CMS-P-0015A Comm2019R83CPS

Cost Payment Summary (CPS)
Variable Name
MR Screen Name

Question type

Question text/description

Code list

COST PAYMENT SUMMARY SPECIFICATIONS
CRITERIA
INTTYPE=C001, C004, C005
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: Prior round events flagged for CPS
PLACEMENT
Administer after NSQ.
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.
BOX CPSBEG

routing

CPS REASON 5 = STATEMENT CHARGE BUNDLE, TOTAL PAYMENTS LESS THAN AMOUNT REMAINING. - NO
EVENTS FLAGGED AS REASON 5 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
EXPECTING TO RECEIVE A STATEMENT FOR THIS EVENT.
THE REMAINING LIST OF CHARGE BUNDLES WILL BE ELIGIBLE FOR CPS. WE WILL SORT THIS LIST IN THE
FOLLOWING WAY: REASON 9, 1, 2...ETC. ENDING WITH REASON 8. IN ROUND 73 REASONS 4-8 WERE
SKIPPED. WE ONLY COLLECTED DATA FOR EVENTS WITH REASONS 9, 1, 2, AND 3. WE WILL THEN COLLECT
CPS DETAILS FOR THE FIRST CHARGE BUNDLE IN THIS LIST.
AFTER COMPLETING THE CPS DETAILS FOR THIS CHARGE BUNDLE, WE WILL RETURN TO BOX CPSBEG.
BECAUSE THE DATA THAT DETERMINES IF A CHARGE BUNDLE IS ELIGIBLE FOR CPS MAY BE UPDATED WHILE
ADMINISTERING CPS, THE LIST OF ELIGIBLE CHARGE BUNDLES WILL BE RECREATED AT THE BEGINNING OF
EACH LOOP IN CPS
IF AT LEAST ONE CHARGE BUNDLE HAS BEEN IDENTIFIED AS ELIGIBLE FOR CPS, GO TO CPS1_IN - NAVIGATOR.
ELSE GO TO BOX CPSEND.

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)?

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

[PROBE IF NECESSARY: Please include any statements received about (your/(SP's)] Medicare prescription
drug benefit.]

KNOWTOTL

BOX CPS2

routing

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.

CPS3

yes/no

Do you happen to know the (total charge/copayment amount) for the [READ EVENT(S) ABOVE]?

routing

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.

BOX CPS3

TOTALCHG

CPS4

numeric

TOTALCHG

CPS5

numeric

Including any amounts that may be paid by Medicare or anyone else, what was the total charge (that is, the
amount billed)?
ENTER 0 IF NO CHARGE FOR THE EVENT.
[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.]
What was the copayment amount for the [READ EVENT(S) ABOVE]?

(01) YES
(02) NO
(-9) Refused

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

[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.

MONTHCOV

BOX CPS5A

routing

BOX CPS5B

routing

CPS6

numeric

NUMLINKS

CPS7

numeric

RVLINKS

CPS8

numeric

BOX CPS8A

routing

BOX CPS8B

routing

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.

CPTCHGPAID1

CPS9

code one

TCHGWRONG

CPS10

no entry

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.

CPTCHGPAID2

TCHGWRONG

CPS11

routing

code one

CPS12

no entry

BOX CPS12

routing

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

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.
[Last time, we recorded that the (total charge/copayment amount) for the [READ EVENT(S) ABOVE] was
(TOTAL CHARGE)), and that no payment had been made.] [Have you/Has (SP)] or any other source[, such as
(an insurance plan/TRICARE/TRICARE or an insurance plan),] now paid any of [the total charge/the
copayment amount/this (TOTAL CHARGE)]?

BOX CPS10

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

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
Medicare paid,]] there was an amount remaining of (CPS AMOUNT REMAINING) for the [READ EVENT(S)
ABOVE.]
[Have you/Has (SP)] or any other source [, such as (an insurance plan/TRICARE/TRICARE or an insurance
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.

(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(03) (TOTAL CHARGE/COPAYMENT AMOUNT) IS
WRONG
(-8) Don't Know
(-9) Refused

(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(03) AMOUNT REMAINING SEEMS WRONG
(-8) Don't Know
(-9) Refused

Let me review what we recorded last time.

CPTCHGPAID3

TCHGWRONG

CPS13

code one

CPS14

no entry

BOX CPS14

routing

CPTCHGPAID4

CPS15

code one

TCHGWRONG

CPS16

no entry

BOX CPS16

routing

CPS17

yes/no

BOX CPS17

routing

EXPAYOUT

[REVIEW WITH RESPONDENT.] The total of all payments is $(TOTAL PAYMENTS). The amount unpaid is
$(DIFFERENCE BETWEEN PAYMENTS AND TOTAL CHARGE).
[Have you/Has (SP)] or any other source [, such as (an insurance plan/TRICARE/TRICARE or an insurance
plan),] paid any additional amount?
YOU CANNOT CORRECT THE AMOUNT 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, 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
(02) NOTHING HAS BEEN PAID
(03) TOTAL CHARGE SEEMS WRONG
(04) PAYMENT AMOUNTS WRONG
(-8) Don't Know
(-9) Refused

(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 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, 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
(-8) Don't Know
EVENT(S) ABOVE]]?
(-9) Refused
IF (CHARGES WERE FIRST COLLECTED 2 ROUNDS PREVIOUS TO CURRENT ROUND), GO TO CPS18 - EXPAYUNT.
ELSE GO TO BOX CPS32.

EXPAYUNT

CPS18

code one

How much do you expect will be paid?

EXPAYPCT
EXPAYAMT

CPS18
CPS18

numeric
numeric

RRDETAIL

CPS23

yes/no

RRADD

CPS24

yes/no

CPADDSOP

CPS25

yes/no

How much do you expect will be paid?
How much do you expect will be paid?
DID RESPONDENT MENTION (AN INSURANCE/A) REFUND OR REIMBURSEMENT ABOUT WHICH HE/SHE IS
NOT SURE OF THE DETAILS?
[DO NOT ENTER A COMMENT HERE TO EXPLAIN THE SITUATION.]
DO YOU WANT TO ADD A REFUND OR REIMBURSEMENT?
[DO NOT SELECT “YES” IF THE RESPONDENT KNOWS A REIMBURSEMENT AMOUNT, BUT DOES NOT KNOW
WHO PAID IT.]
ARE ALL OF THE SOURCES OF PAYMENT FOR THIS CHARGE BUNDLE LISTED BELOW?
SELECT "NO" TO ADD A SOURCE OF PAYMENT.

SOP_CP

CPS26

roster

ADD ALL ADDITIONAL SOURCES OF PAYMENT FOR THIS CHARGE BUNDLE.

(91) PERCENTAGE
(02) DOLLARS
(-8) Don't Know
(-9) Refused
(01) continuous answer
(01) continuous answer
(01) YES
(02) NO
(-8) Don't Know
(01) YES
(02) NO
(01) YES
(02) NO
(01) continuous answer

TSOPREIM_NAME CPS27

grid

Who (else) paid (besides Medicare)? How much did (SOURCE) pay?
How much did (SOURCE) pay?

TSOPREIM_AMT

CPS27

grid

BOX CPS27A

routing

BOX CPS27B

routing

PLANINTRO_CPS

CPS27BINT

no entry

NAVIGATOR

CPS27B_IN

instance navigator

BOX CPS27C

routing

REIMBURSEMENT AMOUNT: (REIMBURSEMENT AMOUNT)
ENTER ALL REIMBURESMENT AMOUNTS.
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
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)]?

CPMPDPCHNG

CPS29A

yes/no

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

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

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

(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

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)
(13) VISION (VU)
(14) HEARING (HU)
(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