CMS-P-0015A Comm2019R83NSQ

No Statement Cost Series (NSQ)
Variable Name

MR Screen Name

Question type

Question text/description

Code list

Routing

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

(01) NS1 - NSINT
(02) BOX NSBEG

NO STATEMENT COST SERIES QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007, C010
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: At least one event entered in the current round is not associated with charge data already entered
PLACEMENT
Administer after PSQ.
CREATE LIST OF EVENTS ENTERED IN THE CURRENT ROUND THAT ARE NOT ASSOCIATED WITH CHARGE DATA
ALREADY ENTERED
IF AT LEAST ONE EVENT ENTERED IN THE CURRENT ROUND IS NOT ASSOCIATED WITH CHARGE DATA
ALREADY ENTERED, GO TO NS1_IN - NAVIGATOR.
ELSE GO TO NS81 - NSTATEMENT.

BOX NSBEG

NAVIGATOR

NS1_IN

instance navigator
[Now that we're done with [your/(SP's)] statements, let's/Let's] talk about the medical services and costs for
which [you/(SP)] did not have a statement.]

NSINT

NS1

no entry

THERE ARE (TOTAL NUMBER OF NS EVENTS) EVENTS (REMAINING) TO ASK ABOUT.

BOX NS1

(Let's start with/Next let's look at) (the/[your/(SP's)]) costs for the (EVENT).

BOX NS1

NSEXMCMAIL

NS2

routing

code one

IF (ST1 - MHMOSTMT = 3/Never AND ((SP HAS A MEDICARE MANAGED CARE PLAN THAT DOES NOT HAVE RX
COVERAGE ANYTIME IN THE CURRENT ROUND) OR (SP HAS A PRIVATE PLAN THAT IS A MANAGED CARE PLAN
ANYTIME IN THE CURRENT ROUND) OR (SP IS IN THE EXIT SAMPLE) OR (EVENT IS ASSOCIATED WITH A
MANAGED CARE PLAN))) OR (EVENT TYPE = 'OM' AND EVENT IS A RENTAL ITEM AND PS1 - HADPYMNT =
1/Yes) OR ((EVNTTYPE = 'DU' OR 'PM' OR 'VU' OR 'HU') AND SP DOES NOT HAVE ANY OTHER HEALTH
INSURANCE PLAN BESIDES MEDICARE IN THE CURRENT ROUND) , GO TO BOX NS4.
ELSE GO TO NS2 - NSEXMCMAIL.

As far as you know, is anything expected in the mail from (Medicare, Insurance, and Tricare/Medicare and
Tricare/Medicare and Insurance/Medicare) about [READ EVENT ABOVE]?

(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(04) HAVE STATEMENT FOR EVENT
(05) YES, BUT CAN ANSWER QUESTIONS
(09) FLAG COST FOR CPS DO NOT DISPLAY.
(-8) DON'T KNOW
(-9) REFUSED

(01) BOX NS4
(02) BOX NS4
(03) NS3 - EVERRVB
(04) ST4 - MATCHST
(05) BOX NS4
(09) DO NOT DISPLAY
(-8) BOX NS4
(-9) BOX NS4

(01) CONTINUOUS ANSWER

BOX NS4

REMINDER: "EVENT ENTERED IN ERROR" INSTRUCTS THE HOME OFFICE TO DELETE THIS EVENT.
EVERRVB

NS3

verbatim text

BOX NS4

routing

BOX NS4A

routing

IF YOU HAVE ENTERED THIS CODE IN ERROR, SELECT PREVIOUS PAGE AND ENTER THE CORRECT CODE AT
NS2. OTHERWISE, EXPLAIN WHY YOU SELECTED "EVENT ENTERED IN ERROR" FOR THIS EVENT.
CREATE A NEW CHARGE BUNDLE FOR THIS EVENT
IF NS2 - NSEXMCMAIL = 1/Yes or 3/EventEnteredInError, GO TO BOX NS80.
ELSE GO TO BOX NS4A.
IF (EVENT TYPE IS NOT AN OTHER MEDICAL EXPENSE) AND (EVENT IS ASSOCIATED WITH A MANAGED CARE
PLAN), GO TO NS6 - TOTALCHG.
ELSE GO TO NS5 - TOTALCHG.

TOTALCHG

NS5

BOX NS5

TOTALCHG

dollar

routing

NS6

dollar

BOX NS6

routing

MONTHCOV

NS7

numeric

MONCOV96

NS7

code one

NUMLINKS

NS8

numeric

RVLINKS

NS9

numeric

BOX NS9

routing

INCOTHER

NS10

code one

INCTYPE

NS12

code all

BOX NS12

routing

Including any amounts that may be paid by Medicare or anyone else, what [was the charge for the (OME
ITEM TYPE) rented (with the option to buy) for the time period between (REFERENCE DATE/UTILDATE) and
(TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)/was the total charge (that is, the total amount
billed)]?
IF CHARGE REPORTED AS HOURLY RATE, CALCULATE AND ENTER THE TOTAL CHARGE FOR THE ENTIRE
ROUND.

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

BOX NS5

[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.]
IF TOTALCHG = 0 AND SP CURRENTLY COVERED BY MEDICAID, GO TO BOX NS80.
ELSE IF EVENT TYPE = 'OM' AND EVENT IS A RENTAL ITEM, GO TO NS7 - MONTHCOV.
ELSE IF (EVENT TYPE = 'PM' OR 'OM') AND NUMBER OF PURCHASES BEING ASKED ABOUT IN NS IS > 1, GO TO
NS8 - NUMLINKS.
ELSE IF (EVENT WAS ENTERED AS A REPEAT VISIT), GO TO NS9 - RVLINKS.
ELSE GO TO BOX NS9.
What was the copayment amount for the [READ EVENT ABOVE]?
(01) CONTINUOUS ANSWER
[EXPLAIN IF NECESSARY: Managed care plans commonly charge a fixed amount, or copayment, each time
(-8) DON'T KNOW
health services are provided. For example, the person may pay $20 for each office visit and $10 for each drug
(-9) REFUSED
prescription.]
ENTER 0 IF NO COPAYMENT FOR THE EVENT.
IF TOTALCHG = 0 AND SP CURRENTLY COVERED BY MEDICAID, GO TO BOX NS80.
IF EVENT TYPE = 'PM' AND THE TOTAL OF NUMBER OF PURCHASES BEING ASKED ABOUT IN NS IS > 1, GO TO
NS8 - NUMLINKS.
ELSE IF (EVENT WAS ENTERED AS A REPEAT VISIT), GO TO NS9 - RVLINKS.
ELSE GO TO BOX NS9.
How many months are covered by the charge for the period of time [since (REFERENCE
(01) CONTINUOUS ANSWER
DATE/UTILDATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?
(-7) EMPTY
(-8) DON'T KNOW
[IF THE RESPONDENT DOES NOT REPORT THE NUMBER OF MONTHS AS A WHOLE NUMBER, ROUND UP.
(-9) REFUSED
(E.G., FOR 2 ½ MONTHS, ENTER “3”.)]
(01) LESS THAN 1 MONTH
(-7) EMPTY
How many of the times [you/(SP)] obtained [READ EVENT ABOVE] since (REFERENCE DATE/UTILDATE) [were (01) CONTINUOUS ANSWER
covered by the total charge/was there no charge/were covered by the (TOTAL CHARGE)/were covered by the (-8) DON'T KNOW
(-9) REFUSED
copayment/was there no copayment/were covered by the (COPAYMENT)]?
How many of the (NUMBER OF VISITS) (visits to the OPD at/lab services provided by/visits to) (PROVIDER
(01) CONTINUOUS ANSWER
NAME) during the month of (EVENT MONTH) [were covered by the total charge/was there no charge/were
(-8) DON'T KNOW
covered by the (TOTAL CHARGE)/were covered by the copayment/was there no copayment/were covered by
(-9) REFUSED
the (COPAYMENT)]?

BOX NS6

NS7 - MONCOV96

BOX NS9
BOX NS9

BOX NS9

IF (COPAYMENT WAS COLLECTED FOR CHARGE BUNDLE INSTEAD OF A TOTAL CHARGE), GO TO BOX NS45.
ELSE GO TO NS10 - INCOTHER.
(01) ONLY THIS EVENT/ITEM/MEDICINE
[READ IF NECESSARY: Does [the total charge/TOTAL CHARGE)] cover this (medicine/item/event) only or does
(02) OTHER EVENTS/ITEMS/MEDICINES
it include other (medicine/item/event)s.]
(03) CAN'T TELL
(01) PROVIDER SERVICE DATES
(02) HOME HEALTH VISITS
What else was included?
(03) OTHER MEDICAL EXPENSES
CHECK ALL THAT APPLY.
(04) PRESCRIBED MEDICINES
IF THE RESPONSE TO NS12 - INCTYPE INCLUDES 1/ProvDates, GO TO NS13 - PROVIDER_NSDATE.
ELSE GO TO BOX NS26.

(01) BOX NS45
(02) NS12 - INCTYPE
(03) BOX NS45
BOX NS12

PROVIDER_NSDATE NS13

roster

WHICH MEDICAL PROVIDER IS IN THIS CHARGE BUNDLE?
SELECT OR ADD ONLY ONE PROVIDER.

[DISPLAY PROVIDER ROSTER AS RESPONSE OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
…
N. [PROVIDER N]
N+1. ADD ANOTHER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP NAME
FOR ALL PROVIDERS WHERE PROVNUM>02.

IF EXISTING PROVIDER SELECTED, GO TO
BOX DU1.
ELSE IF "ADD ANOTHER" SELECTED, GO
TO PROV

[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
ENTER THE NAME OF THE PROVIDER AND THE BILLING/GROUP OR PRACTICE NAME BELOW.

PROVNAME

NS13

verbatim

YOU MUST ENTER A PROVIDER NAME IN THE ‘NAME’ FIELD. IF THE PROVIDER IS AN INDIVIDUAL BUT YOU DO
NOT KNOW THE PROVIDER’S NAME, OR IF THE PROVIDER IS AN ORGANIZATION, ENTER THE GROUP OR
PRACTICE NAME IN THE ‘NAME’ FIELD AND LEAVE THE ‘GROUP’ FIELD BLANK.

NS13-GROUPNAM

YOU CAN CONSULT THE RESPONDENT’S STATEMENTS AND APPOINTMENT CARDS TO ENSURE THE PROVIDER
NAME IS ENTERED CORRECTLY.

GROUPNAM

NS13

verbatim

NAME:
GROUP:

NSDATEUPD

NS14

code one

THE FOLLOWING EVENT DATES HAVE BEEN ENTERED FOR THIS PROVIDER.
DO YOU NEED TO ADD OR EDIT AN EVENT DATE FOR THIS CHARGE BUNDLE?

EVENT_NSDATEDIT

NS15

roster

SELECT AND EDIT THE EVENT DATE THAT NEEDS CORRECTION.

VISITYPE

VISTYPE

select one

SELECT TYPE OF VISIT TO ADD:

[When did [you/(SP)] see (PROVIDER NAME)?/When [were you/was (SP)] admitted to and discharged from
(HOSPITAL NAME)?] Please tell me all the dates [since (REFERENCE DATE/UTILDATE)/between (REFERENCE
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)].
ENTER ALL DATES.
EVENT

NSDATEINTRO

NS16

verbatim

ADD THE MISSING EVENT DATE(S) IN THIS CHARGE BUNDLE.
ADD ALL EVENT DATES FOR THIS PROVIDER.

BOX NS16A

routing

BOX NS16B

routing

[IF R HAD 5 OR MORE VISITS TO THIS PROVIDER DURING THIS REFERENCE PERIOD, SELECT "REPEAT VISITS"
AND LEAVE THE DAY FIELD BLANK. ENTER EACH MONTH SEPARATELY.]
IF AT LEAST ONE EVENT DATE ADDED AT NS16 IS NOT OUTSIDE THE SURVEY REFERENCE PERIOD, GO TO BOX
NS16B.
ELSE GO TO NS14 - NSDATEUPD.
GO TO BOX NS17.

NS17

no entry

Before we continue with this statement, I would like to ask you a few questions about the visit(s) I just added.

NS14- NSDATEUPD
(01) NO, DO NOT NEED TO ADD OR EDIT EVENT
DATES
(02) YES, NEED TO ADD EVENT DATE
(03) YES, NEED TO EDIT EVENT DATE
(01) CONTINUOUS ANSWER
(01) Separately Billing Lab (SL)
(02) Separately Billing Doctor (SD)
(03) Dental (DU)
(09) Vision (VU)
(10) Hearing (HU)
(04) Hospital Emergency Room (ER)
(05) Hospital Inpatient Saty (IP)
(06) Hospital Outpatient Visit (OP)
(07) Institutional Stay (IU)
(08) All other visits to Medical Provider (MP)

MM:
DD:
YYYY:
REPEAT VISIT: YES/NO
# OF VISITS

(01) NS24 - EVENT_NSDATE
(02) NS16 - EVENT_NSDATEADD
(03) NS15 - EVENT_NSDATEDIT
NS14 - NSDATEUPD

EVENT

BOX NS16A

BOX NS17

BOX NS17

routing

IF AT LEAST ONE EVENT ADDED AT NS16 IS AN 'MP' EVENT TYPE AND THE PROVIDER SPECIALTY HAS NOT
BEEN COLLECTED, GO TO NS18 - PROVSPEC.
ELSE IF AT LEAST ONE EVENT ADDED AT NS16 IS A 'DU' EVENT TYPE AND THE PROVIDER SPECIALTY HAS NOT
BEEN COLLECTED, GO TO NS18A - PROVSPEC.
ELSE IF AT LEAST ONE EVENT ADDED AT NS16 IS A 'VU' EVENT TYPE AND THE PROVIDER SPECIALTY HAS NOT
BEEN COLLECTED, GO TO NS18B - PROVSPEC.
ELSE IF AT LEAST ONE EVENT ADDED AT NS16 IS A 'HU' EVENT TYPE AND THE PROVIDER SPECIALTY HAS NOT
BEEN COLLECTED, GO TO NS18C - PROVSPEC.
ELSE GO TO BOX NS18.

(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
What kind of medical person is (PROVIDER NAME)?
(18) PARAMEDIC
(42) PHARMACIST
[SELECT THE CATEGORY FOR A GIVEN SPECIALTY ONLY IF THE RESPONDENT SPECIFICALLY NAMES THE LISTED
(19) PHYSICAL THERAPIST (PT)
SPECIALTY OR MENTIONS THE WORDS OR INITIALS IN PARENTHESES FOLLOWING THAT PROVIDER SPECIALTY.
(20) PHYSICIAN'S ASSISTANT
IF THE RESPONDENT NAMES A MEDICAL SPECIALTY NOT LISTED BELOW, BUT LISTED ON SHOWCARD AC1,
(21) PODIATRIST (FOOT DOCTOR)
SUCH AS ‘CARDIOLOGY,’ SELECT 'MEDICAL DOCTOR.']
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34) LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) DON'T KNOW
(-9) REFUSED

PROVSPEC

NS18

code one

PROVSPOS

NS18

text

OTHER MEDICAL PROVIDER (SPECIFY)

PROVSPEC

NS18A

code one

What kind of dental provider is [PROVNAME]?

(01) CONTINUOUS ANSWER
(01) GENERAL DENTIST
(35) DENTAL HYGIENIST
(36) DENTAL TECHNICIAN
(37) DENTAL/ORAL SURGEON
(38) ORTHODONTIST
(39) ENDODONTIST
(40) PERIODONTIST
(41) PROSTHODONTIST
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED

(01)-(34), (42), (-8), (-9) BOX NS18
(91) NS18 - PROVSPOS

BOX NS18
(01) BOX NS18
(35) BOX NS18
(36) BOX NS18
(37) BOX NS18
(38) BOX NS18
(39) BOX NS18
(40) BOX NS18
(41) BOX NS18
(91) NS18A - PROVSPOS
(-8) BOX NS18
(-9) BOX NS18

PROVSPECOTH

NS18A

code one

What kind of dental provider is [PROVNAME]?

PROVSPECOTH

NS18A

verbatim text

OTHER MEDICAL PROVIDER (SPECIFY)

PROVSPEC

NS18B

code one

What kind of eye care provider is [PROVNAME]?

(01) DENTIST/DENTAL PROVIDER (DO NOT DISPLAY)
(02) MEDICAL DOCTOR
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34)LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(02) MEDICAL DOCTOR, INCLUDING
OPHTHALMOLOGIST
(16) OPTOMETRIST (OD)
(42) OPTICIAN
(09) OTHER
(-8) DON'T KNOW
(-9) REFUSED

BOX NS18
(02) BOX NS18
(16) BOX NS18
(42) BOX NS18
(91) NS18B- PROVSPECOTH
(-8) BOX NS18
(-9) BOX NS18

PROVSPECOTH

NS18B

code one

What kind of eye care provider is [PROVNAME]?

PROVSPECOTH

NS18B

verbatim text

OTHER MEDICAL PROVIDER (SPECIFY)

PROVSPEC

NS18C

code one

What kind of hearing care provider is [PROVNAME]?

(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR (DO NOT DISPLAY)
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD) (DO NOT DISPLAY)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34)LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(02) MEDICAL DOCTOR, INCLUDING
OTOLARYNGOLOGIST (ENT), OTOLOGIST,
NEUROTOLOGIST
(03) AUDIOLOGIST
(43) AUDIOMETRIST
(44) HEARING INSTRUMENT SPECIALIST
(09) OTHER
(-8) Don't Know
(-9) Refused

(01)-(34), (-8), (-9) BOX NS18
(91) NS18B - PROVSPOS

BOX NT18
(02) BOX NS18
(03) BOX NS18
(43) BOX NS18
(44)BOX NS18
(91) NS18C- PROVSPECOTH
(-8) BOX NS18
(-9) BOX NS18

PROVSPECOTH

NS18C

code one

What kind of hearing care provider is [PROVNAME]?

(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR (DO NOT DISPLAY)
(03) AUDIOLOGIST (DO NOT DISPLAY)
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34)LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) Don't Know
(-9) Refused

PROVSPECOTH

NS18C

verbatim text

OTHER MEDICAL PROVIDER (SPECIFY)

(01) [Continuous answer.]

BOX NS18

routing

IF (AT LEAST ONE EVENT ADDED AT NS16 IS A 'DU', 'VU', 'HU', 'ER', 'IP', 'OP', 'IU', OR 'MP' EVENT TYPE) AND
(SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR ANY
PREVIOUS ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH V.A. IS UNKNOWN), GO TO NS19 - VAPLACE.
ELSE GO TO BOX NS19.
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

BOX NS19

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

(01) NS22A_IN - NAVIGATOR
(02) NS21 - HMOREFER
(-8) NS21 - HMOREFER
(-9) NS21 - HMOREFER

BOX NS18

VAPLACE

HMOASSOC

NS19

yes/no

Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A. facility?

BOX NS19

routing

GO TO NS22A_IN - NAVIGATOR.

NS20

yes/no

Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?

(01)-(34), (-8), (-9) BOX NS18
(91) NS18C - PROVSPOS

[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?
HMOREFER

NS21

yes/no
[INCLUDE REFERRALS BY THE RESPONDENT’S PRIMARY CARE PHYSICIAN (PCP).]

NAVIGATOR

NS22A_IN

instance navigator

BOX NS22A

routing

BOX NS22B

routing

MPSDVIS

NS23

yes/no

EVENT_NSDATE

BOX NS23A
BOX NS23B
NS24

routing
routing
check all

BOX NS24

routing

NSDATEMTCH

numeric

BOX NS24A

routing

IF ANOTHER EVENT SELECTED AT NS24 IS A REPEAT VISIT, GO TO NS24A - RVLINKS.
ELSE GO TO NS25 - NSDATEMTCH.

NS25

code one

ARE ALL THE PROVIDER EVENTS FROM THE CHARGE BUNDLE SHOWN BELOW?

roster

SELECT THE EVENT(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE BUNDLE.
IF NS12 – INCTYPE INCLUDES 2/HHVisits, GO TO NS27 - PROVIDER_HH.
ELSE GO TO BOX NS33.
WHICH HOME HEALTH PROVIDER IS IN THIS CHARGE BUNDLE?
SELECT OR ADD ONLY ONE PROVIDER.
IF (HOME HEALTH PROVIDER WAS ADDED AT NS27) OR (AN EXISTING PROVIDER WAS SELECTED AT NS27
THAT WAS NOT ASSOCIATED WITH A HOME HEALTH EVENT), GO TO NS30 - HHEVNTTYPE.
ELSE GO TO BOX NS31B.
IS THE PROVIDER A HOME HEALTH PROFESSIONAL OR SOME OTHER TYPE OF HOME HEALTH PROVIDER
(HOME HEALTH AIDE, HOMEMAKER, ETC.)?
Before we continue with this statement, I would like to ask you a few questions about the home health
provider I just added.
IF NS30 - HHEVNTTYPE = 1/HP, GO TO HH3 - PROVSPEC.
ELSE GO TO HH20 - HHFTYPE.
LINK HOME HEALTH PROVIDER TO CHARGE BUNDLE
GO TO NS32 - NSHHMTCH.
THE FOLLOWING HOME HEALTH PROVIDER EVENT HAS BEEN ADDED TO THIS CHARGE BUNDLE.

BOX NS26

routing

NS27

roster

BOX NS28A

routing

HHEVNTTYPE

NS30

code one

NSHHINTRO

NS31

no entry

BOX NS31A

routing

BOX NS31B

routing

NS32

no entry

BOX NS33

routing

PROVIDER_HH

NSHHMTCH

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

(01) BOX NS22A
(02) NS14 - NSDATEUPD

(01) YES
We have recorded that in (EVENT MONTH) [you were/(SP) was] also in [READ EVENT(S) LISTED BELOW]. Was
(02) NO
this visit with (PROVIDER NAME) a visit while [you were/(SP) was] in [the [READ EVENT LISTED BELOW]/any of
(-8) DON'T KNOW
these places]?
(-9) REFUSED
GO TO BOX NS23B.
GO TO NS22A_IN - NAVIGATOR.
SELECT THE EVENT DATE(S) THAT ARE INCLUDED IN THIS CHARGE BUNDLE.
(01) CONTINUOUS ANSWER
IF AT LEAST ONE EVENT SELECTED AT NS24 IS A REPEAT VISIT, GO TO NS24A - RVLINKS.
ELSE GO TO NS25 - NSDATEMTCH.

NS24A

EVENT_NSDATEDEL NS26

NS22A_IN - NAVIGATOR

IF TYPE OF EVENT = 'MP', GO TO BOX NS22B.
ELSE GO TO BOX NS23B.
IF (PROVIDER SPECIALTY IS A MEDICAL DOCTOR) AND ((EVENT DATE OVERLAPS AN EXISTING IP EVENT) OR
(EVENT DATE MATCHES AN EXISTING ER OR OP EVENT) GO TO NS23 - MPSDVIS.
ELSE GO TO BOX NS23A

ENTER THE NUMBER OF (EVENT TYPE) VISITS IN (EVENT MONTH, YEAR) THAT ARE COVERED BY THIS CHARGE.
RVLINKS

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

[A REPEAT VISIT MEANS THAT THE RESPONDENT HAD AT LEAST 5 VISITS TO THE PROVIDER DURING THE
CURRENT ROUND REFERENCE PERIOD.]

IF NS12 – INCTYPE INCLUDES 3/OMExpenses, GO TO NS34 - NSOMUPD.
ELSE GO TO BOX NS40.

BOX NS23A

BOX NS24

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

BOX NS24A

(01) YES
(02) NO, NEED TO ADD A PROVIDER EVENT
(03) NO, NEED TO REMOVE A PROVIDER EVENT
(01) CONTINUOUS ANSWER

(01) BOX NS26
(02) NS13 - PROVIDER_NSDATE
(03) NS26 - EVENT_NSDATEDEL
NS25 - NSDATEMTCH

(01) CONTINUOUS ANSWER

BOX NS28A

(01) HOME HEALTH PROFESSIONAL
(02) OTHER HOME HEALTH PROVIDER

BOX NS31B
BOX NS31A

(01) CONTINUE
(-7) EMPTY

BOX NS33

NSOMUPD

NS34

code one

THE FOLLOWING OME EVENTS HAVE BEEN ENTERED.
DO YOU NEED TO ADD OR EDIT AN OME EVENT FOR THIS CHARGE BUNDLE?

EVENT_NSOMEDIT

NS35

roster

SELECT AND EDIT THE OTHER MEDICAL EXPENSE EVENT THAT NEEDS CORRECTION.

NSOMADD

NS36

code one

WHAT TYPE OF OTHER MEDICAL EXPENSE NEEDS TO BE ADDED?

EVENT_NSOM

BOX NS36
NS37

routing
roster

BOX NS37

routing

GO TO NS34 - NSOMUPD.
SELECT OTHER MEDICAL EXPENSES THAT ARE IN THIS CHARGE BUNDLE.
IF AT LEAST ONE OTHER MEDICAL EXPENSE SELECTED AT NS37 IS RENTED, GO TO NS38 - MONTHCOV.
ELSE GO TO BOX NS38B.
HOW MANY MONTHS ARE COVERED BY THIS CHARGE BUNDLE?

MONTHCOV

NS38

numeric

MONCOV96

NS38

code one

BOX NS38A

routing

BOX NS38B

routing

NUMLINKS

[IF THE RESPONDENT DOES NOT REPORT THE NUMBER OF MONTHS AS A WHOLE NUMBER, ROUND UP.
(E.G., FOR 2 ½ MONTHS, ENTER “3”.)]

numeric

HOW MANY PURCHASES OF (NAME OF OME ITEM) ARE COVERED BY THIS CHARGE BUNDLE?

BOX NS38AA

routing

IF ANOTHER OTHER MEDICAL EXPENSE SELECTED AT NS37 IS OSTOMY SUPPLIES, INCONTINENCE SUPPLIES OR
BANDAGES, GO TO NS38A - NUMLINKS.
ELSE GO TO NS39 - NSOMMTCH.

NSOMMTCH

NS39

code one

ARE ALL THE OTHER MEDICAL EXPENSES FROM THE CHARGE BUNDLE SHOWN BELOW?

EVENT_NSOMDEL

NS40

roster

BOX NS40

routing

NS41

roster

SELECT THE EVENT(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE BUNDLE.
IF NS12 – INCTYPE INCLUDES 4/PMS, GO TO NS41 - EVENT_NSPM.
ELSE GO TO BOX NS45.
SELECT OR ADD ALL PRESCRIPTION MEDICINES THAT ARE IN THIS CHARGE BUNDLE.

BOX PM2

routing

MEDICINE_PM1

code one

BOX PM3

routing

MEDICINE_PM1

(01) NS37 - EVENT_NSOM
(02) NS36 - NSOMADD
(03) NS35 - EVENT_NSOMEDIT

(01) CONTINUOUS ANSWER

BOX NS37

(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
(-9) REFUSED
(01) LESS THAN 1 MONTH
(-7) EMPTY

BOX NS36

NS38 - MONCOV96

BOX NS38A

IF ANOTHER OTHER MEDICAL EXPENSE SELECTED AT NS37 IS RENTED, GO TO NS38 - MONTHCOV.
ELSE GO TO BOX NS38B.
IF AT LEAST ONE OTHER MEDICAL EXPENSE SELECTED AT NS37 IS OSTOMY SUPPLIES, INCONTINENCE
SUPPLIES OR BANDAGES, GO TO NS38A - NUMLINKS.
ELSE GO TO NS39 - NSOMMTCH.

NS38A

EVENT_NSPM

(01) NO, DO NOT NEED TO ADD OR EDIT OM EVENT
(02) YES, NEED TO ADD AN OME EVENT
(03) YES, NEED TO EDIT AN OME EVENT
(01) CONTINUOUS ANSWER
(01) GLASSES/CONTACTS
(11) HEARING AID
(02) HEARING/SPEECH DEVICE
(03) ORTHOPEDIC ITEM
(04) DIABETIC SUPPLIES
(05) AMBULANCE/RESCUE
(06 PROSTHESIS
(07) ALTERATIONS (HOME/CAR)
(08) OXYGEN
(09) KIDNEY DIALYSIS
(10) ALL OTHER MEDICAL SUPPLIES

IF THERE IS AT LEAST ONE MEDICINE FROM A PRIOR ROUND ON THE EVENT TABLE FOR THIS CASE, GO TO
MEDICINE_PM1-MEDICINE_PM1.
ELSE GO TO PM2B-PMBOTTLE.
What is the name of the medicine?
IF THIS MEDICINE HAS AN EXACT MATCH TO THE FDB LIST ( PMEDID^=.), THEN GO TO PM2A-SAMEFSAM.
ELSE GO TO PMBOTTLE-PMBOTTLE.

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

BOX NS38AA

(01) YES
(02) NO, NEED TO ADD AN OME EVENT
(03) NO, NEED TO REMOVE AN OME EVENT
(01) CONTINUOUS ANSWER

(01) BOX NS40
(02) NS34 - NSOMUPD
(03) NS40 - EVENT_NSOMDEL
NS39 - NSOMMTCH

(01) CONTINUOUS ANSWER

BOX PM2

CODE "YES" WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND FORM, STRENGTH
AND AMOUNT ARE EXACTLY THE SAME AS IN THE PREVIOUS INTERVIEW.
At the time of the last interview, [you/(SP)] purchased (MEDICINE NAME) in the form of (MEDICINE FORM).
The strength was [MEDICINE STRENGTH].
SAMEFSAM

SAMEFSAM

yes/no
The amount in the container when it was obtained was (PREVIOUS ROUND MEDICINE AMOUNT).
Is this medicine in the same strength, form and amount?
CODE "NO" UNLESS FORM, STRENGTH, AND AMOUNT EXACTLY MATCH PREVIOUS ROUND.

BOX PM4

PMBOTTLE

PMBOTTLE

routing

IF SAMEFSAM=1/YES, THEN DO NOT CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM6A-GETNUM.
ELSE, CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM2B-PMBOTTLE.

code one

CODE “YES” WITHOUT ASKING IF BOTTLE, CONTAINER, BAG, STATEMENT, OR RECEIPT IS PRESENT.
Do you have the medicine bottle, container or bag, or Prescription Drug Plan Statement available?
IF R DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF R CAN ANSWER QUESTIONS ABOUT THE
FORM, STRENGTH, AND QUANTITY OF THE MEDICINE.

TO USE THE MEDICINE LOOKUP, START TYPING THE MEDICINE NAME IN THE PRESCRIBED MEDICINE LOOKUP
BOX. CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
ONCE YOU HAVE ENTERED ALL DETAILS FOR A MEDICINE, IF YOU NEED TO GO BACK AND CORRECT, USE THE
GREEN “RETURN TO PRESCRIBED MEDICINE LOOKUP” BUTTON.
PMEDNAME

MED

lookup

[PRESCRIBED MEDICINE LOOKUP TOOL]

PMBRNAME
PMGNNAME

MED
MED

lookup
lookup

[PM BRAND NAME]
[PM GENERIC NAME]

PMFORMFD

MED

lookup

Medicine Form [FDB LIST FORM NAME]

PMFORMMC

MED

code one

Medicine Form [MCBS FORM]

PMFORMOS

MED

verbatim

PMFORMFN

MED

verbatim

[MEDICINE FORM OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE FORM]

PMSTRNFD

MED

verbatim

Medicine Strength

STRNNUMBB

MED

numeric

Medicine strength number

[you] respondent is SP
[(SP)] respondent is proxy
(MEDICINE NAME) = PMEDNAME
(MEDICINE FORM) = IF PMFORMFN IS MISSING, FILL
PMFORM (FROM PRIOR TO R79), ELSE FILL
PMFORMFN
(MEDICINE STRENGTH) = PMSTRUNI
(MEDICINE AMOUNT) = TABNUM OR
AMTNUM/AMTUNIT (SPELL OUT CODE FOR AMOUNT
UNIT).

STRNUNIT

MED

code one

PMSTRNOS

MED

verbatim

PMSTRUNI

MED

ookup

PMEDID

MED

numeric

FAMILYID

MED

numeric

PMKNWNM

PMKNWNM

code one

PMCOND

PMCOND

code one

Medicine strength unit

[MEDICINE STRENGTH UNIT OTHER SPECIFY]

[FINAL CONCATENATED MEDICINE STRENGTH]
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH THE
LOOKUP. IT IS HIDDEN ON SCREEN.]
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES BY NAME ONLY, EXCLUDING
STRENGTH AND FORM, THROUGH THE LOOKUP. IT IS HIDDEN ON SCREEN.]
DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?

What condition is this medicine prescribed for or what is its primary use?
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.

PMCONDOS

PMCOND

verbatim

BOX PM5

routing

OTHER (SPECIFY)
IF GETNUM=996/EVENT ENTERED IN ERROR OR PMKNWNM=02/NO OR SAMEFSAM=1/YES, GO TO PMMOREPMMORE;
ELSE IF MEDICINE FORM IS PILLS, TABLETS OR CAPSULES [PMFORMMC=1 OR PMFORMFD CONTAINS ("PILL",
"TAB", "CAP") GO TO TABNUM-TABNUM;
ELSE GO TO PM16-AMTUNIT.

TABNUM

TABNUM

numeric

HOW MANY PILLS, TABLETS, OR CAPSULES WERE IN THE CONTAINER WHEN IT WAS OBTAINED?

Edit #1
TABNUM = 1-270, DK, RF.
If not true, display message, "THE
AMOUNT ENTERED SEEMS
UNLIKELY. PLEASE VERIFY."

Edit #1
If AMTUNIT= 1/Ounces, then AMTNUM
=.1-16, DK, RF.
Else if AMTUNIT =2/Grams, then
AMTNUM= .1-60, DK, RF.
Else if AMTUNIT = 3/Milliliters, then
AMTNUM = .01-480, DK, RF.
Else if AMTUNIT = 4/Milliequivalents,
then AMTNUM = .1-100, DK, RF.
Else if AMTUNIT = 5/Milligrams, then
AMTNUM = .1- 800, DK, RF.
Else if AMTUNIT = 6/Micrograms, then
AMTNUM = .1- 50, DK, RF.
Else if AMTUNIT = 91/Other, then
AMTNUM = .01-1,000, DK, RF.
If not true, display message "THE
AMOUNT ENTERED SEEMS
UNLIKELY. PLEASE VERIFY."

AMTUNIT

PM16

quantity unit

HOW MUCH MEDICINE WAS IN THE CONTAINER WHEN IT WAS OBTAINED?
[PLEASE ENTER THE AMOUNT IN THE CONTAINER, NOT THE STRENGTH OF THE MEDICINE.]

AMTUNOS

PM16

text

OTHER (SPECIFY)

AMTNUM

PM16

numeric

BOX PM6

routing

IF PRESCRIPTION MEDICINE FORM IS PILLS, TABLETS OR CAPSULES, GO TO PM12 - TABSADAY.
ELSE GO TO BOX PM7.
HOW MANY PILLS, TABLETS, OR CAPSULES ARE PRESCRIBED TO BE TAKEN IN A DAY?

TABSADAY

PM12

numeric

TABSADAY95

PM12

code one

IF LESS THAN ONE UNIT IS TO BE TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A PILL
SHOULD BE ENTERED AS "0.5")
[PILLS] current round, PMFORM = 1/Pill
FOR MEDICINES TO BE TAKEN “AS NEEDED,” ENTER THE MAXIMUM AMOUNT THAT IS TO BE TAKEN IN A DAY [SUPPOSITORIES] current round, PMFORM =
AND SELECT "TAKE AS NEEDED".
5/Suppository
FOR MEDICINES TO BE TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER DOSING
INSTRUCTIONS".
IF THE AMOUNT TO BE TAKEN PER DAY IS NOT CLEAR OR NOT INDICATED, SELECT "DON'T KNOW".

How many pills, tablets, or capsules (do/did/does) [you/(SP)] usually take in a day?
[READ IF NECESSARY: This question is asking about how often you actually take the medicine, not how often
the medicine is prescribed to be taken.]

TABTAKE

TABTAKE96

PM13

PM13
BOX PM7

PMSATVA

PMSATVA

BOX PM8

numeric

IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A PILL
SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TAKEN “AS NEEDED,” SELECT "TAKE AS NEEDED".
FOR MEDICINES TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER DOSING
INSTRUCTIONS".

[do] respondent is SP
[did] respondent is proxy, SP deceased
[does] respondent is proxy, SP alive
[you] respondent is SP
[(SP)] respondent is proxy

Edit #1
TABTAKE = 1-15, DK.
If not true, display message, “THE
AMOUNT ENTERED SEEMS
UNLIKELY. PLEASE VERIFY."

code one
routing

IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR ANY
PREVIOUS ROUND), GO TO PMSATVA - PMSATVA.
ELSE GO TO BOX PM8.

yes/no

Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department
of Veterans Affairs or V.A.?

routing

IF SP COVERED BY A MEDICARE MANAGED CARE PLAN OR A PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO PMSATHMO - PMSATHMO.
ELSE GO TO PMMORE-PMMORE.

[you] respondent is SP
[(SP)] respondent is proxy
[this purchse] PMRO.GETNUM = 1
[any of these purchases] PMRO.GETNUM is not equal
to 1

[you] respondent is SP
[(SP)] respondent is proxy

PMSATHMO

PMSATHMO

yes/no

PMMORE

PMMORE

yes/no

Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) at [READ MANAGED CARE
PLAN NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN
[this purchse] PMRO.GETNUM = 1
NAME(S) BELOW]?
[any of these purchases]
PMRO.GETNUM is not equal 1
[PROBE: This could include obtaining the purchases at a plan pharmacy; at a pharmacy that honors
[your/(SP’s)] plan card; or through a mail order service that the managed care plan referred [you/(SP)] to.]
[your] respondent is SP
[(SP)'s] respondent is proxy
[THE NAMES OF ALL MEDICINES REPORTED FOR THE
CURRENT REFERENCE PERIOD ARE DISPLAYED
BELOW.] SP reported any Prescription Medicine
purchases during the current round
[NO MEDICINES HAVE BEEN REPORTED FOR (SP) FOR
([NO MEDICINES HAVE BEEN REPORTED FOR (SP) FOR THE CURRENT REFERENCE PERIOD/THE NAMES OF ALL
THE CURRENT REFERENCE PERIOD.] SP did not report
MEDICINES REPORTED FOR THE CURRENT REFERENCE PERIOD ARE DISPLAYED BELOW.])
any Prescription Medicine purchases during the
current round
[REVIEW THE INFORMATION BELOW WITH THE RESPONDENT. ASK, OR CODE AS APPROPRIATE IF R ALREADY
INDICATED: Are there any (more) medicines since (REFERENCE DATE/UTILDATE) that we haven't talked
(more) Display if SP reported any Prescription
about?]
Medicine purchases during the current round.
Else do not display.

NUMLINKS

NS42

grid

HOW MANY PURCHASES OF EACH MEDICINE SHOWN BELOW ARE COVERED BY THIS CHARGE BUNDLE?

NSPMMTCH

NS44

code one

ARE ALL THE PRESCRIBED MEDICINES FROM THE CHARGE BUNDLE SHOWN BELOW?

EVENT_NSPMDEL

NS45

roster

SELECT THE PRESCRIBED MEDICINE(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE BUNDLE.

BOX NS45

routing

IF TOTAL CHARGE OR COPAY COLLECTED GE 0, DK OR RF, GO TO NS64 - NSTCHGPAID.
ELSE GO TO BOX NS64B.

If UTILDATE^=MREFDATE, fill " (UTILDATE)"
Else fill "(REFERENCE DATE)".
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO, NEED TO ADD A MEDICINE NAME
(03) NO, NEED TO REMOVE A MEDICINE NAME
(01) CONTINUOUS ANSWER

NS44-NSPMMTCH
(01) BOX NS45
(02) NS41 - EVENT_NSPM
(03) NS45 - EVENT_NSPMDEL
NS44 - NSPMMTCH

NSTCHGPAID

NS64

code one

[[Have you/Has (SP)] or any other source [, such as (an insurance plan/TRICARE/TRICARE or an insurance
plan),] already paid any of [the charge/the total charge/the copayment amount/this (TOTAL CHARGE)]?
[IF COPAYMENT AMOUNT IS ZERO, SELECT “NO.”]

BOX NS64A

routing

BOX NS64B

routing

NSADDSOP1

NS65

yes/no

SOP_NS1

NS66

roster

TSOPAMT

PAYMHE

NS67

grid

BOX NS67HE

routing

NS67HE

no entry

BOX NS67A

routing

BOX NS67B

routing

PLANINTRO_NS

NS67BINT

no entry

NAVIGATOR

NS67B_IN

instance navigator

IF SP OR ANY SOURCE HAS PAID, GO TO BOX NS64B.
ELSE IF (NOTHING HAS BEEN PAID) OR (RESPONDENT DOES NOT KNOW IF ANYTHING HAS BEEN PAID), GO TO
BOX NS78B.
ELSE GO TO BOX NS80.
CREATE SOURCE OF PAYMENT ROSTER
GO TO NS65 - NSADDSOP1.
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
(01) CONTINUOUS ANSWER
ADD ALL ADDITIONAL SOURCES OF PAYMENT FOR THIS CHARGE BUNDLE.

Who (else) paid? How much did (SOURCE) pay?
ENTER ALL PAYMENT AMOUNTS. CORRECT PAYMENT AMOUNTS AS NECESSARY.

ELSE IF SOURCE OF PAYMENT IS A MEDICARE PRESCRIPTION DRUG PLAN AND SP HAS A MEDICARE
PRESCRIPTION DRUG PLAN THAT IS CURRENT, GO TO NS69A -NSMPDPCHNG.
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 NS69B - NSSOPCURR2.
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.

(01) NS67 - TSOPAMT
(02) NS66 - SOP_NS1
NS67 - TSOPAMT

BOX NS67HE

NS67B_IN - NAVIGATOR
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED

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 NS69 -NSSOPCURR1.

BOX NS64A

NS67HE - PAYMHE

USE "PREVIOUS PAGE" TO RETURN TO THE SOP GRID AND
MAKE CORRECTIONS.
IF AT LEAST ONE SOURCE OF PAYMENT WAS ADDED AT NS66, GO TO BOX NS67B.
ELSE GO TO BOX NS69F.
IF AT LEAST ONE SOURCE OF PAYMENT ADDED AT NS66 IS A HEALTH INSURANCE PLAN, GO TO NS67BINT PLANINTRO_NS.
ELSE GO TO BOX NS69E.
Before we continue, I would like to ask you a few questions about the health insurance plan(s) you just
added.

IF SOURCE OF PAYMENT IS A MEDICARE MANAGED CARE PLAN AND SP HAS A MEDICARE MANAGED CARE
PLAN THAT IS CURRENT, GO TO NS68 -NSMHMOCHNG1.

routing

(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
(-9) REFUSED

IF AT LEAST ONE TSOPAMT = DK OR RF OR THE SUM OF ALL TSOPAMT VALUES FOR THIS COST > 0.00, GO TO
BOX NS67A.
ELSE GO TO NS67HE - PAYMHE.
THE SUM OF ALL PAYMENT AMOUNTS MUST BE GREATER
THAN $0.00 OR AT LEAST ONE PAYMENT AMOUNT MUST BE
'DON'T KNOW' OR 'REFUSED'.

CREATE A NEW HEALTH INSURANCE PLAN FOR FIRST/NEXT SOURCE OF PAYMENT ADDED AT NS66.

BOX NS67C

(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(-8) DON'T KNOW
(-9) REFUSED

(01) BOX NS67C
(02) BOX NS69E

NSMHMOCHNG1

NS68

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?

NSSOPCURR1

NS69

yes/no

[Are you/Is (SP)/Was (SP)] [currently] covered or enrolled in (NS66 SOP MEDICARE MANAGED CARE PLAN
NAME) [on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?

NSMPDPCHNG

NS69A

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?

NSSOPCURR2

AMTSCORR

AMTSCORR

ENTERCOM

EXPPAYBK

EXPAYOUT

NS69B

yes/no

BOX NS69A

routing

BOX NS69E

routing

BOX NS69F

routing

NS70

NS71

NS72

code one

code one

no entry

[Are you/Is (SP)/Was (SP)] (currently) covered or enrolled in (NS66 SOP MEDICARE PRESCRIPTION DRUG
PLAN) [on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?
GO TO NS67B_IN - NAVIGATOR.
IF AN "OTHER SOURCE OF PAYMENT" ADDED AT NS66, CREATE AN OSOP FOR EACH SOURCE OF PAYMENT
ADDED AT NS66 THAT IS AN "OTHER SOURCE OF PAYMENT" .
GO TO BOX NS69F.
IF (TOTAL CHARGE ^= DK AND TOTAL CHARGE ^= RF) AND (AT LEAST ONE PAYMENT ENTERED AT NS67 = DK
OR RF) AND (AT LEAST ONE PAYMENT ENTERED AT NS67 ^= DK AND ^= RF AND ^= 0) AND (TOTAL OF ALL
NON-MISSING PAYMENTS ENTERED AT NS67 >= TOTAL CHARGE), GO TO NS71 - AMTSCORR.
ELSE IF (TOTAL CHARGE ^= DK AND TOTAL CHARGE ^= RF) AND (ALL PAYMENTS ENTERED AT NS67 ^= DK AND
^= RF) AND (THE ABSOLUTE VALUE OF THE DIFFERENCE BETWEEN THE TOTAL PAYMENTS ENTERED AT NS67
AND TOTAL CHARGE IS > $1.00), GO TO NS70 - AMTSCORR.
ELSE GO TO BOX NS77C.
There seems to be [some amount still unpaid/more payments than the charge].
[REVIEW WITH RESPONDENT.] The total of all payments is $(TOTAL PAYMENTS). The amount
[unpaid/overpaid] is $(DIFFERENCE BETWEEN PAYMENTS AND TOTAL CHARGE). Is that correct?
IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION,
USE "PREVIOUS PAGE" TO RETURN TO THE SOP GRID.
THE AMOUNTS ENTERED FOR THE SOURCES OF PAYMENT EQUAL OR EXCEED THE [TOTAL
CHARGE/COPAYMENT], WITH AT LEAST ONE SOP BEING A MISSING AMOUNT. VERIFY ALL AMOUNTS AS
ENTERED.
IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION,
USE "PREVIOUS PAGE" TO RETURN TO THE SOP GRID.
[THE TOTAL OF PAYMENTS IS $(TOTAL PAYMENTS). THE AMOUNT [UNPAID/OVERPAID] IS $(DIFFERENCE
BETWEEN PAYMENTS AND TOTAL CHARGE).]

routing

BOX NS77D

routing

IF THE SP OR FAMILY MADE A PAYMENT AND PAYMENT IS GREATER THAN $5.00, GO TO NS78 - EXPPAYBK.
ELSE GO TO BOX NS80.

yes/no

I have recorded that [you have/(SP) has] paid $(SP/FAMILY PAYMENT). Do you expect any source to pay
[you/(SP)] back any or all of that amount?

BOX NS78A

routing

BOX NS78B

routing

NS79

yes/no

(01) NS69 - NSSOPCURR1
(02) BOX NS69A
(-8) BOX NS69A
(-9) BOX NS69A
(01) HIMC6A - MHMORXTM
(02) BOX NS69A
(-8) BOX NS69A
(-9) BOX NS69A
(01) NS69B - NSSOPCURR2
(02) BOX NS69A
(-8) BOX NS69A
(-9) BOX NS69A

(01) ENTRIES ABOVE ARE CORRECT
(02) NO, SOP NEEDS ADDITION OR CORRECTION
(03) AMOUNT REMAINING SEEMS INCORRECT
(-8) DON'T KNOW
(-9) REFUSED

(01) BOX NS77C
(02) DO NOT DISPLAY.
(03) NS72 - ENTERCOM
(-8) BOX NS77C
(-9) BOX NS77C

(01) ENTRIES ABOVE ARE CORRECT
(02) NO, SOP NEEDS ADDITION OR CORRECTION
(03) AMOUNT REMAINING SEEMS INCORRECT
(-8) DON'T KNOW
(-9) REFUSED

(01) BOX NS77C
(02) DO NOT DISPLAY.
(03) NS72 - ENTERCOM
(-8) BOX NS77C
(-9) BOX NS77C

BOX NS69A

BOX NS77C

USE THE BOX BELOW TO EXPLAIN WHY THE AMOUNT REMAINING SEEMS INCORRECT.
CREATE PAYMENTS FOR AMOUNTS ENTERED AT NS67
GO TO BOX NS77D.

BOX NS77C

NS78

(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

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

BOX NS78A

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

(01) NS80 - EXPAYUNT
(02) BOX NS80
(-8) BOX NS80
(-9) BOX NS80

IF NS78 - EXPPAYBK = 1/Yes AND ((CURRENTLY ADMINISTERING CPS AND CHARGES WERE FIRST COLLECTED 2
ROUNDS PREVIOUS TO CURRENT ROUND)), GO TO NS80 - EXPAYUNT.
ELSE GO TO BOX NS80.
IF (CURRENTLY ADMINISTERING CPS AND CHARGES WERE FIRST COLLECTED 2 ROUNDS PREVIOUS TO
CURRENT ROUND), GO TO NS79 - EXPAYOUT.
ELSE GO TO BOX NS80.
Do you expect anyone to pay any of this amount?

EXPAYUNT

NS80

quantity unit

EXPAYPCT
EXPAYAMT

NS80
NS80

numeric
numeric

BOX NS80

routing

How much do you expect will be paid?

(01) PERCENTAGE NS80 - EXPAYPCT
(02) DOLLARS NS80 - EXPAYAMT
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER

(01) NS80 - EXPAYPCT
(02) NS80 - EXPAYAMT
(-8) BOX NS80
(-9) BOX NS80
BOX NS80
BOX NS80

IF CURRENTLY ADMINISTERING CPS, GO TO BOX CPSBEG.
ELSE GO TO BOX NSL1.
GO TO BOX NSBEG
IF (CHARGE DATA WAS COLLECTED IN NS FOR THIS NS CHARGE BUNDLE) AND (NS CHARGE BUNDLE IS LINKED
TO ONLY ONE EVENT) AND (SP OR ANY OTHER SOURCE HAS PAID) AND

BOX NSL1

routing

((EVENT LINKED TO NS CHARGE BUNDLE HAS EVNT.EVNTTYPE = 'PM' AND (THE TOTAL CHARGE ^= RF) AND
(PM WAS PURCHASED THROUGH AN HMO) AND (THERE ARE OTHER CURRENT ROUND PRESCRIPTION
MEDICINE EVENTS NOT LINKED TO A CURRENT ROUND CHARGE BUNDLE THAT WERE PURCHASED THROUGH
AN HMO))
OR
(EVENT LINKED TO NS CHARGE BUNDLE HAS EVNT.EVNTTYPE = 'PM' AND (TOTAL CHARGE ^= RF) AND (PM
WAS NOT PURCHASED THROUGH AN HMO OR HAD AN UNKNOWN PURCHASE LOCATION) AND (THERE ARE
OTHER CURRENT ROUND PRESCRIPTION MEDICINE EVENTS NOT LINKED TO A CURRENT ROUND CHARGE
BUNDLE THAT WERE NOT PURCHASED THROUGH AN HMO OR HAD AN UNKNOWN PURCHASE LOCATION))
OR
(EVENT LINKED TO NS CHARGE BUNDLE HAS EVNT.EVNTTYPE = 'DU', 'VU', 'HU', 'ER', 'OP', 'MP', 'SD', OR 'SL'
AND (THE TOTAL CHARGE ^= DK AND TOTAL CHARGE ^= RF) AND (SP REFERRED TO PROVIDER BY HMO FOR
THIS EVENT) AND (THERE ARE OTHER CURRENT ROUND EVENTS WITH THE SAME EVENT TYPE FOR THIS
PROVIDER WHERE THE SP WAS REFERRED TO THE PROVIDER BY THE HIMO THAT ARE NOT LINKED TO A
CURRENT ROUND CHARGE BUNDLE))
OR
(EVENT LINKED TO NS CHARGE BUNDLE HAS EVNT.EVNTTYPE = 'DU', 'VU', 'HU', 'ER', 'OP', 'MP', 'SD', OR 'SL'
AND (THE TOTAL CHARGE ^= DK AND TOTAL CHARGE ^= RF) AND (SP WAS NOT REFERRED TO PROVIDER BY
HMO OR REFERRAL IS UNKNOWN FOR THE EVENT) AND (THERE ARE OTHER CURRENT ROUND EVENTS WITH
THE SAME EVENT TYPE FOR THIS PROVIDER WHERE THE SP WAS NOT REFERRED TO PROVIDER BY HMO OR
REFERRAL IS UNKNOWN FOR THE EVENT THAT ARE NOT LINKED TO A CURRENT ROUND CHARGE BUNDLE)),
), GO TO NSL1 - NSEVSAME.
ELSE GO TO BOX NSBEG.
You told me earlier that [you/(SP)] had other [visits to (PROVIDER NAME)/prescribed medicine purchases].

NSEVSAME

NSL1

code one

BOX NSL2

routing

NSL3

roster

BOX NSL3

NUMLINKS

NSL4

routing

grid

(01) YES
(02) NO
Are any other [visits to (PROVIDER NAME)/prescribed medicine purchases] the same -- where the [total
(-8) DON'T KNOW
charge was (TOTAL CHARGE TEXT)/copayment was (TOTAL CHARGE TEXT)] per (visit/purchase) and payments
(-9) REFUSED
were: [READ PAYMENTS LISTED ABOVE]?
IF EVENT LINKED TO NS CHARGE BUNDLE HAS EVNT.EVNTTYPE = 'PM', GO TO NSL3 - EVENT_PMSAME.
ELSE GO TO NSL5 - EVENT_VISITSAME.
Which ones are the same?
REVIEW LIST WITH RESPONDENT AND SELECT ALL PRESCRIPTION MEDICINES WHERE THE COSTS AND
PAYMENTS ARE THE SAME.

(01) BOX NSL2
(02) BOX NSBEG
(-8) BOX NSBEG
(-9) BOX NSBEG

(01) CONTINUOUS ANSWER

BOX NSL3

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

BOX NSBEG

IF NO PRESCRIPTION MEDICINES HAD THE SAME COST AND PAYMENTS, PRESS ENTER WITHOUT SELECTING
ANY MEDICINES.
IF AT LEAST ONE PRESCRIBED MEDICINE SELECTED AT NSL3 HAS NUMBER OF PURCHASES BEING ASKED
ABOUT IN NS > 1, GO TO NSL4 - NUMLINKS.
ELSE GO TO BOX NSBEG.
How many times are the same?
ENTER THE NUMBER OF PURCHASES OF EACH MEDICINE SHOWN BELOW THAT ARE THE SAME.

EVENT_VISITSAME

NSL5

BOX NSL5
RVLINKS

NSTATEMENT

roster

routing

NSL6

numeric

BOX NSL6

routing

NS81

yes/no

BOX NSEND

routing

Which ones are the same?
REVIEW LIST WITH THE RESPONDENT AND SELECT ALL PROVIDER EVENTS WHERE THE COST AND PAYMENTS
ARE THE SAME.
IF NO PROVIDER EVENTS HAD THE SAME COST AND PAYMENTS, PRESS ENTER WITHOUT SELECTING ANY
EVENTS.
IF AT LEAST ONE EVENT SELECTED AT NSL5 IS A REPEAT VISIT, GO TO NSL6 - RVLINKS.
ELSE GO TO BOX NSBEG.
How many times are the same for (EVENT)?
ENTER THE NUMBER OF (EVENT TYPE) VISITS IN (EVENT
MONTH, YEAR) THAT ARE THE SAME.
IF ANOTHER EVENT SELECTED AT NSL5 IS A REPEAT VISIT, GO TO NSL6 - RVLINKS.
ELSE GO TO BOX NSBEG.
YOU HAVE ENTERED ALL CHARGE/PAYMENT DATA FOR ALL EVENTS REPORTED.
DO YOU HAVE ANY MSN, INSURANCE, TRICARE, OR MEDICARE PRESCRIPTION DRUG BENEFIT STATEMENTS
THAT YOU HAVE NOT YET ENTERED?
IF INTTYPE in(C001, C004, C005), GO TO CPS.
IF INTTYPE in(C002, C006, C007, C010), GO TO MBQ.

(01) CONTINUOUS ANSWER

BOX NSL5

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

BOX NSL6

(01) YES
(02) NO

(01) ST5 - ST_CHARGEBUNDLE
(02) BOX NSEND