment?

IF NECESSARY, READ BACK AMOUNT(S) RECORDED IN Q16.

YES, FINAL PAYMENTS RECORDED IN Q16 AND Q17……………………..1

NO…………………………………………………………….…..……………… 2

SECTION 21 – PAYMENTS LESS THAN CHARGES (Q18_UNDERPAYMENT)

[Page 10 – SOURCES OF PAYMENT (1 of 1)]

PLC2. It appears that the total payments were less than the total charge.  Is that because …

a. There were adjustments or discounts          YES=1 NO=2    

b. You are expecting additional payment        YES=1 NO=2    

c. This was charity care or sliding scale    YES=1 NO=2     

d. This was bad debt                                 YES=1 NO=2     

ELIGVET2_2

It appears that the total payment was less than the total charges. Is that because the person is an eligible veteran?

YES=1,

NO=2

DCS:  IF THE POC IS CONFUSED BY THE QUESTION, ANSWER THE QUESTION “NO”

SECTION 22 – PATIENT ACCOUNTS – DIFFERENCE BETWEEN payment AND CHARGES 2

[Page 29 – PATIENT ACCOUNTS - DIFFERENCE BETWEEN payment AND CHARGES (1 of 1)]

Are you expecting additional payment from: IF THE ONLY PAYMENT FOR THIS EVENT WAS A LUMP SUM, ANSWER “NO” TO ALL OPTIONS ADJEXTRA_2 It appears that the total payments were more than the total charges. Is that correct? YES=1, NO=2 DCS:  IF THE ANSWER IS “NO” PLEASE GO BACK TO C5 (VERIFY TOTAL PAYMENTS) TO RECONFIRM CHARGES AND PAYMENTS AS NEEDED

Expecting additional payment i. Patient or Patient’s Family; YES=1, NO=2 j. Medicare; YES=1, NO=2 k. Medicaid; YES=1, NO=2 l. Private Insurance; YES=1, NO=2 m. VA/Champva; YES=1, NO=2 n. Tricare; YES=1, NO=2 o. Worker’s Comp; or YES=1, NO=2 p. Something else? YES=1, NO=2 (IF SOMETHING ELSE: What was that?)

SECTION 23 – PATIENT ACCOUNTS – BILLING PERIOD INFORMATION 2

[Page 30 – PATIENT ACCOUNTS – BILLING PERIOD INFORMATION (1 of 1)]

Q19. Perhaps it would be easier if you gave me the information about ancillary charges by billing period.

a. First, what was the start date of the first billing period in which (PATIENT NAME) was a patient? ENTER MONTH ONLY IF BILLING PERIOD IS MONTHLY.	(MONTH) or (START DATE)
b. And what was the end date?	(END DATE)
c. What was the total of full established charges for health-related ancillary care during this billing period? Please exclude charges for non-health related services such as television, beautician services, etc.	$__________.____

SECTION 24 – PATIENT ACCOUNTS – SOURCES OF PAYMENT 5

[Page 31 – PATIENT ACCOUNTS – SOURCES OF PAYMENT (1 of 2)]

Q20. From which of the following sources did the facility receive payments for ancillary charges for the billing period that began (BILLING PERIOD DATE) and how much was paid by each source? Please include all payments that have taken place between (ADMIT DATE) and now for this stay. SELECT ALL THAT APPLY

a. Patient or Patient’s Family; b. Medicare; c. Medicaid; d. Private Insurance; e. VA/Champva; f. Tricare; g. Worker’s Comp; or h. Something else? (IF SOMETHING ELSE: What was that?) _________________ Q20(h) – Menu for “Something else?”; Auto or Accident Insurance CHDP/CHIP Indian Health Service State Public Mental Plan State/County Local program Other

$__________.____ $__________.____ $__________.____ $__________.____ $__________.____ $__________.____ $__________.____ $__________.____

[Page 32 – PATIENT ACCOUNTS – SOURCES OF PAYMENT (2 of 2)]

Q20a. I show the total payment as [TOTAL]. Is that correct?

IF NO, CORRECT ENTRIES ABOVE AS NEEDED.

SECTION 25 – PATIENT ACCOUNTS – capitated basis

[Page 33 – PATIENT ACCOUNTS – capitated basis (1 of 4)]

CAPITATED BASIS
Q21a. What kind of insurance plan covered the patient for this stay? Was it: [DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO, PROBE: And is that Medicare, Medicaid, or private insurance? OTHER SPECIFY: PROBE FOR SOURCE OF FUNDS AND TYPE OF PLAN. Q21a(g) – “Other Specify” menu Auto or Accident Insurance CHDP/CHIP Indian Health Service State Public Mental Plan State/County Local program Other	a. Medicare; YES=1, NO=2 b. Medicaid; YES=1, NO=2 c. Private Insurance; YES=1, NO=2 d. VA/Champva; YES=1, NO=2 e. Tricare; YES=1, NO=2 f. Worker’s Comp; or YES=1, NO=2 g. Something else? YES=1, NO=2 (IF SOMETHING ELSE: What was that?)
Q21b. What was the monthly payment from that plan?	$___________.__
Q21c. Was there a co-payment for any part of this stay?	YES=1, NO=2

[Page 34 – PATIENT ACCOUNTS – capitated basis (2 of 4)]

Q21d. How much was the co-payment? [DCS ONLY] PROBE TO DETERMINE IF FOR DAY, WEEK, ETC.	$___________.__ per DAY 1 WEEK 2 MONTH 3 OTHER 4 SPECIFY:
Q21e. For how many (days/weeks/months/other) was the co-payment paid?	_______________#
Q21f. Who paid the co-payment? Was it: [DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO, PROBE: And is that Medicare, Medicaid, or private insurance? OTHER SPECIFY: PROBE FOR SOURCE OF FUNDS AND TYPE OF PLAN.	a. Patient or Patient’s Family; YES=1, NO=2 b. Medicare; YES=1, NO=2 c. Medicaid; YES=1, NO=2 d. Private Insurance; or YES=1, NO=2 e. Something else? YES=1, NO=2 (IF SOMETHING ELSE: What was that?)

Q21f(e) – Include the following options in a drop down menu for the “Other Specify”;

Auto or Accident Insurance

CHDP/CHIP

Indian Health Service

State Public Mental Plan

State/County/Local program

Other

[Page 35 – PATIENT ACCOUNTS – capitated basis (3 of 4)]

Q21g. Do your records show any other payments for this stay?	YES=1, NO=2

[Page 36 – PATIENT ACCOUNTS – capitated basis (4 of 4)]

Q21h. From which of the following other sources has the facility received payment for this stay and how much was paid by each source? Please include all payments that have taken place between (ADMIT DATE) and now for this stay. SELECT ALL THAT APPLY [DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO, PROBE: And is that Medicare, Medicaid, or private insurance? OTHER SPECIFY: PROBE FOR SOURCE OF FUNDS AND TYPE OF PLAN.

SOURCE a. Patient or Patient’s Family; b. Medicare; c. Medicaid; d. Private Insurance; e. VA/Champva; f. Tricare; g. Worker’s Comp; or h. Something else? (IF SOMETHING ELSE: What was that?)

PAYMENT AMOUNT $ $ $ $ $ $ $ $

21h (h) – Include the following options in a drop down menu for the “Other Specify”;

Auto or Accident Insurance

CHDP/CHIP

Indian Health Service

State Public Mental Plan

State/County/Local program

Other

FINISH SCREEN

PRESS VALIDATE TO COMPLETE THIS EVENT FORM.

Institution Event Form Page 25 of 25