CMS-P-0015A Comm2019R83STQ

Variable Name

MR Screen Name

Question type

Question text/description

Code List

Routing

STATEMENT COST SERIES QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007, C010
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
Administer after OMQ.

BOX STBEG

routing

IF ((SP WAS COVERED BY A MEDICARE MANAGED CARE PLAN WITHOUT RX COVERAGE ANYTIME DURING THE
CURRENT ROUND) OR (SP WAS COVERED BY A PRIVATE MANAGED CARE PLAN ANYTIME DURING THE
CURRENT ROUND)) AND (SP WAS NOT COVERED BY A MEDICARE PRESCRIPTION DRUG PLAN ANYTIME
DURING THE CURRENT ROUND), GO TO ST1 - MHMOSTMT.
ELSE GO TO ST2 - MCSAVAIL.

Now that we have finished talking about medical visits and prescribed medicines, let’s talk about [your/(SP’s)]
medical costs. We should start by looking at any paperwork or written explanations of what was paid by
Medicare, any insurance company, or TRICARE.

MHMOSTMT

ST1

code one

(01) ALWAYS
[Do you/Does (SP)] usually receive any statements or papers from Medicare, insurance, such as (MANAGED
(02) SOMETIMES
CARE PLAN NAME), or TRICARE that show the charges for medical visits or equipment?/Last time, we
(03) NEVER
recorded that [you/(SP)] (always/sometimes/never) received statements or papers from Medicare, insurance,
(-8) DON'T KNOW
or TRICARE that show the charges for medical visits or equipment.]
(-9) REFUSED

(01) ST2 - MCSAVAIL
(02) ST2 - MCSAVAIL
(03) BOX STEND
(-8) ST2 - MCSAVAIL
(-9) ST2 - MCSAVAIL

Please tell me if (currently) [you always receive statements, sometimes receive statements, or never receive
statements/(SP) always receives statements, sometimes receives statements, or never receives statements].

[Now that we have finished talking about medical visits and prescribed medicines, let’s talk about
[your/(SP’s)] medical costs. We should start by looking at any paperwork or written explanations of what
costs were paid by Medicare, any insurance company, or TRICARE.]
MCSAVAIL

ST2

yes/no
[PROBE IF NECESSARY: Do you have any statements or paper from Medicare, insurance, or TRICARE [that
[you/(SP)] received since the last interview]? (Please include any statements received about [your/(SP's)]
prescription drug benefit.)]

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

(01) ST3 - STHIREP
(02) BOX STEND
(-8) BOX STEND
(-9) BOX STEND

STHIREP

ST3

no entry

BASED ON THE INFORMATION RECORDED IN THE HEALTH INSURANCE SECTION FOR RECENT ROUNDS, THE
PLAN(S) LISTED BELOW ARE THE SOURCES OF STATEMENTS YOU MIGHT EXPECT TO FIND FOR THIS SP.

ST4 - MATCHST

MATCHST

ST4

no entry

[MATCH UP MEDICARE, INSURANCE, TRICARE, AND MEDICARE PRESCRIPTION BENEFIT STATEMENTS BY
PROVIDER AND DATE OF SERVICE./PRESS ENTER TO CONTINUE TO THE NEXT (STATEMENT/BUNDLE).]

ST5 - ST_CHARGEBUNDLE

roster

ADD THE SOURCE(S) AND TYPE OF STATEMENT(S) FOR THE (FIRST/NEXT) BUNDLE OF EVENTS.
ADD ONE CHARGE BUNDLE AT THIS ROSTER.

STTYPE

ST_CHARGEBUNDLE ST5

Variable Name

STTYPE

MCARTYPE

PDPTYPE

MR Screen Name

ST5AA

Question type

code one

Question text/description

Code List

Routing

SELECT SOURCE OF THE STATEMENT(S) FOR THIS CHARGE BUNDLE

(01) MEDICARE SUMMARY NOTICE
(MSN) ONLY
(02) INSURANCE STATEMENT ONLY
(03) BOTH MEDICARE SUMMARY NOTICE
(MSN) AND INSURNACE STATEMENT
(04) TRICARE STATEMENT ONLY
(05) BOTH MEDICARE SUMMARY NOTICE
(MSN) AND TRICARE STATEMENTS
(06) BOTH TRICARE AND INSURNACE
STATEMENTS
(07) MEDICARE SUMMARY NOTICE
(MSN) AND TRICARE AND INSURANCE
STATEMENTS
(08) MPDP STATEMENT OR MA/TRICARE
PRESCIRPTION DRUG BUNDLE

(01) ST5AA-MCARTYPE
(02) BOX ST5A
(03) ST5AA-MCARTYPE
(04) BOX ST5A
(05) ST5AA-MCARTYPE
(06) BOX ST5A
(07) ST5AA-MCARTYPE
(08) BOX ST5A

(01) MEDICARE SUMMARY NOTICE: PART
B MEDICAL INSURANCE - ASSIGNED OR
UNASSIGNED (EXAMPLE 1)
(02) MEDICARE SUMMARY NOTICE: PART
B MEDICAL INSURNACE OUTPATIENT
FACILITY CLAIMS (EXAMPLE 2)
(03) MEDICARE SUMMARY NOTICE: PART
BOX ST5A
A HOSPITAL INSURANCE INPATIENT
CLAIMS (EXAMPLE 3)
(04) MEDICARE SUMMARY NOTICE:
HOME HEALTH CARE CLAIMS (EXAMPLE
4)
(05) MEDICARE SUMMARY NOTICE: PART
A HOSPICE FACILITY CLAIMS (EXAMPLE 5)

ST5AAA

code one

WHICH TYPE OF MEDICARE STATEMENT DO YOU HAVE TO ENTER? [SEE REFERENCE CARDS FOR MEDICARE
STATEMENT EXAMPLES]

BOX ST5A

routing

IF ST5 – STTYPE = 8/MPDPorMAorTricare THEN GO TO ST5A - PDPTYPE.
ELSE GO TO BOX ST5B.

ST5A

code one

BOX ST5B

routing

BOX ST5

routing

SELECT THE TYPE OF PRESCRIPTION DRUG STATEMENT FOR THIS BUNDLE.

SET STATEMENT TYPE.
GO TO BOX ST5.
IF TYPE OF STATEMENT = 1/Medicare, 3/MedicareAndInsurance, 5/MedicareAndTricare, OR
7/MedicareAndTricareAndInsurance, GO TO ST7 - MSNCLNUM.
ELSE IF TYPE OF STATEMENT = 2/Insurance OR 6/TricareAndInsurance, GO TO ST10 - INSCLNUM.
ELSE IF TYPE OF STATEMENT = 4/Tricare AND ST5 - STTYPE = 4/Tricare, GO TO ST11 - TRICLNUM.
ELSE GO TO ST11B - PDPBEGMM.

(01) MEDICARE PRESCRIPTION DRUG
BENEFIT STATEMENT
BOX ST5B
(02) MEDICARE ADVANTAGE STATEMENT
(03) TRICARE STATEMENT

Variable Name

MR Screen Name

Question type

Question text/description
ENTER THE CLAIM CONTROL NUMBER FROM THE MEDICARE SUMMARY NOTICE (MSN) ASSOCIATED WITH
THE CLAIM TOTAL.
IF NO CLAIM CONTROL NUMBER(S) LISTED, ENTER "DON'T KNOW".
DO NOT ENTER ANY CLAIM CONTROL NUMBERS IN COMMENTS.

MSNCLNUM

ST7

text
[INSERT TEXT BOX 1 FOR CLAIM 1]

Code List

Routing

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

ST7 - MSNCLNM2

IF THERE ARE MULTIPLE CLAIM NUMBERS ASSOCIATED WITH THE CLAIM TOTAL, ENTER BELOW:
[INSERT REMAINING TEXT BOXES]
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW

MSNCLNM2

ST7

text

MSNCLNM3

ST7

text

MSNCLNM4

ST7

text

MSNCLNM5

ST7

text

BOX ST7

routing

IF ST7 - MSNCLNUM = DK, GO TO BOX ST9.
ELSE GO TO ST8 - MSCLVER1.

ST8

text

PLEASE ENTER THE FIRST CLAIM CONTROL NUMBER FROM THE MEDICARE SUMMARY NOTICE (MSN) AGAIN. (01) CONTINUOUS ANSWER

routing

IF ST8 - MSCLVER1 MATCHES ST7 - MSNCLNUM, GO TO BOX ST9.
ELSE GO TO ST9 - WHICHNUM.

MSCLVER1

BOX ST8

YOU HAVE ENTERED THE CLAIM CONTROL NUMBERS FROM THE MEDICARE SUMMARY NOTICE (MSN)
DIFFERENTLY.
FIRST TIME: (FIRST MSN CLAIM CONTROL NUMBER)
WHICHNUM

ST9

code one
SECOND TIME: (SECOND MSN CLAIM CONTROL NUMBER)

ST7 - MSNCLNM3
ST7 - MSNCLNM4
ST7 - MSNCLNM5
BOX ST7

BOX ST8

IF ST8 - MSCLVER1 MATCHES ST7 MSNCLNUM, GO TO BOX ST9.
ELSE GO TO ST9 - WHICHNUM.

(01) FIRST
(02) SECOND
(03) NEITHER

(01) BOX ST9
(02) BOX ST9
(03) ST9 - NEWCLNUM

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

BOX ST9

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

BOX ST10

WHICH IS CORRECT?
NEWCLNUM

ST9

text

BOX ST9

routing

ST10

text

BOX ST10

routing

TRICLNUM

ST11

text

PDPBEGMM

ST11B

date

PDPBEGDD

ST11B

date

PDPBEGYY

ST11B

date

INSCLNUM

ENTER CORRECT MSN CLAIM CONTROL NUMBER:
IF TYPE OF STATEMENT = 3/MedicareAndInsurance OR 7/MedicareAndTricareAndInsurance, GO TO ST10 INSCLNUM.
ELSE IF TYPE OF STATEMENT = 5/MedicareAndTricare, GO TO ST11 - TRICLNUM.
ELSE GO TO ST12 - INCTYPE.
ENTER THE CLAIM CONTROL NUMBER FROM THE INSURANCE STATEMENT. IF NO CLAIM CONTROL NUMBER
LISTED, ENTER "DON'T KNOW".
IF TYPE OF STATEMENT = 6/TricareAndInsurance OR 7/MedicareAndTricareAndInsurance, GO TO ST11 TRICLNUM.
ELSE GO TO ST12 - INCTYPE.
ENTER THE CLAIM CONTROL NUMBER FROM THE TRICARE STATEMENT. IF NO CLAIM CONTROL NUMBER
LISTED, ENTER "DON'T KNOW".
ENTER THE BEGINNING AND ENDING DATES OF SERVICE FROM THE PRESCRIPTION DRUG BENEFIT
STATEMENT.
BEGINNING DATE:

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

ST12 - INCTYPE
ST11B - PDPBEGDD

ST11B - PDPBEGYY

ST11B - PDPENDMM

Variable Name

MR Screen Name

Question type

Question text/description

PDPENDMM

ST11B

date

ENDING DATE:

PDPENDDD

ST11B

date

PDPENDYY

ST11B

date

INCTYPE

ST12

code all

WHAT TYPE(S) OF EVENT(S) ARE INCLUDED IN THIS CHARGE BUNDLE ON THE (TYPE OF STATEMENT)?
CHECK ALL THAT APPLY.

BOX ST12

routing

IF THE RESPONSE TO ST12 - INCTYPE INCLUDES 1/ProvDates, GO TO ST13 - PROVIDER_STDATE.
ELSE GO TO BOX ST26.

PROVIDER_STDATE ST13

roster

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

Code List
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) PROVIDER SERVICE DATES
(02) HOME HEALTH VISITS
(03) OTHER MEDICAL EXPENSES
(04) PRESCRIBED MEDICINES

[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.

Routing
ST11B - PDPENDDD

ST11B - PDPENDYY

ST12 - INCTYPE

BOX ST12

"IF EXISTING PROVIDER SELECTED, GO
TO ST14 - STDATEUPD.
ELSE IF ""ADD ANOTHER"" SELECTED,
GO TO PROV"

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

PROVNAME

ST13

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.

ST13-GROUPNAM

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

STDATEUPD

ST13

ST14

verbatim

GROUP:

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?

ST14 - STDATEUPD
(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) ST24 - EVENT_STDATE
(02) EVENT DATE ST16 EVENT_STDATEADD
(03) ST15 - EVENT_STDATEDIT

Variable Name

MR Screen Name

Question type

VISITYPE

VISTYPE

select one

EVENT_STDATEDIT

ST15

roster

Question text/description

Code List

Routing

SELECT TYPE OF VISIT TO ADD:

(01) Separately Billing Lab (SL)
(02) Separately Billing Doctor (SD)
(03) Dental (DU)
(08) Vision (VU)
(09) Hearing (HU)
(04) Hospital Emergency Room (ER)
(05) Hospital Inpatient Saty (IP)
(06) Hospital Outpatient Visit (OP)
(07) Institutional Stay (IU)
(10) All other visits to Medical Provider
(MP)

ST16 - EVENT

(01) CONTINUOUS ANSWER

ST16-EVENT

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

BOX ST16A

SELECT AND EDIT THE EVENT DATE THAT NEEDS CORRECTION.
[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/ENDUTILD)].
ENTER ALL DATES.
EVENT

ST16

roster

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

routing

IF AT LEAST ONE EVENT DATE ADDED AT ST16 IS NOT OUTSIDE THE SURVEY REFERENCE PERIOD, GO TO BOX
ST16B.
ELSE GO TO ST14 - STDATEUPD.

BOX ST16B

routing

IF AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU', 'VU', 'HU' , 'IP', 'OP', OR 'MP' EVENT TYPE, GO TO ST17 STDATEINTRO.
ELSE GO TO BOX ST17.

ST17

no entry

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

routing

IF AT LEAST ONE EVENT ADDED AT ST16 IS AN 'MP' EVENT TYPE AND THE PROVIDER SPECIALTY HAS NOT
BEEN COLLECTED, GO TO ST18 - PROVSPEC.
ELSE IF AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU' EVENT TYPE AND THE PROVIDER SPECIALTY HAS NOT
BEEN COLLECTED, GO TO ST18A - PROVSPEC.
ELSE IF AT LEAST ONE EVENT ADDED AT ST16 IS A 'VU' EVENT TYPE AND THE PROVIDER SPECIALTY HAS NOT
BEEN COLLECTED, GO TO ST18B - PROVSPEC.
ELSE IF AT LEAST ONE EVENT ADDED AT ST16 IS A 'HU' EVENT TYPE AND THE PROVIDER SPECIALTY HAS NOT
BEEN COLLECTED, GO TO ST18C - PROVSPEC.
ELSE GO TO BOX ST18.

BOX ST16A

STDATEINTRO

BOX ST17

BOX ST17

Variable Name

MR Screen Name

Question type

PROVSPEC

ST18

code one

Question text/description

Code List
(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
What kind of medical person is (PROVIDER NAME)?
(10) HOSPICE WORKER
[SELECT THE CATEGORY FOR A GIVEN SPECIALTY ONLY IF THE RESPONDENT SPECIFICALLY NAMES THE LISTED (11) I.V. THERAPIST
SPECIALTY OR MENTIONS THE WORDS OR INITIALS IN PARENTHESES FOLLOWING THAT PROVIDER SPECIALTY. (12) NURSE (RN)
(13) NURSE PRACTITIONER
IF THE RESPONDENT NAMES A MEDICAL SPECIALTY NOT LISTED BELOW, BUT LISTED ON SHOWCARD AC1,
(14) NURSE'S AIDE
SUCH AS ‘CARDIOLOGY,’ SELECT 'MEDICAL DOCTOR.']
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(42) PHARMACIST
(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

Routing

(01)-(34), (42), (-8), (-9) BOX ST18
(91) ST18 - PROVSPOS

Variable Name

MR Screen Name

Question type

Question text/description

Code List

Routing

PROVSPOS

ST18

text

OTHER MEDICAL PROVIDER (SPECIFY)

(01) CONTINUOUS ANSWER

BOX ST18

What kind of dental provider is [PROVNAME]?

(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) BOX ST18
(35) BOX ST18
(36) BOX ST18
(37) BOX ST18
(38) BOX ST18
(39) BOX ST18
(40) BOX ST18
(41) BOX ST18
(91) ST18A - PROVSPOS
(-8) BOX ST18
(-9) BOX ST18

PROVSPEC

ST18A

code one

Variable Name

PROVSPECOTH

MR Screen Name

ST18A

Question type

code one

Question text/description

Code List

Routing

What kind of dental 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)

(01)-(34), (-8), (-9) BOX ST18
(91) ST18A - PROVSPOS

(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

Variable Name

MR Screen Name

Question type

Question text/description

Code List

Routing

PROVSPECOTH

ST18A

verbatim text

OTHER MEDICAL PROVIDER (SPECIFY)

(01) [Continuous answer.]

BOX ST18

What kind of eye care provider is [PROVNAME]?

(02) MEDICAL DOCTOR, INCLUDING
OPHTHALMOLOGIST
(16) OPTOMETRIST (OD)
(42) OPTICIAN
(09) OTHER
(-8) DON'T KNOW
(-9) REFUSED

(02) BOX ST18
(16) BOX ST18
(42) BOX ST18
(91) ST18B- PROVSPECOTH
(-8) BOX ST18
(-9) BOX ST18

What kind of eye 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)

(01)-(34), (-8), (-9) BOX ST18
(91) ST18B - PROVSPOS

PROVSPEC

PROVSPECOTH

ST18B

ST18B

code one

code one

(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

ST18B

verbatim text

OTHER MEDICAL PROVIDER (SPECIFY)

(01) [Continuous answer.]

BOX ST18

Variable Name

PROVSPEC

PROVSPECOTH

MR Screen Name

ST18C

ST18C

Question type

code one

code one

Question text/description

Code List

Routing

What kind of hearing care provider is [PROVNAME]?

(02) MEDICAL DOCTOR, INCLUDING
OTOLARYNGOLOGIST (ENT), OTOLOGIST,
NEUROTOLOGIST
(03) AUDIOLOGIST
(43) AUDIOMETRIST
(44) HEARING INSTRUMENT SPECIALIST
(09) OTHER
(-8) Don't Know
(-9) Refused

(02) BOX ST18
(03) BOX ST18
(43) BOX ST18
(44) BOX ST18
(91) ST18C- PROVSPECOTH
(-8) BOX ST18
(-9) BOX ST18

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

(01)-(34), (-8), (-9) BOX ST18
(91) ST18C - PROVSPOS

Variable Name

MR Screen Name

Question type

Question text/description

Code List

Routing

PROVSPECOTH

ST18C

verbatim text

OTHER MEDICAL PROVIDER (SPECIFY)

(01) [Continuous answer.]

BOX ST18

routing

IF (AT LEAST ONE EVENT ADDED AT ST16 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 ST19 - VAPLACE.

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

BOX ST19

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

(01) ST22A_IN - NAVIGATOR
(02) ST21 - HMOREFER
(-8) ST21 - HMOREFER
(-9) ST21 - HMOREFER

BOX ST18

ELSE GO TO BOX ST19.

VAPLACE

ST19

BOX ST19

HMOASSOC

ST20

yes/no

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

routing

IF (AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU', 'VU', 'HU'', 'ER', 'IP', 'OP', OR 'MP' EVENT TYPE) AND (SP
COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (IF THIS PROVIDER IS
ASSOCIATED WITH A MANAGED CARE PLAN IS UNKNOWN), GO TO ST20 - HMOASSOC.
ELSE IF (AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU', 'VU', 'HU', 'ER', 'IP', 'OP', OR 'MP' EVENT TYPE) AND
(SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (THIS PROVIDER IS
NOT ASSOCIATED WITH A MANAGED CARE PLAN), GO TO ST21 - HMOREFER.
ELSE GO TO ST22A_IN - NAVIGATOR.

yes/no

HMOREFER

ST21

yes/no

NAVIGATOR

ST22A_IN

instance navigator

MPSDVIS

EVENT_STDATE

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

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

BOX ST22A

routing

FOR THIS EVENT ADDED AT ST16,
IF TYPE OF EVENT = 'IP', GO TO IP7 - ANYOPERS.
ELSE IF TYPE OF EVENT = 'OP', GO TO OP5 - ANYOPERS.
ELSE IF TYPE OF EVENT = 'MP', GO TO BOX ST22B.
ELSE IF TYPE OF EVENT = 'DU', GO TO DU7 - DVPROCDR.
ELSE IF TYPE OF EVENT = 'VU', GO TO VU7 - VUPROCDR.
ELSE IF TYPE OF EVENT = 'HU', GO TO HU7 - HUPROCDR.
ELSE GO TO BOX ST23B.

BOX ST22B

routing

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 ST23 - MPSDVIS.
ELSE GO TO BOX ST23A.

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) ITEM SELECTED IN INSTANCE
NAVIGATOR BOX ST22A
(02) CONTINUE INTERVIEW SELECTED
ST14 - STDATEUPD

(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
IF ST23 ASKED AND ST23 - MPSDVIS = 1/Yes, GO TO BOX ST23B.
ELSE GO TO BOX MP2C.

ST23

yes/no

BOX ST23A

routing

BOX ST23B

routing

GO TO ST22A_IN - NAVIGATOR.

ST24

roster

SELECT THE EVENT DATE(S) THAT ARE INCLUDED IN THIS CHARGE BUNDLE.

BOX ST24

routing

IF AT LEAST ONE EVENT SELECTED AT ST24 IS A REPEAT VISIT, GO TO ST24A - RVLINKS.
ELSE GO TO ST25 - STDATEMTCH.

(01) CONTINUOUS ANSWER

ST22A_IN - NAVIGATOR

(01) BOX ST22A
(02) ST14 - STDATEUPD

BOX ST23A

BOX ST24

Variable Name

MR Screen Name

Question type

RVLINKS

ST24A

numeric

BOX ST24A

routing

STDATEMTCH

Code List
(01) CONTINUOUS ANSWER
ENTER THE NUMBER OF (EVENT TYPE) VISITS IN (EVENT MONTH, YEAR) THAT ARE COVERED BY THIS CHARGE. (-8) DON'T KNOW
(-9) REFUSED
IF ANOTHER EVENT SELECTED AT ST24 IS A REPEAT VISIT, GO TO ST24A - RVLINKS.
ELSE GO TO ST25 - STDATEMTCH.
(01) YES
(02) NO, NEED TO ADD A PROVIDER
ARE ALL THE PROVIDER EVENTS FROM THE CHARGE BUNDLE ON (TYPE OF STATEMENT) SHOWN BELOW?
EVENT
(03) NO, NEED TO REMOVE A PROVIDER
EVENT

Routing

roster

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

(01) CONTINUOUS ANSWER

ST25 - STDATEMTCH

BOX ST26

routing

IF ST12 – INCTYPE INCLUDES 2/HHVisits, GO TO ST27 - PROVIDER_STHH.
ELSE GO TO BOX ST33.

ST27

roster

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

(01) CONTINUOUS ANSWER

ST28 - COSTBEGM

ST25

EVENT_STDATEDEL ST26

PROVIDER_STHH

code one

Question text/description

ENTER THE START DATE AND STOP DATE COVERED BY THE CHARGE BUNDLE.
COSTBEGM

ST28

numeric
START DATE:

COSTBEGD

ST28

numeric

COSTBEGY

ST28

numeric

COSTENDM

ST28

numeric

COSTENDD

ST28

numeric

COSTENDY

ST28

numeric

BOX ST28A

routing

IF (HOME HEALTH PROVIDER WAS ADDED AT ST27) OR (AN EXISTING PROVIDER WAS SELECTED AT ST27 THAT
WAS NOT ASSOCIATED WITH A HOME HEALTH EVENT), GO TO ST30 - HHEVNTTYPE.
ELSE GO TO BOX ST31B.

HHEVNTTYPE

ST30

code one

IS THE PROVIDER A HOME HEALTH PROFESSIONAL OR SOME OTHER TYPE OF HOME HEALTH PROVIDER
(HOME HEALTH AIDE, HOMEMAKER, ETC.)?

STHHINTRO

ST31

no entry

BOX ST31A

routing

BOX ST31B

routing

ST32

code one

BOX ST33

routing

STHHMTCH

STOP DATE:

Before we continue with this statement, I would like to ask you a few questions about the home health
provider I just added.
IF ST30 - HHEVNTTYPE = 1/HP, GO TO HH3 - PROVSPEC.
ELSE GO TO HH20 - HHFTYPE.
LINK HOME HEALTH PROVIDER TO CHARGE BUNDLE
GO TO ST32 - STHHMTCH.
THE FOLLOWING HOME HEALTH PROVIDER EVENT HAS BEEN ADDED TO THIS CHARGE BUNDLE.

ST34

code one
DO YOU NEED TO ADD OR EDIT AN OME EVENT FOR THIS CHARGE BUNDLE?

EVENT_STOMEDIT

ST35

roster

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

(01) BOX ST26
(02) ST13 - PROVIDER_STDATE
(03) ST26 - EVENT_STDATEDEL

ST28 - COSTBEGD

ST28 - COSTBEGY

ST28 - COSTENDM

ST28 - COSTENDD

ST28 - COSTENDY

BOX ST28A

ST31 - STHHINTRO

BOX ST31A

BOX ST33

IF ST12 – INCTYPE INCLUDES 3/OMExpenses, GO TO ST34 - STOMUPD.
ELSE GO TO BOX ST40.
THE FOLLOWING OME EVENTS HAVE BEEN ENTERED.

STOMUPD

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

BOX ST24A

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

(01) NO, DO NOT NEED TO ADD OR EDIT
(01) ST37 - EVENT_STOM
OM EVENT
(02) ST36 - STOMADD
(02) YES, NEED TO ADD AN OME EVENT
(03) ST35 - EVENT_STOMEDIT
(03) YES, NEED TO EDIT AN OME EVENT

Variable Name

STOMADD

MR Screen Name

(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

WHAT TYPE OF OTHER MEDICAL EXPENSE NEEDS TO BE ADDED?

BOX ST36

routing

GO TO ST34 - STOMUPD.

ST37

roster

SELECT OTHER MEDICAL EXPENSES THAT ARE IN THIS CHARGE BUNDLE ON THE (TYPE OF STATEMENT).

BOX ST37

routing

IF AT LEAST ONE OTHER MEDICAL EXPENSE SELECTED AT ST37 IS RENTED, GO TO ST38 - MONTHCOV.
ELSE GO TO BOX ST38B.

MONCOV96

ST38

numeric

BOX ST38A

routing

BOX ST38B

routing

ST38A

BOX ST38AA

HOW MANY MONTHS ARE COVERED BY THIS CHARGE BUNDLE?

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

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

routing

IF ANOTHER OTHER MEDICAL EXPENSE SELECTED AT ST37 IS OSTOMY SUPPLIES, INCONTINENCE SUPPLIES OR
BANDAGES, GO TO ST38A - NUMLINKS.
ELSE GO TO ST39 - STOMMTCH.
(01) YES
ARE ALL THE OTHER MEDICAL EXPENSES FROM THE CHARGE BUNDLE ON THE (TYPE OF STATEMENT) SHOWN (02) NO, NEED TO ADD AN OME EVENT
BELOW?
(03) NO, NEED TO REMOVE AN OME
EVENT

code one

EVENT_STOMDEL

ST40

roster

BOX ST40

routing

ST41

roster

BOX PM2

routing

MEDICINE_PM1

code one

BOX PM3

routing

ST38 - MONCOV96

BOX ST38A

IF ANOTHER OTHER MEDICAL EXPENSE SELECTED AT ST37 IS RENTED, GO TO ST38 - MONTHCOV.
ELSE GO TO BOX ST38B.
IF AT LEAST ONE OTHER MEDICAL EXPENSE SELECTED AT ST37 IS OSTOMY SUPPLIES, INCONTINENCE SUPPLIES
OR BANDAGES, GO TO ST38A - NUMLINKS.
ELSE GO TO ST39 - STOMMTCH.
HOW MANY PURCHASES OF (NAME OF OME ITEM) ARE COVERED BY THIS CHARGE BUNDLE?

ST39

Routing
(01) OM2 - EVENT_OMEYEG OM1BVUTYPE
(11) OM3B-INLEFT
(02) OM4 - EVENT_OMHEAR OM33EVENT_OMHRSP
(03) OM6 - ORTHTYPE
(04) OM10 - EVENT_OMDIAB
(05) OM12 - EVENT_OMAMBL
(06) OM14 - EVENT_OMPROS
(07) OM29 - ALTRTYPE
(08) OM19A - OXGNTYPE
(09) OM21A - KDNYTYPE
(10) OM24 - OTHRTYPE
BOX ST37

numeric

STOMMTCH

MEDICINE_PM1

Code List

code one

ST38

EVENT_STPM

Question text/description

ST36

MONTHCOV

NUMLINKS

Question type

SELECT THE EVENT(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE BUNDLE.
IF ST12 – INCTYPE INCLUDES 4/PMS, GO TO ST41 - EVENT_STPM.
ELSE GO TO BOX ST45.
SELECT OR ADD ALL PRESCRIPTION MEDICINES THAT ARE IN THIS CHARGE BUNDLE ON THE (TYPE OF
STATEMENT).
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.

BOX ST38AA

(01) BOX ST40
(02) ST34 - STOMUPD
(03) ST40 - EVENT_STOMDEL

(01) CONTINUOUS ANSWER

(01) CONTINUOUS ANSWER

BOX PM2

Variable Name

MR Screen Name

Question type

Question text/description

Code List

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.

PMEDNAME

MED

lookup

PMBRNAME
PMGNNAME
PMFORMFD
PMFORMMC
PMFORMOS
PMFORMFN
PMSTRNFD
STRNNUMBB
STRNUNIT
PMSTRNOS
PMSTRUNI

MED
MED
MED
MED
MED
MED
MED
MED
MED
MED
MED

lookup
lookup
lookup
code one
verbatim
verbatim
verbatim
numeric
code one
verbatim
ookup

PMEDID

MED

numeric

FAMILYID

MED

numeric

PMKNWNM

PMKNWNM

code one

PMCOND

PMCOND

code one

PMCONDOS

PMCOND

verbatim

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.

[PRESCRIBED MEDICINE LOOKUP TOOL]
[PM BRAND NAME]
[PM GENERIC NAME]
Medicine Form [FDB LIST FORM NAME]
Medicine Form [MCBS FORM]
[MEDICINE FORM OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE FORM]
Medicine Strength
Medicine strength number
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.
OTHER (SPECIFY)

(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).

Routing

Variable Name

TABNUM

MR Screen Name

Question type

BOX PM5

routing

TABNUM

numeric

AMTUNIT

PM16

quantity unit

AMTUNOS
AMTNUM

PM16
PM16

text
numeric

BOX PM6

routing

TABSADAY

PM12

numeric

TABSADAY95

PM12

code one

Question text/description
Code List
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.

Routing

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."

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

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."

OTHER (SPECIFY)
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?
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,
AND SELECT "TAKE AS NEEDED".
PMFORM = 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

PM13

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".

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

Variable Name
TABTAKE96

PMSATVA

MR Screen Name
PM13

PMMORE

Question text/description

Code List

BOX PM7

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.

PMSATVA

yes/no

[this purchse] PMRO.GETNUM = 1
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department of
[any of these purchases] PMRO.GETNUM
Veterans Affairs or V.A.?
is not equal to 1

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.

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.]

BOX PM8

PMSATHMO

Question type
code one

PMSATHMO

PMMORE

yes/no

Routing

[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
([NO MEDICINES HAVE BEEN REPORTED FOR (SP) FOR THE CURRENT REFERENCE PERIOD/THE NAMES OF ALL FOR (SP) FOR THE CURRENT REFERENCE
PERIOD.] SP did not report any
MEDICINES REPORTED FOR THE CURRENT REFERENCE PERIOD ARE DISPLAYED BELOW.])
Prescription Medicine purchases during
[REVIEW THE INFORMATION BELOW WITH THE RESPONDENT. ASK, OR CODE AS APPROPRIATE IF R ALREADY the current round
INDICATED: Are there any (more) medicines since (REFERENCE DATE/UTILDATE) that we haven't talked
(more) Display if SP reported any
about?]
Prescription Medicine purchases during
the current round.
Else do not display.
If UTILDATE^=MREFDATE, fill "
(UTILDATE)"
Else fill "(REFERENCE DATE)".

NUMLINKS

ST42

grid

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

STPMMTCH

ST44

code one

ARE ALL THE PRESCRIBED MEDICINES FROM THE CHARGE BUNDLE ON THE (TYPE OF STATEMENT) SHOWN
BELOW?

EVENT_STPMDEL

ST45

roster

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

BOX ST45

routing

IF ALL EVENT DATES SELECTED FOR THIS CHARGE BUNDLE ARE OUTSIDE THE SURVEY REFERENCE PERIOD, GO
TO ST46 - ORPMESSAGE.
ELSE GO TO BOX ST46.

(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

ST44-STPMMTCH

(01) BOX ST45
(02) ST41 - EVENT_STPM
(03) ST45 - EVENT_STPMDEL
ST44 - STPMMTCH

Variable Name

MR Screen Name

Question type

ORPMESSAGE

ST46

no entry

BOX ST46

ASGNTAKE

ST47

BOX ST47

routing

code one

routing

TOTALCHG

ST47A

dollar

TOTALCHG

ST48

numeric

MCAPPAMT

ST48

numeric

MCPAYAMT

ST48

numeric

BOX ST48

STTCHGPAID1

ST49

Question text/description
SINCE ALL EVENTS IN THIS BUNDLE ARE OUTSIDE THE SURVEY REFERENCE PERIOD, WE DO NOT NEED ANY
CHARGE INFORMATION ABOUT THE BUNDLE.

Code List

Routing
BOX ST80

IF (TYPE OF STATEMENT = 2/Insurance OR 6/TricareAndInsurance) OR (TYPE OF STATEMENT = 4/Tricare AND
ST5 – STTTYPE = 4/Tricare) OR (ST5 - MCARTYPE = 4/MSNPartB), GO TO ST47 - ASGNTAKE.
ELSE GO TO BOX ST47.
WAS ASSIGNMENT TAKEN FOR THIS CHARGE BUNDLE?
IF ((TYPE OF STATEMENT = 8/MPDPBenefit) or (TYPE OF STATEMENT = 4/Tricare and ST5 - STTYPE =
8/MPDPorMAorTricare)), GO TO ST47A - TOTALCHG.
ELSE IF (TYPE OF STATEMENT = 2/Insurance) OR (TYPE OF STATEMENT = 4/Tricare AND ST5 - STTYPE =
4/Tricare) OR (TYPE OF STATEMENT = 6/TricareAndInsurance), GO TO ST48 - TOTALCHG.
ELSE IF ST5 - MCARTYPE = 4/MSNPartB, GO TO ST52 - TOTALCHG.
ELSE IF ST5 - MCARTYPE = 6/MSNPartAInpatient, GO TO ST56 - DAYSUSED.
ELSE GO TO ST60 - TOTALCHG.
ENTER THE TOTAL COST OF PRESCRIPTION(S) FROM THE PRESCRIPTION DRUG BENEFIT STATEMENT. IF A
TOTAL COST IS NOT LISTED, IT MAY BE NECESSARY TO CALCULATE A TOTAL BY ADDING THE COSTS OF
INDIVIDUAL ITEMS LISTED ON THE STATEMENT.
ENTER THE FOLLOWING AMOUNTS FROM THE (TYPE OF STATEMENT). IF AMOUNT NOT AVAILABLE, ENTER
"DON'T KNOW".

routing

IF AMOUNT REMAINING = DK OR EMPTY, GO TO BOX ST51.
ELSE IF (AMOUNT REMAINING < $1.00) OR ((ST48 - MCAPPAMT ^= DK OR RF) AND (AMOUNT REMAINING <
.02 * ST48 - MCAPPAMT)), GO TO BOX ST80.
ELSE GO TO ST49 - STTCHGPAID1.

code one

REVIEW CHARGE BUNDLE ON (TYPE OF STATEMENT) WITH RESPONDENT IF YOU HAVEN'T ALREADY DONE SO.
POINT OUT PROVIDER NAME, DATE(S), AND TYPE OF SERVICE. THEN ASK:
So, I have an amount remaining of $(AMOUNT REMAINING) that Medicare didn't pay. [Have you/Has (SP)] or
any other source, [such as (TRICARE/an insurance plan/TRICARE or an insurance plan)], paid any of this
amount?

(01) YES
(02) NO
(03) CAN'T TELL

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

BOX ST47

ST64 - STTCHGPAID2

ST48 - MCAPPAMT

ST48 - MCPAYAMT

BOX ST48

(01) BOX ST64A
(02) BOX ST64A
(03) ST50 - CHANGAMT
(-8) BOX ST64A
(-9) BOX ST64A

THESE AMOUNTS WERE ENTERED FROM THE (TYPE OF STATEMENT) STATEMENT:
TOTAL CHARGE/BILLED AMOUNT: (TOTAL CHARGE AMOUNT)
TOTAL MEDICARE APPROVED AMOUNT: (MEDICARE APPROVED AMOUNT)
CHANGAMT

ST50

yes/no
TOTAL MEDICARE PAYMENT: (MEDICARE PAYMENT)

(01) YES
(02) NO

(01) ST51 - TOTALCHG
(02) BOX ST51

AMOUNT REMAINING AFTER MEDICARE PAYMENT: (AMOUNT REMAINING)
DO YOU WANT TO MAKE ANY CHANGES?
TOTALCHG

ST51

numeric

MCAPPAMT

ST51

numeric

MCPAYAMT

ST51

numeric

MAKE ALL THE NECESSARY CORRECTIONS TO THE AMOUNTS THAT WERE ENTERED FROM THE (TYPE OF
STATEMENT).

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

ST51 - MCAPPAMT

ST51 - MCPAYAMT

BOX ST51

Variable Name

MR Screen Name

Question type

BOX ST51

routing

TOTALCHG

ST52

numeric

MCAPPAMT

ST52

numeric

MCPAYAMT

ST52

numeric

MAYBBILL

ST52

numeric

BOX ST52

routing

STTCHGPAID1

ST53

code one

CHANGAMT

ST54

yes/no

Question text/description
Code List
IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND ((AMOUNT REMAINING < $1.00)
OR ((ST51 - MCAPPAMT ^= DK AND ST51 - MCAPPAMT ^= RF) AND (AMOUNT REMAINING < .02 * ST51 MCAPPAMT))), GO TO BOX ST80.
ELSE GO TO ST64 - STTCHGPAID2.
(01) CONTINUOUS ANSWER
ENTER THE FOLLOWING AMOUNTS FROM THE MSN:
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
IF AMOUNT REMAINING = DK OR EMPTY, GO TO BOX ST55.
ELSE IF (AMOUNT REMAINING < $1.00), GO TO BOX ST80.
ELSE GO TO ST53 - STTCHGPAID1.
(01) SP OR ANY SOURCE PAID
REVIEW CHARGE BUNDLE ON THE (TYPE OF STATEMENT) WITH RESPONDENT IF YOU HAVEN'T ALREADY
(02) NOTHING HAS BEEN PAID
DONE SO. POINT OUT PROVIDER NAME, DATE(S), AND TYPE OF SERVICE. THEN ASK:
(03) AMOUNT REMAINING SEEMS
So, I have an amount remaining of $(AMOUNT REMAINING) that Medicare didn't pay. [Have you/Has (SP)] or
WRONG
any other source, [such as (TRICARE/an insurance plan/TRICARE or an insurance plan)], paid any of this
(-8) DON'T KNOW
amount?
(-9) REFUSED
THESE AMOUNTS WERE ENTERED FROM THE (TYPE OF STATEMENT) :
AMOUNT CHARGED: (TOTAL CHARGE AMOUNT)

Routing

MEDICARE APPROVED: (MEDICARE APPROVED AMOUNT)

(01) ST55 - TOTALCHG
(02) BOX ST55

MEDICARE PAID: (MEDICARE PAYMENT)

(01) YES
(02) NO

ST52 - MCAPPAMT

ST52 - MCPAYAMT

ST52 - MAYBBILL
BOX ST52

(01) BOX ST64A
(02) BOX ST64A
(03) ST54 - CHANGAMT
(-8) BOX ST64A
(-9) BOX ST64A

YOU MAY BE BILLED: (MAY BE BILLED)
DO YOU WANT TO MAKE ANY CHANGES?
TOTALCHG

ST55

numeric

MCAPPAMT

ST55

numeric

MCPAYAMT

ST55

numeric

MAYBBILL

ST55

numeric

BOX ST55

routing

DAYSUSED

ST56

numeric

NONCOVRD

ST56

numeric

MCPAYAMT

ST56

numeric

MAYBBILL

ST56

numeric

MAKE ALL THE NECESSARY CORRECTIONS TO THE AMOUNTS THAT WERE ENTERED FROM THE (TYPE OF
STATEMENT).

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

IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND (AMOUNT REMAINING < $1.00),
GO TO BOX ST80.
ELSE GO TO ST64 - STTCHGPAID2.
ENTER THE FOLLOWING AMOUNTS FROM THE MSN.
(01) CONTINUOUS ANSWER
DISREGARD "AMOUNT CHARGED" IF IT APPEARS ON THE STATEMENT.
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW

ST55 - MCAPPAMT

ST55 - MCPAYAMT

ST55 - MAYBBILL
BOX ST55

ST56 - NONCOVRD
ST56 - MCPAYAMT

ST56 - MAYBBILL
BOX ST56

Variable Name

STTCHGPAID1

MR Screen Name

Question type

BOX ST56

routing

ST57

code one

Question text/description
IF AMOUNT REMAINING = DK OR EMPTY, GO TO BOX ST59.
ELSE IF AMOUNT REMAINING < $1.00, GO TO BOX ST80.
ELSE GO TO ST57 - STTCHGPAID1.
REVIEW CHARGE BUNDLE ON (TYPE OF STATEMENT) WITH RESPONDENT IF YOU HAVEN'T ALREADY DONE SO.
POINT OUT PROVIDER NAME, DATE(S), AND TYPE OF SERVICE. THEN ASK:
So, I have an amount remaining $(AMOUNT REMAINING) that Medicare didn't pay. [Have you/Has (SP)] or
any other source, [such as (TRICARE/an insurance plan/TRICARE or an insurance plan)], paid any of this
amount?

Code List

Routing

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

(01) BOX ST64A
(02) BOX ST64A
(03) ST58 - CHANGAMT
(-8) BOX ST64A
(-9) BOX ST64A

(01) YES
(02) NO

(01) ST59 - DAYSUSED
(02) BOX ST59

THESE AMOUNTS WERE ENTERED FROM THE MSN:
BENEFITS DAYS USED: (DAYS USED)
NON-COVERED CHARGES: (NON COVERED CHARGES)
CHANGAMT

ST58

yes/no
AMOUNT MEDICARE PAID: (MEDICARE PAYMENT)

DAYSUSED

ST59

numeric

NONCOVRD

ST59

numeric

MCPAYAMT

ST59

numeric

MAYBBILL

ST59

numeric

BOX ST59

routing

TOTALCHG

ST60

numeric

MCAPPAMT

ST60

numeric

MCPAYAMT

ST60

numeric

MAYBBILL

ST60

numeric

BOX ST60

STTCHGPAID1

ST61

code one

MAXIMUM YOU MAY BE BILLED: (MAY BE BILLED)
DO YOU WANT TO MAKE ANY CHANGES?
MAKE ALL THE NECESSARY CORRECTIONS TO THE AMOUNTS THAT WERE ENTERED FROM THE (TYPE OF
STATEMENT).

(01) CONTINUOUS ANSWER

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND (AMOUNT REMAINING < $1.00), (01) CONTINUOUS ANSWER
GO TO BOX ST80.
(-8) DON'T KNOW
ELSE GO TO ST64 - STTCHGPAID2.
(-9) REFUSED
(01) CONTINUOUS ANSWER
ENTER THE FOLLOWING AMOUNTS FROM THE MSN.
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
IF AMOUNT REMAINING = DK OR EMPTY, GO TO BOX ST63.
ELSE IF AMOUNT REMAINING < $1.00, GO TO BOX ST80.
ELSE GO TO ST61 - STTCHGPAID1.
(01) SP OR ANY SOURCE PAID
REVIEW CHARGE BUNDLE ON (TYPE OF STATEMENT) WITH RESPONDENT IF YOU HAVEN'T ALREADY DONE SO. (02) NOTHING HAS BEEN PAID
POINT OUT PROVIDER NAME, DATE(S), AND TYPE OF SERVICE. THEN ASK:
(03) AMOUNT REMAINING SEEMS
So, I have an amount remaining (AMOUNT REMAINING) that Medicare didn't pay. [Have you/Has (SP)] or any WRONG
other source, [such as (TRICARE/an insurance plan/TRICARE or an insurance plan)], paid any of this amount? (-8) DON'T KNOW
(-9) REFUSED

ST59 - MCPAYAMT

ST59 - MAYBBILL

BOX ST59

ST60 - NONCOVRD

ST60 -MCAPPAMT

ST60 - MCPAYAMT

ST60 - MAYBBILL

BOX ST60

(01) BOX ST64A
(02) BOX ST64A
(03) ST62 - CHANGAMT
(-8) BOX ST64A
(-9) BOX ST64A

Variable Name

MR Screen Name

Question type

Question text/description
THESE AMOUNTS WERE ENTERED FROM THE MSN:
AMOUNT CHARGED: (TOTAL CHARGE AMOUNT)
MEDICARE APPROVED AMOUNT: (MEDICARE APPROVED AMOUNT)

CHANGAMT

ST62

yes/no
AMOUNT MEDICARE PAID: (MEDICARE PAYMENT)

Code List

Routing

(01) YES
(02) NO

(01) ST63 - TOTALCHG
(02) BOX ST63

MAXIMUM YOU MAY BE BILLED: (MAY BE BILLED)
DO YOU WANT TO MAKE ANY CHANGES?
TOTALCHG

ST63

numeric

MCAPPAMT

ST63

numeric

MCPAYAMT

ST63

numeric

MAYBBILL

ST63

numeric

routing

IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND (AMOUNT REMAINING < $1.00),
GO TO BOX ST80.
ELSE GO TO ST64 - STTCHGPAID2.

code one

REVIEW CHARGE BUNDLE ON [TYPE OF STATEMENT] WITH RESPONDENT IF YOU HAVEN'T ALREADY DONE SO.
POINT OUT (PROVIDER NAME), DATE(S), AND TYPE OF SERVICE(S). (THEN ASK:/SELECT "SP OR ANY SOURCE
PAID" IF ALREADY KNOWN. OTHERWISE ASK:)
[The total cost of prescriptions reported on this statement is (TOTAL CHARGE TEXT).] [[Have you/Has
(SP)]/Besides Medicare, [have you/has (SP)]] or any other source [, such as (an insurance
plan/TRICARE/TRICARE or an insurance plan),] paid anything for this?

routing

IF SP OR ANY SOURCE HAS PAID, GO TO BOX ST64B.
ELSE IF (NOTHING HAS BEEN PAID) OR (RESPONDENT DOES NOT KNOW IF ANYTHING HAS BEEN PAID), GO TO
BOX ST78B.
ELSE GO TO BOX ST80.

BOX ST64B

routing

CREATE SOURCE OF PAYMENT ROSTER
IF ADMINISTERING ST AND (ONE OR MORE CHARGE BUNDLES ENTERED IN ST SECTION) AND (ST65 –
STADDSOP1 HAS BEEN ASKED IN THE CURRENT ROUND) AND (PAYMENTS HAVE BEEN COLLECTED AT ST67),
GO TO ST67 - TSOPAMT.

ST65

yes/no

ARE ALL OF THE SOURCES OF PAYMENT NECESSARY FOR COMPLETING THE STATEMENT SECTION LISTED
BELOW?
SELECT "NO" TO ADD A SOURCE OF PAYMENT.

BOX ST63

STTCHGPAID2

ST64

BOX ST64A

STADDSOP1

ENTER THE FOLLOWING AMOUNTS FROM THE MSN.

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

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

(01) YES
(02) NO

ST63- MCAPPAMT

ST63 - MCPAYAMT

ST63 - MAYBBILL

BOX ST63

BOX ST64A

(01) ST67 - TSOPAMT
(02) ST66 - SOP_ST1

(01) CONTINUOUS ANSWER
SOP_ST1

TSOPAMT

ST66

roster

ST67

grid

BOX ST67HE

routing

ADD ALL ADDITIONAL SOURCES OF PAYMENT.
(REFER TO INSURANCE STATEMENT/REFER TO TRICARE STATEMENT/REFER TO INSURANCE AND TRICARE
STATEMENTS/REFER TO MEDICARE PRESCRIPTION DRUG BENEFIT STATEMENT).
Who (else) paid besides Medicare? How much did (SOURCE) pay?
ENTER ALL PAYMENT AMOUNTS. CORRECT PAYMENT AMOUNTS AS NECESSARY.
IF AT LEAST ONE TSOPAMT = DK OR RF OR THE SUM OF ALL TSOPAMT
VALUES FOR THIS COST > 0.00, GO TO BOX ST67A.
ELSE GO TO ST67HE - PAYMHE.

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

BOX ST67HE

Variable Name

MR Screen Name

Question type

PAYMHE

ST67HE

no entry

PLANINTRO

NAVIGATOR

BOXST67A

routing

BOX ST67B

routing

ST67BINT

no entry

ST67B_IN

BOX ST67C

Question text/description
Code List
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'.
(01) CONTINUOUS ANSWER

ST67HE-PAYMHE

USE "PREVIOUS PAGE" TO RETURN TO THE SOP GRID AND MAKE CORRECTIONS.
IF AT LEAST ONE SOURCE OF PAYMENT WAS ADDED AT ST66, GO TO BOX ST67B.
ELSE GO TO BOX ST69F.
IF AT LEAST ONE SOURCE OF PAYMENT ADDED AT ST66 IS A HEALTH INSURANCE PLAN, GO TO ST67BINT PLANINTRO. ELSE GO TO BOX ST69E.
Before we continue, I would like to ask you a few questions about the health insurance plan(s) you just added. (01) CONTINUOUS ANSWER
(01) ITEM SELECTED IN INSTANCE
NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED

instance navigator

routing

Routing

ST67B_IN - NAVIGATOR
(01) BOX ST67C
(02)BOX ST69E

CREATE A NEW HEALTH INSURANCE PLAN FOR FIRST/NEXT SOURCE OF PAYMENT ADDED AT ST66
IF SOURCE OF PAYMENT IS A MEDICARE MANAGED CARE PLAN AND SP HAS A MEDICARE MANAGED CARE
PLAN THAT IS CURRENT, GO TO ST68 - STMHMOCHNG1.
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 ST69 - STSOPCURR1.
ELSE IF SOURCE OF PAYMENT IS A MEDICARE PRESCRIPTION DRUG PLAN AND SP HAS A MEDICARE
PRESCRIPTION DRUG PLAN THAT IS CURRENT, GO TO ST69A - STMPDPCHNG.
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 ST69B - STSOPCURR2.
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) YES
I recorded previously that (CURRENT MEDICARE MANAGED CARE PLAN NAME) was [your/(SP's)] current
(02) NO
Medicare Managed Care Plan. Has this information changed?
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
[Are you/Is (SP)/Was (SP)] [currently] covered or enrolled in (ST66 SOP MEDICARE MANAGED CARE PLAN
(02) NO
NAME) [on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?
(-8) DON'T KNOW
(-9) REFUSED
I recorded previously that (CURRENT MEDICARE PRESCRIPTION DRUG PLAN) was [your/(SP's)] current
(01) YES
Medicare Prescription Drug Care Plan.
(02) NO
(-8) DON'T KNOW
Has this information changed?
(-9) REFUSED
(01) YES
[Are you/Is (SP)/Was (SP)] [currently] covered or enrolled in (ST66 SOP MEDICARE PRESCRIPTION DRUG PLAN) (02) NO
[on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?
(-8) DON'T KNOW
(-9) REFUSED

STMHMOCHNG1

ST68

yes/no

STSOPCURR1

ST69

yes/no

STMPDPCHNG

ST69A

yes/no

STSOPCURR2

ST69B

yes/no

BOX ST69A

routing

GO TO ST67B_IN - NAVIGATOR.

BOX ST69E

routing

IF AN "OTHER SOURCE OF PAYMENT" ADDED AT ST66, CREATE AN OSOP FOR EACH SOURCE OF PAYMENT
ADDED AT ST66 THAT IS AN "OTHER SOURCE OF PAYMENT"
GO TO BOX ST69F.

(01) ST69 - STSOPCURR1
(02) BOX ST69A
(-8) BOX ST69A
(-9) BOX ST69A
(01) HIMC6A - MHMORXTM
(02) BOX ST69A
(-8) BOX ST69A
(-9) BOX ST69A
(01) ST69B - STSOPCURR2
(02) BOX ST69A
(-8) BOX ST69A
(-9) BOX ST69A
BOX ST69A

Variable Name

MR Screen Name

BOX ST69F

AMTSCORR

AMTSCORR

ENTERCOM

ST70

ST71

ST72

Question type

Question text/description

routing

IF ((TYPE OF STATEMENT = 8/MPDPBenefit) or (TYPE OF STATEMENT = 4/Tricare and ST5 - STTYPE =
8/MPDPorMAorTricare)) and ((TOTAL CHARGE ^= DK and TOTAL CHARGE ^= RF) and (ALL PAYMENTS
ENTERED AT ST67 ^= DK AND ^= RF)) AND ((TOTAL CHARGE IS > TOTAL PAYMENTS ENTERED AT ST67) AND
(THE DIFFERENCE BETWEEN TOTAL CHARGE AND TOTAL PAYMENTS ENTERED AT ST67 IS > $1.00)), GO TO
ST73 - AMTSCORR.
IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND (AT LEAST ONE PAYMENT
ENTERED AT ST67 = DK OR RF) AND (AT LEAST ONE PAYMENT ENTERED AT ST67 ^= DK AND ^= RF) AND
(TOTAL OF ALL NON-MISSING PAYMENTS ENTERED AT ST67 IS >= AMOUNT REMAINING), GO TO ST71 AMTSCORR.
ELSE IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND (ALL PAYMENTS ENTERED
AT ST67 ^= DK AND ^= RF) AND (THE ABSOLUTE VALUE OF THE DIFFERENCE BETWEEN THE TOTAL PAYMENTS
ENTERED AT ST67 AND AMOUNT REMAINING IS > $1.00), GO TO ST70 - AMTSCORR.
ELSE GO TO BOX ST77C.

code one

There seems to be (some amount still unpaid/more payments than the amount left after Medicare paid). The
total of non-Medicare payments is $(TOTAL PAYMENTS). The amount (unpaid/overpaid) is $(DIFFERENCE
BETWEEN PAYMENTS AND AMOUNT REMAINING). Is that correct?
IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION, USE "PREVIOUS PAGE" TO RETURN TO THE SOP
GRID.

code one

no entry

Code List

Routing

(01) ENTRIES ABOVE ARE CORRECT
(02) DO NOT DISPLAY
(03) AMOUNT REMAINING SEEMS
INCORRECT
(-8)
(-9) REFUSED

(01) BOX ST77C
(02) DO NOT DISPLAY.
(03) ST72 - ENTERCOM
(-8) BOX ST77C
(-9) BOX ST77C

(01) ENTRIES ABOVE ARE CORRECT
(02) NO, SOP NEEDS ADDITION OR
THE AMOUNTS ENTERED FOR THE SOURCES OF PAYMENT EQUAL OR EXCEED THE (TOTAL CHARGE/AMOUNT
CORRECTION DO NOT DISPLAY.
REMAINING), WITH AT LEAST ONE SOP BEING A MISSING AMOUNT. VERIFY ALL AMOUNTS AS ENTERED.
(03) AMOUNT REMAINING SEEMS
INCORRECT
IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION, USE "PREVIOUS PAGE" TO RETURN TO THE SOP
(-8)
GRID.
(-9) REFUSED

(01) BOX ST77C
(02) DO NOT DISPLAY.
(03) ST72 - ENTERCOM
(-8) BOX ST77C
(-9) BOX ST77C

[THE TOTAL OF NON-MEDICARE PAYMENTS IS $(TOTAL PAYMENTS). THE AMOUNT (UNPAID/OVERPAID) IS
$(DIFFERENCE BETWEEN PAYMENTS AND AMOUNT REMAINING).]

(01) CONTINUOUS ANSWER

BOX ST77C

(01) ENTRIES ABOVE ARE CORRECT
(02) NO, SOP NEEDS ADDITION OR
CORRECTION DO NOT DISPLAY.
(03) AMOUNT REMAINING SEEMS
INCORRECT DO NOT DISPLAY.
(-8)
(-9) REFUSED

(01) ST74 - INFOEXPLAIN
(02) DO NOT DISPLAY.
(03) DO NOT DISPLAY.
(-8) BOX ST77C
(-9) BOX ST77C

USE COMMENTS TO EXPLAIN WHY THE AMOUNT REMAINING SEEMS INCORRECT.

There seems to be some amount still unpaid. The total of non-Medicare payments is $(TOTAL PAYMENTS).
The amount unpaid is $(DIFFERENCE BETWEEN TOTAL CHARGE AND PAYMENTS). Is that correct?
IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION, USE "PREVIOUS PAGE" TO RETURN TO THE SOP
GRID.

AMTSCORR

ST73

yes/no

INFOEXPLAIN

ST74

yes/no

ENTERCOM2

ST75

verbatim text

BOX ST77C

routing

BOX ST77D

routing

IF THE SP OR FAMILY MADE A PAYMENT AND PAYMENT IS GREATER THAN $5.00, GO TO ST78 - EXPPAYBK.
ELSE GO TO BOX ST80.

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?

EXPPAYBK

ST78

IS THERE ADDITIONAL INFORMATION ON THE DRUG BENEFIT STATEMENT THAT EXPLAINS THE AMOUNT STILL (01) YES
UNPAID?
(02) NO
USE THE BOX BELOW TO ENTER ANY INFORMATION THAT EXPLAINS THE AMOUNT STILL UNPAID.
(01) CONTINUOUS ANSWER
CREATE PAYMENTS FOR AMOUNTS ENTERED AT ST67
GO TO BOX ST77D.

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

(01) ST75 - ENTERCOM2
(02) BOX ST77C

BOX ST78A

Variable Name

MR Screen Name

Question type

BOX ST78A

routing

BOX ST78B

routing

EXPAYOUT

ST79

yes/no

EXPAYUNT

ST80

quantity unit

EXPAYPCT
EXPAYAMT

ST80
ST80

numeric
numeric

BOX ST80

routing

ST82

yes/no

BOX STEND

routing

ASTATEMENT

Question text/description
Code List
IF ST78 - EXPPAYBK = 1/Yes AND ((CURRENTLY ADMINISTERING CPS AND CHARGES WERE FIRST COLLECTED 2
ROUNDS PREVIOUS TO CURRENT ROUND) , GO TO ST80 - EXPAYUNT.
ELSE GO TO BOX ST80.
IF (CURRENTLY ADMINISTERING CPS AND CHARGES WERE FIRST COLLECTED 2 ROUNDS PREVIOUS TO
CURRENT ROUND), GO TO ST79 - EXPAYOUT.
ELSE GO TO BOX ST80.
(01) YES
(02) NO
Do you expect anyone to pay any of this amount?
(-8) DON'T KNOW
(-9) REFUSED
(01) PERCENTAGE
(02) DOLLARS
How much do you expect will be paid?
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
IF CURRENTLY ADMINISTERING NS, GO TO BOX NSBEG.
ELSE IF CURRENTLY ADMINISTERING CPS, GO TO BOX CPSBEG.
ELSE GO TO ASTATEMENT.
IS THERE ANOTHER CHARGE BUNDLE FROM THIS (TYPE OF STATEMENT) OR ANOTHER MSN, INSURANCE,
(01) YES
TRICARE, OR MEDICARE PRESCRIPTION DRUG BENEFIT STATEMENT TO ENTER?
(02) NO
GO TO PSQ.

Routing

(01) ST80 - EXPAYUNT
(02) BOX ST80
(-8) BOX ST80
(-9) BOX ST80
(01) ST80 - EXPAYPCT
(02) ST80 - EXPAYAMT
(-8) BOX ST80
(-9) BOX ST80
BOX ST80
BOX ST80

(01) ST4 - MATCHST
(02) BOX STEND