CMS-P-0015A Comm2017R79PSQ

2017 MCBS Community Questionnaire

Variable Name

MR Screen Name

Question Type

PSQ-POST STATEMENT COST

Question Text/Description

Code List

Routing

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

PS2 - EXPPYMNT

POST STATEMENT COST QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007, C009, C010
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: 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.
PLACEMENT
Administer after STQ.

BOX PS1

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

PS1A

yes/no

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

EXPPYMNT

PS2

BOX PS3

yes/no

routing

(01) YES
(02) NO
THIS INCLUDES PAYMENTS MADE BY SP, MEDICARE, INSURANCE, TRICARE, OR ANY OTHER SOURCE (-8) Don't Know
OF PAYMENT.
(-9) Refused

BOX PS3

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.
ELSE GO TO BOX PSEND.

BOX PSEND

routing

GO TO NSQ.

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