CMS-P-0015A Fac2019R85EX

Variable Name

MR Screen Name

Question type

Question text/description

Code list

Routing

(01) Continue

(01) BOX EXS2

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

(00) BOX EX7BS1
(01) EX17S1 - ANYANCIL
(-8) BOX EX7BS1
(-9) BOX EX7BS1

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(00) BOX EX7BS1
(01) EX18S1 - ANCILAMT
(-8) BOX EX7BS1
(-9) BOX EX7BS1
(01) BOX EX7BS1
(-8) BOX EX7BS1
(-9) BOX EX7BS1

(01) Continue

(01) BOX EX7BS1

(00) NO
(01) YES
(00) NO
(01) YES

(00) BOX EX14S1
(01) EX21AAS1 - ADDSOP1
(00) EX21ACS1 - BASRATE
(01) EX21ABS1 - PAYMPLN1

EXPENDITURES SECTION SPECIFICATIONS
CRITERIA
SAMPLE TYPE= CFR, CFC, FFC, FCF
SEASON= ALL
PLACEMENT
Administered in flexible order after FQ and RH sections are completed.
BOX EXS1

BOX EXS1A

routing

IF COST DATA FROM THE PREVIOUS ROUND REMAINS TO BE COLLECTED, GO TO BOX EXS1A.
ELSE GO TO BOX EXBEG.

routing

IF FIRST/NEXT PRELOAD BPER HAS PreloadBPRO.ANCLPOST = 0/No, DK or PreloadBPRO.ANYANCIL
= DK, GO TO EX15PRES1 - EX15PRCT.
ELSE GO TO EX20S1PRE - BASSMINT.
The next questions are about health-related services received by (SP) for which there was a
separate charge, that is, your (facility/home)'s ancillary services.

EX15PRCT

EX15PRES1

code one

(Please do not include non-health-related services such as hairdressing, television, or telephone).
PRESS F1 FOR EXAMPLES OF NON-HEALTH-RELATED ANCILLARIES.
PRESS "1" TO CONTINUE.

BOX EXS2

ANCLPOST

EX16S1

routing

yes/no

If PreloadBPRO.ANCLPOST = 0/No, DK, GO TO EX16S1 - ANCLPOST.
ELSE GO TO EX17S1 - ANYANCIL.
Have all charges for ancillaries been posted for the period from (BP START DATE) to (BP END
DATE)?

ANYANCIL

EX17S1

yes/no

Does (SP) have any ancillary charges between (BP START DATE) and (BP END DATE)?

ANCILAMT

EX18S1

dollar

Altogether, what was the total charge for those health-related ancillary services?

BASSMINT

EX20S1PRE

code one

BOX EX7BS1

routing

RECDBASP

EX20S1

yes/no

ADDSOP1

EX21AAS1

yes/no

The next questions are about (SP)'s expenditures for room and board while a resident of
(FACILITY).
IF PreloadBPRO.RECDBASP = 0/No, GO TO EX20S1 - RECDBASP.
ELSE IF PreloadBPRO.RECDANCP = 0/No or EX17S1 - ANYANCIL = 1/Yes, GO TO EX28S1 RECDANCP.
ELSE GO TO EX33BS1 - EXSBKCT.
Have you received all of the payments for basic care you expect to receive for (SP) during the
[READ BILLING PERIOD ABOVE] billing period?
Do you need to add any Source(s) of Payment for (SP)'s basic care for [READ BILLING PERIOD
ABOVE]?

Variable Name

MR Screen Name

Question type

Question text/description

What Source(s) of Payment do you need to add for (SP)'s basic care for [READ BILLING PERIOD
ABOVE]?
PAYMPLN1

EX21ABS1

code one

SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
IF NO RESPONSES ARE AVAILABLE, BACK UP AND CORRECT YOUR RESPONSE.

HMOOS1
SOPOS1

EX21ABS1
EX21ABS1

verbatim
verbatim

HMO CONTRACT (SPECIFY)
OTHER (SPECIFY)

BASRATE

EX21ACS1

Grid

What is the total amount each source paid for [READ BILLING PERIOD ABOVE]?

VEXPTXTB

BOX EX7CS1

routing

EX21BS1

verbatim

Code list
(01) MEDICAID
(02) PRIVATE PAY OR SP/FAMILY
INCOME
(03) SOCIAL SECURITY
(04) SP/FAMILY INCOME
(05) PRIVATE INSURANCE
(06) PENSION
(07) MEDICARE
(08) VA CONTRACT
(09) HMO CONTRACT
(10) SUPPLEMENTAL SECURITY
INCOME (SSI)
(91) OTHER
(-8) Don't Know
(-9) Refused

Routing
(01) EX21ACS1 - BASRATE
(02) EX21ACS1 - BASRATE
(03) EX21ACS1 - BASRATE
(04) EX21ACS1 - BASRATE
(05) EX21ACS1 - BASRATE
(06) EX21ACS1 - BASRATE
(07) EX21ACS1 - BASRATE
(08) EX21ACS1 - BASRATE
(09) EX21ABS1 - HMOOS1
(10) EX21ACS1 - BASRATE
(91) EX21ABS1 - SOPOS1
(-8) EX21ACS1 - BASRATE
(-9) EX21ACS1 - BASRATE

(01) [Continuous answer.]
(01) [Continuous answer.]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) EX21ACS1 - BASRATE
(01) EX21ACS1 - BASRATE
(01) BOX EX7CS1
(-8) BOX EX7CS1
(-9) BOX EX7CS1

(01) [Continuous answer.]

(01) BOX EX8S1

(01) MEDICAID WRITEOFF/ADJUSTMENT
(02) OTHER WRITE-OFF/ADJUSTMENT
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) BOX EX9S1
(02) BOX EX9S1
(91) EX22S1 - BAS10POS
(-8) BOX EX9S1
(-9) BOX EX9S1

(01) [Continuous answer.]

(01) BOX EX9S1

IF MEDICARE IS IDENTIFIED AS A SOURCE OF PAYMENT FOR BASIC CARE AND THERE IS NO STAY IN
A HOSPITAL BETWEEN (BP START DATE - 60 DAYS) AND (BP END DATE + 60 DAYS) AND THIS WAS
NOT EXPLAINED THIS ROUND, GO TO EX21BS1 - VEXPTXTB.
ELSE GO TO BOX EX8S1.
Medicare has been reported as a payment source for basic care for (SP) for [READ BILLING PERIOD
ABOVE], but I have not recorded any preceding hospital stays for (him/her).
Please tell me why Medicare paid for (SP) during this billing period.
RECORD VERBATIM BELOW. IF NECESSARY, BACK UP TO CORRECT.

BOX EX8S1

BAS10PCT

EX22S1

routing

code one

IF HOSPITAL STAY IS REPORTED, RECORD DATES OF STAY BELOW.
IF BPER.BASICAMT = DK, RF OR BPER.BASICPAY = DK OR ((BASICPAY >= BASICAMT*0.9) AND
(BASICPAY <= BASICAMT*1.1)) OR (MEDICAID IS A SOURCE OF PAYMENT AND (BASICPAY >=
BASICAMT*0.7) AND (BASICPAY <= BASICAMT*1.1)) OR (A WRITE-OFF WAS PREVIOUSLY
REPORTED AND EX22S1 - BAS10PCT WAS ASKED THIS BP ROUND AND (BASICPAY >=
BASICAMT*0.7) AND (BASICPAY <= BASICAMT*1.1)), GO TO BOX EX9S1.
ELSE GO TO EX22S1 - BAS10PCT.
There seems to be a difference between what (FACILITY) billed between (BP START DATE) and (BP
END DATE) and the payments received. The total amount billed I have entered for this billing
period is (TOTAL AMOUNT BILLED FOR THIS BILLING PERIOD) and the total payments for the
period are (SUM OF EX21 PAYMENTS). Why is that?
PRESS F1 FOR DEFINITION OF "MEDICAID WRITE-OFF".

BAS10POS

EX22S1

verbatim

BOX EX9S1

routing

OTHER (SPECIFY)
IF (MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICAID CERTIFIED
AND FACILITY HAS NEVER CONFIRMED), GO TO EX23A1S1 - EX23A1S1C.
ELSE GO TO BOX EX9AAS1.

Variable Name

MR Screen Name

Question type

Question text/description

Code list

Routing

(01) Continue

(01) BOX EX9AAS1

(01) Continue

(01) BOX EX9AS1 BOX EX10S1

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(01) EX23BS1 - ECAIDVR1
(-8) BOX EX10S1
(-9) BOX EX10S1
(00) BOX EX10S1
(01) BOX EX10S1
(-8) BOX EX10S1
(-9) BOX EX10S1

(01) Continue

(01) BOX EX11S1

I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not
certified by Medicaid but I have identified Medicaid as a payment source.
EX23A1S1C

EX23A2S1C

EX23A1S1

code one

BOX EX9AAS1

routing

EX23A2S1

code one

Is Medicaid indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.
IF (MEDICARE IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICARE CERTIFED
AND FACILITY HAS NEVER CONFIRMED), GO TO EX23A2S1 - EX23A2S1C.
ELSE GO TO BOX EX9AS1 BOX EX10S1.
I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not
certified by Medicare but I have identified Medicare as a payment source.
Is Medicare indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.
IF (THIS IS THE FIRST TIME MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE FOR AN SP WHOSE
MEDICAID STATUS IN THIS ROUND IS "PENDING" OR WHOSE MEDICAID NUMBER IS UNKNOWN),
GO TO EX23AS1 - ECAIDNUM.
ELSE GO TO BOX EX11S1.

BOX EX9AS1

routing

ECAIDNUM

EX23AS1

verbatim

Please tell me (SP)'s [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] ID number.

ECAIDVR1

EX23BS1

yes/no

I'd like to verify the [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] ID number that I have
recorded. I have entered (MEDICAID ID NUMBER). Is this correct?

BOX EX10S1

routing

IF EX23AS1 - ECAIDNUM = DK, RF OR EX23BS1 - ECAIDVR1 = DK, RF, IF THIS IS THE FIRST TIME
MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE FOR AN SP WHOSE MEDICAID STATUS IN THIS
ROUND IS "NO" GO TO EX24AS1 - EX24AS1C.
ELSE GO TO BOX EX11S1.
Earlier, I recorded that (SP) was not a Medicaid recipient, but I have identified Medicaid as a
source of payment.

EX24AS1C

EX24AS1

BOX EX11S1

code one

routing

Is Medicaid indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.
IF MEDICAID IS NOT IDENTIFIED AS A PAYMENT SOURCE FOR THE CURRENT BILLING PERIOD BUT
APPEARS IN THE PRECEDING BILLING PERIOD, GO TO EX25S1 - EX25S1C.
ELSE GO TO BOX EX12S1.

Variable Name

MR Screen Name

Question type

Question text/description

Code list

Routing

(01) Continue

(01) BOX EX12S1

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

(00) EX27S1 - VBPETXTE
(01) BOX EX14S1
(-8) EX27S1 - VBPETXTE
(-9) BOX EX14S1

(01) [Continuous answer.]

(01) BOX EX14S1

(00) NO
(01) YES
(00) NO
(01) YES
(01) MEDICAID
(02) PRIVATE PAY OR SP/FAMILY
INCOME
(03) SOCIAL SECURITY
(04) SP/FAMILY INCOME
(05) PRIVATE INSURANCE
(06) PENSION
(07) MEDICARE
(08) VA CONTRACT
(09) HMO CONTRACT
(10) SUPPLEMENTAL SECURITY
INCOME (SSI)
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(01) [Continuous answer.]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(00) EX33BS1 - EXSBKCT
(01) EX29AAS1 - ADDSOP2
(00) EX29ACS1 - ANCRATE
(01) EX29ABS1 - PAYMPLN2

It seems that I might have made a mistake in identifying the various sources of payment for (SP)'s
care. Earlier, I recorded that (his/her) basic charges from a previous billing period were paid by
Medicaid, and in this billing period, Medicaid is no longer a payment source.
EX25S1C

EX25S1

code one

Is Medicaid indeed no longer paying for (her/his) care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

BOX EX12S1

CAREPRTB

EX26S1

routing

yes/no

IF MEDICARE IS IDENTIFIED AS A PAYMENT SOURCE AND THE AMOUNT PAID BY MEDICARE
REPRESENTS LESS THAN 10 PERCENT OF THE TOTAL PAYMENTS RECEIVED FOR THE BILLING
PERIOD, GO TO EX26S1 - CAREPRTB.
ELSE GO TO BOX EX14S1.
Medicare's payment for this billing period represents less than 10 percent of the total payments
for basic care. Is this Medicare payment a Part B payment?
IF NECESSARY, BACK UP TO CORRECT PAYMENTS.
Can you tell me why the Medicare payment is so small?

VBPETXTE

EX27S1

verbatim
RECORD VERBATIM BELOW. IF NECESSARY, BACK UP TO CORRECT PAYMENTS.

BOX EX14S1

routing

RECDANCP

EX28S1

yes/no

ADDSOP2

EX29AAS1

yes/no

IF PreloadBPRO.RECDANCP = 0/No or EX17S1 – ANYANCIL = 1/Yes, GO TO EX28S1 - RECDANCP.
ELSE GO TO EX33BS1 - EXSBKCT.
Have you received all the payments you expect to receive for (SP)'s ancillary services during the
[READ BILLING PERIOD ABOVE] billing period?
Do you need to add any Source(s) of Payment for (SP)'s ancillary services for [READ BILLING
PERIOD ABOVE]?

What Source(s) of Payment do you need to add for (SP)'s ancillary services for [READ BILLING
PERIOD ABOVE]?
PAYMPLN2

EX29ABS1

code all

SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
IF NO RESPONSES ARE AVAILABLE, BACK UP AND CORRECT YOUR RESPONSE.

HMOOS2
SOPOS2

EX29ABS1
EX29ABS1

verbatim
verbatim

HMO CONTRACT (SPECIFY)
OTHER (SPECIFY)

ANCRATE

EX29ACS1

Grid

What is the total amount each source paid for [READ BILLING PERIOD ABOVE]?

(01) EX29ACS1 - ANCRATE
(02) EX29ACS1 - ANCRATE
(03) EX29ACS1 - ANCRATE
(04) EX29ACS1 - ANCRATE
(05) EX29ACS1 - ANCRATE
(06) EX29ACS1 - ANCRATE
(07) EX29ACS1 - ANCRATE
(08) EX29ACS1 - ANCRATE
(09) EX29ABS1 - HMOOS2
(10) EX29ACS1 - ANCRATE
(91) EX29ABS1 - SOPOS2
(-8) EX29ACS1 - ANCRATE
(-9) EX29ACS1 - ANCRATE
(01) EX29ACS1 - ANCRATE
(01) EX29ACS1 - ANCRATE
(01) BOX EX15S1
(-8) BOX EX15S1
(-9) BOX EX15S1

Variable Name

MR Screen Name

BOX EX15S1

ANC10PCT

EX30S1

Question type

Question text/description

routing

IF BPER.ANCILAMT = DK, RF OR BPER.ANCILPAY = DK OR ((BPER.ANCILPAY >=
BPER.ANCILAMT*0.9) AND (BPER.ANCILPAY <= BPER.ANCILAMT*1.1)) OR (MEDICAID IS A SOURCE
OF PAYMENT AND (BPER.ANCILPAY >= BPER.ANCILAMT*0.7) AND (BPER.ANCILPAY <=
BPER.ANCILAMT*1.1)) OR (A WRITE-OFF WAS PREVIOUSLY REPORTED AND EX30S1 - ANC10PCT
WAS ASKED THIS BP ROUND AND (BPER.ANCILPAY >= BPER.ANCILAMT*0.7) AND (BPER.ANCILPAY
<= BPER.ANCILAMT*1.1)), GO TO BOX EX16S1.
ELSE GO TO EX30S1 - ANC10PCT.

code one

There seems to be a difference between what (FACILITY) billed for ancillary services between (BP
START DATE) and (BP END DATE) and the payments received. The total amount billed I have
entered for [READ BILLING PERIOD ABOVE] is (TOTAL AMOUNT BILLED FOR BILLING PERIOD) and
the total payments for the period are (SUM OF ANCILLARY PAYMENTS). Why is that?
PRESS F1 FOR DEFINITION OF "MEDICAID WRITE-OFF".

ANC10POS

EX30S1

verbatim

BOX EX16S1

routing

OTHER (SPECIFY)
(IF MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICAID CERTIFIED
AND FACILITY HAS NEVER CONFIRMED), GO TO EX31A1S1 - EX31A1S1C.
ELSE GO TO BOX EX16AAS1.

Code list

Routing

(01) MEDICAID WRITEOFF/ADJUSTMENT
(02) OTHER WRITE-OFF/ADJUSTMENT
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) BOX EX16S1
(02) BOX EX16S1
(91) EX30S1 - ANC10POS
(-8) BOX EX16S1
(-9) BOX EX16S1

(01) [Continuous answer.]

(01) BOX EX16S1

(01) Continue

(01) BOX EX16AAS1

(01) Continue

(01) BOX EX16AS1 BOX EX17S1

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(01) EX31BS1 - ECAIDVR2
(-8) BOX EX17S1
(-9) BOX EX17S1
(00) EX31AS1 - ECAIDNM3
(01) BOX EX17S1
(-8) BOX EX17S1
(-9) BOX EX17S1

I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not
certified by Medicaid but I have identified Medicaid as a payment source.
EX31A1S1C

EX31A1S1

code one

Is Medicaid indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

EX31A2S1C

BOX EX16AAS1

routing

IF (MEDICARE IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICARE CERTIFED
AND FACILITY HAS NEVER CONFIRMED), GO TO EX31A2S1 - EX31A2S1C.
ELSE GO TO BOX EX16AS1 BOX EX17S1.
I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not
certified by Medicare but I have identified Medicare as a payment source.

EX31A2S1C

EX31A2S1

code one

Is Medicare indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

BOX EX16AS1

routing

IF (THIS IS THE FIRST TIME MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE FOR AN SP WHOSE
MEDICAID STATUS IN THIS ROUND IS "PENDING" OR WHOSE MEDICAID NUMBER IS UNKNOWN),
GO TO EX31AS1 - ECAIDNM3.
ELSE GO TO BOX EX18S1.

ECAIDNM3

EX31AS1

text

Please tell me (SP)'s [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] ID number.

ECAIDVR2

EX31BS1

yes/no

I'd like to verify the [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] ID number that I have
recorded. I have entered (MEDICAID ID NUMBER). Is this correct?

Variable Name

EX32AS1C

MR Screen Name

Question type

BOX EX17S1

routing

EX32AS1

code one

BOX EX18S1

routing

Question text/description

Code list

Routing

(01) Continue

(01) BOX EX18S1

(01) Continue

(01) EX33BS1 - EXSBKCT

(01) Continue

(01) BOX EX20S1

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

(00) EX35S1 - VEXPTXTG
(01) BOX EX21AS1
(-8) BOX EX21AS1
(-9) BOX EX21AS1

(01) [Continuous answer.]

(01) BOX EX21AS1

(01) STILL PENDING
(02) DENIED
(-8) Don't Know
(-9) Refused

(01) BOX EXSEND
(02) BOX EXSEND
(-8) BOX EXSEND
(-9) BOX EXSEND

IF EX31AS1 - ECAIDNM3 = DK, RF OR EX31BS1-ECAIDVR2 = DK, RF, IF THIS IS THE FIRST TIME
MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE FOR AN SP WHOSE MEDICAID STATUS IN THIS
ROUND IS "NO" GO TO EX32AS1 - EX32AS1C.
ELSE GO TO BOX EX18S1.
Earlier, I recorded that (SP) was not a Medicaid recipient but I have identified Medicaid as a source
of payment.
Is Medicaid indeed paying for (SP)'s ancillaries?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.
IF MEDICAID IS NOT IDENTIFIED AS PAYMENT SOURCE FOR
ANCILLARIES FOR THE CURRENT BILLING PERIOD BUT APPEARS IN THE PRECEDING PERIOD, GO TO
EX33S1 - EX33S1C.
ELSE GO TO EX33BS1 - EXSBKCT.
It seems that I might have made a mistake in identifying the various sources of payment for (SP)'s
care. Earlier, I recorded that (his/her) charges for ancillaries in a previous billing period were paid
by Medicaid, and in this billing period, Medicaid is no longer a payment source.

EX33S1C

EX33S1

code one

Is Medicaid indeed no longer paying for (his/her) ancillary services?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS..

EXSBKCT

EX33BS1

code one

BOX EX20S1

routing

BOX EX21S1

routing

Earlier I was told that (SP) had long-term care insurance from (NAME OF FIRST LTC INSURANCE
COMPANY REPORTED). Is it correct that this policy paid for none of (his/her) care?

EX34S1

VEXPTXTG

THIS IS THE LAST SCREEN FOR THIS BILLING PERIOD WHERE YOU CAN BACK UP TO MAKE
CORRECTIONS.
PRESS "1" TO CONTINUE.
IF THERE IS ADDITIONAL PREVIOUS ROUND DATA THAT HAS NOT BEEN ANOTHER BPER IN
PreloadBPER COLLECTED, GO TO BOX EXS1A.
ELSE IF THERE IS CURRENT ROUND BILLING TO COLLECT, GO TO BOX EXSEND.
ELSE GO TO BOX EX21S1.
IF PRIVATE PAY HAS NEVER BEEN REPORTED AS A SOURCE OF PAYMENT AND SP WAS COVERED
BY A LONG-TERM CARE POLICY, GO TO EX34S1 - USENOLTC.
ELSE GO TO BOX EX21AS1.

EX35S1

verbatim

Can you explain this to me?
RECORD VERBATIM BELOW.

BOX EX21AS1

routing

IF IT IS PENDING WHETHER SP HAS BEEN COVERED BY MEDICAID FROM CRIN-1 AND MEDICAID
HAS NEVER BEEN REPORTED AS A SOURCE OF PAYMENT, GO TO EX35AS1 - ECAIDECO.
ELSE TO TO BOX EXSEND.

EX35AS1

code one

The last time I was here, I collected information that (SP)'s [(PREFERRED NAME(S) FOR
MEDICAID)/MEDICAID] eligibility status was pending. Is it still pending or has [(PREFERRED
NAME(S) FOR MEDICAID)/MEDICAID] been denied?

BOX EXSEND

routing

IF THERE IS CURRENT ROUND BILLING TO COLLECT, GO TO BOX EXBEG.
ELSE GO TO BOX EXEND.

Variable Name

EX1PRECT

MR Screen Name

Question type

Question text/description

BOX EXBEG

routing

GO TO EX1PRE - EX1PRECT.
This series of questions asks about (SP)'s expenditures for room and board and ancillary charges
while a resident of (FACILITY).

EX1PRE

code one

[The first few questions are about billing and sources of payment when (he/she) first became a
resident here on (FAD/RAD).]
PRESS "1" TO CONTINUE.

Code list

Routing

(01) Continue

(01) EX2 - ANYBASIC

ANYBASIC

EX2

yes/no

The following questions are about (SP)'s basic care between (EX REFERENCE START DATE) and (EX
REFERENCE END DATE).
(00) NO
(01) YES
Was there a charge for (her/his) room and board and basic care between (EX REFERENCE START
(-8) Don't Know
DATE) and (EX REFERENCE END DATE)? Please include any charges to (SP), (her/his) family, or a
(-9) Refused
third party, such as Medicaid, Medicare, or a legal guardian.

EX2ANAME

EX2A

roster

Please tell me the name of someone in (FACILITY) who could give me that information.
SELECT A RESPONSE BELOW OR ADD TO THE PERSON ROSTER.

VEXPTXTA

ANCILSEP

EX3

verbatim

BOX EX1A

routing

EX4

yes/no

Why were there no charges?
IF ANSWER IS "MEDICAID PAID", BACK UP TO EX2 AND ENTER "1".
RECORD VERBATIM.
If FQ.ANCNVSEP = 1/Indicated, GO TO EX5 - COMRECMM.
ELSE GO TO EX4 - ANCILSEP.
Between (EX REFERENCE START DATE) and (EX REFERENCE END DATE), was (SP) billed separately
for health-related ancillary services? (That is, were there charges for ancillary services that were
not included in the basic rate?)
IF FACILITY NEVER BILLS SEPARATELY FOR ANCILLARIES, ENTER 96.

(00) EX3 - VEXPTXTA
(01) BOX EX1A
(-8) EX2A - EX2ANAME
(-9) EXEND - EXENDCNT

(01) [Continuous answer.]

(01) EXEND - EXENDCNT

(01) [Continuous answer.]

(01) EXEND - EXENDCNT

(00) NO
(01) YES
(96) NEVER BILLS SEPARATELY

(00) EX5 - COMRECMM
(01) EX5 - COMRECMM
(96) EX5 - COMRECMM

(01) [Continuous answer.]

(01) EX5 - COMRECDD

(01) [Continuous answer.]
(01) [Continuous answer.]

(01) EX5 - COMRECYY
(01) BOX EX2AA

(01) monthly,
(02) every two weeks,
(03) every week, or
(04) quarterly?
(91) OTHER
(01) [Continuous answer.]

(01) BOX EX2AA1
(02) BOX EX2AA1
(03) BOX EX2AA1
(04) BOX EX2AA1
(91) EX6 - BPLNCROS
(01) BOX EX2AA1

PRESS F1 FOR DEFINITION OF ANCILLARY SERVICES.
Through what date do you have complete billing records for the services provided to (SP)?
COMRECMM

EX5

date
MONTH

COMRECDD
COMRECYY

EX5
EX5

date
date

BOX EX2AA

routing

DAY
YEAR
IF BILLING PERIOD LENGTH IS UNKNOWN, GO TO EX6 - BPLENCUR.
ELSE GO TO BOX EX2AA1.

BPLENCUR

EX6

code one

What is the length of the (facility/home)'s billing period? Is it…

BPLNCROS

EX6
BOX EX2AA1

verbatim
routing

OTHER (SPECIFY)
GO TO BOX EX2A.

BOX EX2A

routing

IF EX REFERENCE START DATE IS LATER THAN THE DATE FOR WHICH THE FACILITY HAS COMPLETE
BILLING RECORDS FOR THE SERVICES PROVIDED TO RESIDENTS, GO TO EXEND - EXENDCNT.
ELSE GO TO EX7PRE - EX7PCNT.

Variable Name

MR Screen Name

Question type

Question text/description

Code list

Routing

(01) Continue

(01) FEX2 - BILLINFO

(01) ALL BILLING AND THEN ALL
PAYMENT INFORMATION
(02) BILLING AND PAYMENT
INFORMATION BY BILLING PERIOD
(-8) Don't Know
(-9) Refused

(01) BOX EX3AB2
(02) BOX EX3A
(-8) BOX EX3A
(-9) EXEND - EXENDCNT

(01) [Continuous answer.]

(01) EX8 - BPENDDATE

(01) [Continuous answer.]

(01) EX8 - BPENDDATE

(01) [Continuous answer.]

(01) BOX EX3

FACILITY HAS UP-TO-DATE RECORDS THROUGH (COMPLETED RECORDS DATE)
LENGTH OF BILLING PERIOD: (LENGTH OF BILLING PERIOD.)
START WITH EARLIEST BILLING PERIOD.
EX7PCNT

EX7PRE

code one
COLLECT BILLING INFORMATION FROM (EX REFERENCE START DATE) THROUGH (EX REFERENCE
END DATE).
PRESS "1" TO CONTINUE.

BILLINFO

BPBEGDATE

FEX2

code one

BOX EX3A

routing

EX8

Date

BPENDDATE

EX8
BOX EX3A2

Date
routing

BILLDAYS

EX9

Numeric

BOX EX3

routing

Do you prefer to report billing information for all billing periods before reporting any payment
information or do you prefer to report billing and then payment information for a billing period,
then billing and payment information for each remaining billing period?
GO TO EX8 - BPBEGDATE.
ENTER THE START AND END DATES FOR THE (NEXT) BILLING PERIOD.
ENTER DATES IN "MM DD YY" FORMAT.
BP START DATE[: (BILLSTARTDATE)]
BP END DATE[: (BILLENDDATE)]
GO TO EX9 - BILLDAYS.
Between (BP START DATE) and (BP END DATE), how many days was (SP) billed for care?
PRESS F1 FOR HELP ENTERING FLAT-RATE BILLING.
IF EX9 - BILLDAYS = 0, GO TO EX33B - EXABKCT.
ELSE IF (RHDAYS = DK) OR (EX9 - BILLDAYS = RHDAYS AND (BPDAYS = EX9 - BILLDAYS OR (RHDAYS
< BPDAYS))), GO TO EX11 - BRATRATE.
ELSE IF BPDAYS = RHDAYS AND RHDAYS > EX9 - BILLDAYS, GO TO EX10 - EX10CODE.
ELSE IF (BPDAYS > EX9 - BILLDAYS AND EX9 - BILLDAYS > RHDAYS) OR (BPDAYS > RHDAYS AND
RHDAYS > EX9 - BILLDAYS) OR (BPDAYS = EX9 - BILLDAYS AND EX9 - BILLDAYS > RHDAYS), GO TO
EX10A - EX10ACOD.
ELSE GO TO EX10 - EX10CODE.

EX10CODE

EX10

Code one

(01) SP DISCHARGED TO COMMUNITY
(02) SP SENT TO HOSPITAL
Can you tell me why I have a discrepancy between the number of days in this billing period, that is,
(03) SP DECEASED
(DAYS IN BILLING PERIOD) and the number of days for which (SP) was billed, that is, (DAYS
(04) SP ADMITTED AFTER BP START
BILLED)?
DATE
(05) SP DISCHARGED TO ANOTHER NH
SELECT ALL THAT APPLY.
(91) OTHER
SEPARATE RESPONSES BY USING THE SPACEBAR.
(-8) Don't Know
(-9) Refused

EX10OS

EX10

Code one

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) BOX EX3B
(02) BOX EX3B
(03) BOX EX3B
(04) BOX EX3B
(05) BOX EX3B
(91) EX10 - EX10OS
(-8) BOX EX3B
(-9) BOX EX3B
(01) BOX EX3B

Variable Name

MR Screen Name

Question type

Question text/description

Earlier, I collected information that (SP) was a resident of this (facility/home) for (NUMBER OF
DAYS SP IN ELIGIBLE FACILITY) days during this billing period. Yet, (he/she) was billed for (DAYS
BILLED) days.
EX10ACOD

EX10A

code all

Can you tell me why I have this discrepancy?
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

EX10AOS

EX10A
BOX EX3B

verbatim
routing

OTHER (SPECIFY)
GO TO EX11 - BRATRATE
Between (BP START DATE) and (BP END DATE), what rates were billed for (SP)'s care? (I'll ask
about billing for ancillary services later.)

BRATRATE

EX11

Quantity Unit

[PROBE: If more than one rate was billed, let's start with the first rate within the billing period.]

Code list

Routing

(01) SP SENT TO HOSPITAL, BED HELD
(02) SP NOT BILLED ON ADMISSION
DAY
(03) SP NOT BILLED ON DISCHARGE
DAY
(04) SP NOT BILLED ON DATE OF
DEATH
(05) FACILITY CHARGES FLAT-RATE
BILLING
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) BOX EX3B
(02) BOX EX3B
(03) BOX EX3B
(04) BOX EX3B
(05) BOX EX3B
(91) EX10A - EX10AOS
(-8) BOX EX3B
(-9) BOX EX3B

(01) [Continuous answer.]

(01) BOX EX3B

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) EX11 - BRATUNIT
(-8) EX11 - BRATUNIT
(-9) EX11 - BRATUNIT

(01) DAY
(02) MONTH
(03) QUARTER
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(01) [Continuous answer.]

(01) EX11 - BRATDAYS
(02) EX11 - BRATDAYS
(03) EX11 - BRATDAYS
(91) EX11 - BRATUNOS
(-8) EX11 - BRATDAYS
(-9) EX11 - BRATDAYS
(01) EX11 - BRATDAYS
(01) BOX EX4

(01) Continue

(01) EX16 - ANCLPOST

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

(00) BOX EX7B
(01) EX17 - ANYANCIL
(-8) BOX EX7B
(-9) BOX EX7B

What is the amount?

BRATUNIT

EX11

Quantity Unit

Is that per day, per month, per quarter, or some other amount of time?

BRATUNOS
BRATDAYS

EX11
EX11

verbatim
Numeric

BOX EX4

routing

BOX EX5

routing

OTHER (SPECIFY)
How many days were billed at that rate?
IF ALL BILLED DAYS IN THE BILLING PERIOD HAVE BEEN ACCOUNTED FOR, GO TO BOX EX5.
ELSE GO TO BOX EX3B.
IF SP BILLED SEPARATELY FOR ANCILLARIES, GO TO EX15PRE - EX15PRCT.
ELSE GO TO BOX EX7B.
The next questions are about health-related services received by (SP) for which there was a
separate charge, that is, your (facility/home)'s ancillary services.
(Please do not include non-health-related services such as hairdressing, television, or telephone).

EX15PRCT

EX15PRE

code one
PRESS F1 FOR EXAMPLES OF NON-HEALTH-RELATED ANCILLARIES.
PRESS "1" TO CONTINUE.

ANCLPOST

EX16

yes/no

Have all charges for ancillaries been posted for the period from (BP START DATE) to (BP END
DATE)?

Variable Name

ANYANCIL

ANCILAMT

MR Screen Name

EX17

Question type

yes/no

Question text/description

Does (SP) have any ancillary charges between (BP START DATE) and (BP END DATE)?

EX18

dollar

Altogether, what was the total charge for those health-related ancillary services?

BOX EX7B

routing

RECDBASP

EX20

yes/no

ADDSOP1

EX21AA

yes/no

GO TO EX20 - RECDBASP
Have you received all of the payments for basic care you expect to receive for (SP) during the
[READ BILLING PERIOD ABOVE] billing period?
Do you need to add any Source(s) of Payment for (SP)'s basic care for [READ BILLING PERIOD
ABOVE]?

What Source(s) of Payment do you need to add for (SP)'s basic care for [READ BILLING PERIOD
ABOVE]?
PAYMPLN1

EX21AB

code all

SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
IF NO RESPONSES ARE AVAILABLE, BACK UP AND CORRECT YOUR RESPONSE.

HMOOS1
SOPOS1

EX21AB
EX21AB

verbatim
verbatim

HMO CONTRACT (SPECIFY)
OTHER (SPECIFY)

BASRATE

EX21AC

Grid

What is the total amount each source paid for [READ BILLING PERIOD ABOVE]?

BOX EX7C

routing

Code list

Routing

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

(00) BOX EX7B
(01) EX18 - ANCILAMT
(-8) BOX EX7B
(-9) BOX EX7B

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) BOX EX7B
(-8) BOX EX7B
(-9) BOX EX7B

(00) NO
(01) YES
(00) NO
(01) YES
(01) MEDICAID
(02) PRIVATE PAY OR SP/FAMILY
INCOME
(03) SOCIAL SECURITY
(04) SP/FAMILY INCOME
(05) PRIVATE INSURANCE
(06) PENSION
(07) MEDICARE
(08) VA CONTRACT
(09) HMO CONTRACT
(10) SUPPLEMENTAL SECURITY
INCOME (SSI)
(91) OTHER
(01) [Continuous answer.]
(01) [Continuous answer.]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(00) BOX EX14
(01) EX21AA - ADDSOP1
(00) EX21AC - BASRATE
(01) EX21AB - PAYMPLN1
(01) EX21AC - BASRATE
(02) EX21AC - BASRATE
(03) EX21AC - BASRATE
(04) EX21AC - BASRATE
(05) EX21AC - BASRATE
(06) EX21AC - BASRATE
(07) EX21AC - BASRATE
(08) EX21AC - BASRATE
(09) EX21AB - HMOOS1
(10) EX21AC - BASRATE
(91) EX21AB - SOPOS1
(-8) EX21AC - BASRATE
(-9) EX21AC - BASRATE
(01) EX21AC - BASRATE
(01) EX21AC - BASRATE
(01) BOX EX7C
(-8) BOX EX7C
(-9) BOX EX7C

(01) [Continuous answer.]

(01) BOX EX8

IF MEDICARE IS IDENTIFIED AS A SOURCE OF PAYMENT FOR BASIC CARE AND THERE IS NO STAY IN
A HOSPITAL BETWEEN (BP START DATE - 60 DAYS) AND (BP END DATE + 60 DAYS) AND THIS WAS
NOT EXPLAINED THIS ROUND, GO TO EX21B - VEXPTXTB.
ELSE GO TO BOX EX8.
Medicare has been reported as a payment source for basic care for (SP) for [READ BILLING PERIOD
ABOVE], but I have not recorded any preceding hospital stays for (him/her).

VEXPTXTB

EX21B

Verbatim Text

Please tell me why Medicare paid for (SP) during this billing period.
RECORD VERBATIM BELOW. IF NECESSARY, BACK UP TO CORRECT.
IF HOSPITAL STAY IS REPORTED, RECORD DATES OF STAY BELOW.

Variable Name

MR Screen Name

BOX EX8

Question type

routing

BAS10PCT

EX22

code one

BAS10POS

EX22

verbatim

BOX EX9

routing

Question text/description

Code list

Routing

(01) MEDICAID WRITEOFF/ADJUSTMENT
(02) OTHER WRITE-OFF/ADJUSTMENT
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) BOX EX9
(02) BOX EX9
(91) EX22 - BAS10POS
(-8) BOX EX9
(-9) BOX EX9

(01) [Continuous answer.]

(01) BOX EX9

(01) Continue

(01) BOX EX9AA

(01) Continue

(01) BOX EX9A BOX EX10

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) EX23B - ECAIDVR1
(-8) BOX EX10
(-9) BOX EX10

IF BPER.BASICAMT = DK, RF OR BPER.BASICPAY = DK OR ((BASICPAY >= BASICAMT*0.9) AND
(BASICPAY <= BASICAMT*1.1)) OR (MEDICAID IS A SOURCE OF PAYMENT AND (BASICPAY >=
BASICAMT*0.7) AND (BASICPAY <= BASICAMT*1.1)) OR (A WRITE-OFF WAS PREVIOUSLY
REPORTED AND EX22 - BAS10PCT WAS ASKED THIS ROUND AND (BASICPAY >= BASICAMT*0.7)
AND (BASICPAY <= BASICAMT*1.1)), GO TO BOX EX9.
ELSE GO TO EX22 - BAS10PCT.
There seems to be a difference between what (FACILITY) billed between (BP START DATE) and (BP
END DATE) and the payments received. The total amount billed I have entered for this billing
period is (TOTAL AMOUNT BILLED FOR THIS BILLING PERIOD) and the total payments for the
period are (SUM OF EX21 PAYMENTS). Why is that?
PRESS F1 FOR DEFINITION OF "MEDICAID WRITE-OFF".
OTHER (SPECIFY)
IF (MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICAID CERTIFIED
AND FACILITY HAS NEVER CONFIRMED), GO TO EX23A1 - EX23A1C.
ELSE GO TO BOX EX9AA.
I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not
certified by Medicaid but I have identified Medicaid as a payment source.
Is Medicaid indeed paying for (SP)'s care?

EX23A1C

EX23A1

code one
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

BOX EX9AA

routing

IF (MEDICARE IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICARE CERTIFED
AND FACILITY HAS NEVER CONFIRMED), GO TO EX23A2 - EX23A2C.
ELSE GO TO BOX EX9A BOX EX10.
I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not
certified by Medicare but I have identified Medicare as a payment source.
Is Medicare indeed paying for (SP)'s care?

EX23A2C

EX23A2

code one
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

BOX EX9A

ECAIDNUM

EX23A

routing

text

IF (THIS IS THE FIRST TIME MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE FOR AN SP WHOSE
MEDICAID STATUS IN THIS ROUND IS "PENDING" OR WHOSE MEDICAID NUMBER IS UNKNOWN),
GO TO EX23A - ECAIDNUM.
ELSE GO TO BOX EX11.

Please tell me (SP)'s [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] ID number.

Variable Name

ECAIDVR1

EX24AC

MR Screen Name

EX23B

Question type

yes/no

BOX EX10

routing

EX24A

code one

Question text/description
I'd like to verify the [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] ID number that I have
recorded. I have entered (MEDICAID ID NUMBER). Is this correct?

Code list

Routing

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

(00) BOX EX10
(01) BOX EX10
(-8) BOX EX10
(-9) BOX EX10

(01) Continue

(01) BOX EX11

(01) Continue

(01) BOX EX12

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

(00) EX27 - VBPETXTE
(01) BOX EX14
(-8) EX27 - VBPETXTE
(-9) BOX EX14

(01) [Continuous answer.]

(01) BOX EX14

(00) NO
(01) YES
(00) NO
(01) YES

(00) EX33B - EXABKCT
(01) EX29AA - ADDSOP2
(00) EX29AC - ANCRATE
(01) EX29AB - PAYMPLN2

IF EX23A - ECAIDNUM = DK, RF OR EX23B - ECAIDVR1 = DK, RF, IF THIS IS THE FIRST TIME
MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE FOR AN SP WHOSE MEDICAID STATUS IN THIS
ROUND IS "NO" GO TO EX24A - EX24AC.
ELSE GO TO BOX EX11.
Earlier, I recorded that (SP) was not a Medicaid recipient, but I have identified Medicaid as a
source of payment.
Is Medicaid indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.

BOX EX11

routing

IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.
IF MEDICAID IS NOT IDENTIFIED AS A PAYMENT SOURCE FOR THE CURRENT BILLING PERIOD BUT
APPEARS IN THE PRECEDING BILLING PERIOD, GO TO EX25 - EX25C.
ELSE GO TO BOX EX12.
It seems that I might have made a mistake in identifying the various sources of payment for (SP)'s
care. Earlier, I recorded that (his/her) basic charges from a previous billing period were paid by
Medicaid, and in this billing period, Medicaid is no longer a payment source.

EX25C

EX25

code

Is Medicaid indeed no longer paying for (her/his) care?
IF YES, PRESS '1' TO CONTINUE.

BOX EX12

routing

IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.
IF MEDICARE IS IDENTIFIED AS A PAYMENT SOURCE AND THE AMOUNT PAID BY MEDICARE
REPRESENTS LESS THAN 10 PERCENT OF THE TOTAL PAYMENTS RECEIVED FOR THE BILLING
PERIOD, GO TO EX26 - CAREPRTB.
ELSE GO TO BOX EX14.
Medicare's payment for this billing period represents less than 10 percent of the total payments
for basic care. Is this Medicare payment a Part B payment?

CAREPRTB

EX26

yes/no
IF NECESSARY, BACK UP TO CORRECT PAYMENTS.
Can you tell me why the Medicare payment is so small?

VBPETXTE

EX27

Verbatim Text

BOX EX14

routing

RECDANCP

EX28

yes/no

ADDSOP2

EX29AA

yes/no

RECORD VERBATIM BELOW. IF NECESSARY, BACK UP TO CORRECT PAYMENTS.
IF SP HAS ANY ANCILLARY CHARGES BETWEEN THE BILLING PERIOD START DATE AND THE BILLING
PERIOD END DATE, GO TO EX28 - RECDANCP.
ELSE GO TO EX33B - EXABKCT.
Have you received all the payments you expect to receive for (SP)'s ancillary services during the
[READ BILLING PERIOD ABOVE] billing period?
Do you need to add any Source(s) of Payment for (SP)'s ancillary services for [READ BILLING
PERIOD ABOVE]?

Variable Name

MR Screen Name

Question type

Question text/description

What Source(s) of Payment do you need to add for (SP)'s ancillary services for [READ BILLING
PERIOD ABOVE]?
PAYMPLN2

EX29AB

code all

SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
IF NO RESPONSES ARE AVAILABLE, BACK UP AND CORRECT YOUR RESPONSE.

HMOOS2
SOPOS2

EX29AB
EX29AB

Verbatim Text
Verbatim Text

HMO CONTRACT (SPECIFY)
OTHER (SPECIFY)

ANCRATE

EX29AC

Grid

What is the total amount each source paid for [READ BILLING PERIOD ABOVE]?

routing

IF EX18 - ANCILAMT = DK, RF OR BPER.ANCILPAY = DK OR ((BPER.ANCILPAY >= EX18 ANCILAMT*0.9) AND (BPER.ANCILPAY <= EX18 - ANCILAMT*1.1)) OR (MEDICAID IS A SOURCE OF
PAYMENT AND (BPER.ANCILPAY >= EX18 - ANCILAMT*0.7) AND (BPER.ANCILPAY <= EX18 ANCILAMT*1.1)) OR (A WRITE-OFF WAS PREVIOUSLY REPORTED AND EX30 - ANC10PCT WAS
ASKED THIS BP ROUND AND (BPER.ANCILPAY >= EX18 - ANCILAMT*0.7) AND (BPER.ANCILPAY <=
EX18 - ANCILAMT*1.1)), GO TO BOX EX16.
ELSE GO TO EX30 - ANC10PCT.

BOX EX15

ANC10PCT

EX30

code one

There seems to be a difference between what (FACILITY) billed for ancillary services between (BP
START DATE) and (BP END DATE) and the payments received. The total amount billed I have
entered for [READ BILLING PERIOD ABOVE] is (TOTAL AMOUNT BILLED FOR BILLING PERIOD) and
the total payments for the period are (SUM OF ANCILLARY PAYMENTS). Why is that?
PRESS F1 FOR DEFINITION OF "MEDICAID WRITE-OFF".

ANC10POS

EX31A1C

EX30

verbatim text

BOX EX16

routing

EX31A1

code one

OTHER (SPECIFY)
IF (MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICAID CERTIFIED
AND FACILITY HAS NEVER CONFIRMED), GO TO EX31A1 - EX31A1C.
ELSE GO TO BOX EX16AA.
I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not
certified by Medicaid but I have identified Medicaid as a payment source.
Is Medicaid indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

BOX EX16AA

routing

IF (MEDICARE IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICARE CERTIFED
AND FACILITY HAS NEVER CONFIRMED), GO TO EX31A2 - EX31A2C.
ELSE GO TO BOX EX16A.

Code list

Routing

(01) MEDICAID
(02) PRIVATE PAY OR SP/FAMILY
INCOME
(03) SOCIAL SECURITY
(04) SP/FAMILY INCOME
(05) PRIVATE INSURANCE
(06) PENSION
(07) MEDICARE
(08) VA CONTRACT
(09) HMO CONTRACT
(10) SUPPLEMENTAL SECURITY
INCOME (SSI)
(91) OTHER
(01) [Continuous answer.]
(01) [Continuous answer.]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) EX29AC - ANCRATE
(02) EX29AC - ANCRATE
(03) EX29AC - ANCRATE
(04) EX29AC - ANCRATE
(05) EX29AC - ANCRATE
(06) EX29AC - ANCRATE
(07) EX29AC - ANCRATE
(08) EX29AC - ANCRATE
(09) EX29AB - HMOOS2
(10) EX29AC - ANCRATE
(91) EX29AB - SOPOS2
(-8) EX29AC - ANCRATE
(-9) EX29AC - ANCRATE
(01) EX29AC - ANCRATE
(01) EX29AC - ANCRATE
(01) BOX EX15
(-8) BOX EX15
(-9) BOX EX15

(01) MEDICAID WRITEOFF/ADJUSTMENT
(02) OTHER WRITE-OFF/ADJUSTMENT
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) BOX EX16
(02) BOX EX16
(91) EX30 - ANC10POS
(-8) BOX EX16
(-9) BOX EX16

(01) [Continuous answer.]

(01) BOX EX16

(01) Continue

(01) BOX EX16AA

Variable Name

MR Screen Name

Question type

Question text/description

Code list

Routing

(01) Continue

(01) BOX EX16A

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) EX31B - ECAIDVR2
(-8) BOX EX17
(-9) BOX EX17

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

(00) BOX EX17
(01) BOX EX17
(-8) BOX EX17
(-9) BOX EX17

(01) Continue

(01) BOX EX18

(01) Continue

(01) EX33B - EXABKCT

I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not
certified by Medicare but I have identified Medicare as a payment source.
EX31A2C

EX31A2

code one

Is Medicare indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.

BOX EX16A

ECAIDNM3

ECAIDVR2

EX32AC

EX31A

EX31B

routing

text

yes/no

BOX EX17

routing

EX32A

code one

IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.
IF (THIS IS THE FIRST TIME MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE FOR AN SP WHOSE
MEDICAID STATUS IN THIS ROUND IS "PENDING" OR WHOSE MEDICAID NUMBER IS UNKNOWN),
GO TO EX31A - ECAIDNM3.
ELSE GO TO BOX EX18 BOX EX17.

Please tell me (SP)'s [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] ID number.

I'd like to verify the [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] ID number that I have
recorded. I have entered (MEDICAID ID NUMBER). Is this correct?
IF EX31A - ECAIDNM3 = DK, RF OR EX31B - ECAIDVR2 = DK, RF, IF THIS IS THE FIRST TIME
MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE FOR AN SP WHOSE MEDICAID STATUS IN THIS
ROUND IS "NO" GO TO EX32A - EX32AC.
ELSE GO TO BOX EX18.
Earlier, I recorded that (SP) was not a Medicaid recipient but I have identified Medicaid as a source
of payment.
Is Medicaid indeed paying for (SP)'s ancillaries?
IF YES, PRESS '1' TO CONTINUE.

BOX EX18

routing

IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.
IF MEDICAID IS NOT IDENTIFIED AS PAYMENT SOURCE FOR ANCILLARIES FOR THE CURRENT
BILLING PERIOD BUT APPEARS IN THE PRECEDING PERIOD (INCLUDING IF THE BILLING PERIOD
OCCURRED IN THE PREVIOUS ROUND), GO TO EX33 - EX33C.
ELSE GO TO EX33B - EXABKCT.
It seems that I might have made a mistake in identifying the various sources of payment for (SP)'s
care. Earlier, I recorded that (his/her) charges for ancillaries in a previous billing period were paid
by Medicaid, and in this billing period, Medicaid is no longer a payment source.

EX33C

EX33

code one

Is Medicaid indeed no longer paying for (his/her) ancillary services?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

Variable Name
EXABKCT

USENOLTC

MR Screen Name
EX33B

Question type
code one

BOX EX20

routing

BOX EX21

routing

EX34

yes/no

Question text/description
THIS IS THE LAST SCREEN FOR THIS BILLING PERIOD WHERE YOU CAN BACK UP TO MAKE
CORRECTIONS.

Code list

Routing

(01) Continue

(01) BOX EX20

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

(00) EX35 - VEXPTXTG
(01) BOX EX21A
(-8) BOX EX21A
(-9) BOX EX21A

(01) [Continuous answer.]

(01) BOX EX21A

(01) STILL PENDING
(02) DENIED
(-8) Don't Know
(-9) Refused

(01) EXEND - EXENDCNT
(02) EXEND - EXENDCNT
(-8) EXEND - EXENDCNT
(-9) EXEND - EXENDCNT

(01) [Continuous answer.]

(01) EX8B2 - BPENDDATE

(01) [Continuous answer.]

(01) BOX EX3A2B2

(01) [Continuous answer.]

(01) BOX EX3B2

PRESS "1" TO CONTINUE.
IF AMOUNTS BILLED FOR ALL BILLING PERIODS HAVE NOT BEEN COLLECTED, GO TO BOX EX3A.
ELSE GO TO BOX EX21.
IF PRIVATE PAY HAS NEVER BEEN REPORTED AS A SOURCE OF PAYMENT AND SP WAS COVERED
BY A LONG-TERM CARE POLICY, GO TO EX34 - USENOLTC.
ELSE GO TO BOX EX21A.
Earlier I was told that (SP) had long-term care insurance from (NAME OF FIRST LTC INSURANCE
COMPANY REPORTED). Is it correct that this policy paid for none of (his/her) care?
Can you explain this to me?

VEXPTXTG

ECAIDECO

BPBEGDATE

EX35

verbatim text

BOX EX21A

routing

IF IT IS PENDING WHETHER SP HAS BEEN COVERED BY MEDICAID FROM CRIN-1 AND MEDICAID
HAS NEVER BEEN REPORTED AS A SOURCE OF PAYMENT, GO TO EX35A - ECAIDECO.
ELSE GO TO EXEND - EXENDCNT.

EX35A

code one

The last time I was here, I collected information that (SP)'s [(PREFERRED NAME(S) FOR
MEDICAID)/MEDICAID] eligibility status was pending. Is it still pending or has [(PREFERRED
NAME(S) FOR MEDICAID)/MEDICAID] been denied?

BOX EX3AB2

routing

EX8B2

Date

RECORD VERBATIM BELOW.

GO TO EX8B2 - BPBEGDATE.
ENTER THE START AND END DATES FOR THE (NEXT) BILLING PERIOD.
BP START DATE[: (BILLSTARTDATE)]
ENTER THE START AND END DATES FOR THE (NEXT) BILLING PERIOD.

BPENDDATE

BILLDAYS

EX8B2

Date

BOX EX3A2B2

routing

EX9B2

Numeric

BOX EX3B2

routing

BP END DATE[: (BILLENDDATE)]
GO TO EX9B2 - BILLDAYS.
Between (BP START DATE) and (BP END DATE), how many days was (SP) billed for care?
PRESS F1 FOR HELP ENTERING FLAT-RATE BILLING.
IF EX9B2 - BILLDAYS = 0, THEN GO TO BOX EX6B2.
ELSE IF (RHDAYS = DK) OR (EX9B2 - BILLDAYS = RHDAYS AND (BPDAYS = EX9B2 - BILLDAYS OR
(RHDAYS < BPDAYS))), GO TO EX11B2 - BRATRATE.
ELSE IF BPDAYS = RHDAYS AND RHDAYS > EX9B2 - BILLDAYS, GO TO EX10B2 - EX10CODE.
ELSE IF (BPDAYS > EX9B2 - BILLDAYS AND EX9B2 - BILLDAYS > RHDAYS) OR (BPDAYS > RHDAYS
AND RHDAYS > EX9B2 - BILLDAYS) OR (BPDAYS = EX9B2 - BILLDAYS AND EX9B2 - BILLDAYS >
RHDAYS), GO TO EX10AB2 - EX10ACOD.
ELSE GO TO EX10B2 - EX10CODE.

Variable Name

MR Screen Name

Question type

EX10CODE

EX10B2

code all

EX10OS

EX10B2

Verbatim Text

EX10ACOD

EX10AB2

code all

EX10AOS

EX10AB2
BOX EX3BB2

Verbatim Text
routing

Question text/description

Code list
(01) SP DISCHARGED TO COMMUNITY
(02) SP SENT TO HOSPITAL
Can you tell me why I have a discrepancy between the number of days in this billing period, that is,
(03) SP DECEASED
(DAYS IN BILLING PERIOD) and the number of days for which (SP) was billed, that is, (DAYS
(04) SP ADMITTED AFTER BP START
BILLED)?
DATE
(05) SP DISCHARGED TO ANOTHER NH
SELECT ALL THAT APPLY.
(91) OTHER
SEPARATE RESPONSES BY USING THE SPACEBAR.
(-8) Don't Know
(-9) Refused

Routing

OTHER (SPECIFY)
Earlier, I collected information that (SP) was a resident of this (facility/home) for (NUMBER OF
DAYS SP IN ELIGIBLE FACILITY) days during this billing period. Yet, (he/she) was billed for (DAYS
BILLED) days.

(01) [Continuous answer.]
(01) SP SENT TO HOSPITAL, BED HELD
(02) SP NOT BILLED ON ADMISSION
DAY
(03) SP NOT BILLED ON DISCHARGE
DAY
(04) SP NOT BILLED ON DATE OF
DEATH
(05) FACILITY CHARGES FLAT-RATE
(01) [Continuous answer.]

(01) BOX EX3BB2
(01) BOX EX3BB2
(02) BOX EX3BB2
(03) BOX EX3BB2
(04) BOX EX3BB2
(05) BOX EX3BB2
(91) EX10AB2 - EX10AOS
(-8) BOX EX3BB2
(-9) BOX EX3BB2
(01) BOX EX3BB2

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) EX11B2 - BRATUNIT
(-8) EX11B2 - BRATUNIT
(-9) EX11B2 - BRATUNIT

(01) DAY
(02) MONTH
(03) QUARTER
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) EX11B2 - BRATDAYS
(02) EX11B2 - BRATDAYS
(03) EX11B2 - BRATDAYS
(91) EX11B2 - BRATUNOS
(-8) EX11B2 - BRATDAYS
(-9) EX11B2 - BRATDAYS

(01) [Continuous answer.]
(01) [Continuous answer.]

(01) EX11B2 - BRATDAYS
(01) BOX EX4B2

(01) Continue

(01) EX16B2 - ANCLPOST

Can you tell me why I have this discrepancy?
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
OTHER (SPECIFY)
GO TO EX11B2 - BRATRATE.
Between (BP START DATE) and (BP END DATE), what rates were billed for (SP)'s care? (I'll ask
about billing for ancillary services later.)

BRATRATE

EX11B2

Quantity Unit

[PROBE: If more than one rate was billed, let's start with the first rate within the billing period.]

(01) BOX EX3BB2
(02) BOX EX3BB2
(03) BOX EX3BB2
(04) BOX EX3BB2
(05) BOX EX3BB2
(91) EX10B2 - EX10OS
(-8) BOX EX3BB2
(-9) BOX EX3BB2

What is the amount?

BRATUNIT

EX11B2

Quantity Unit

Is that per day, per month, per quarter, or some other amount of time?

BRATUNOS
BRATDAYS

EX11B2
EX11B2

Quantity Unit
Quantity Unit

BOX EX4B2

routing

BOX EX5B2

routing

OTHER (SPECIFY)
How many days were billed at that rate?
IF ALL BILLED DAYS IN THE BILLING PERIOD HAVE BEEN ACCOUNTED FOR, GO TO BOX EX5B2.
ELSE GO TO BOX EX3BB2.
IF SP BILLED SEPARATELY FOR ANCILLARIES, GO TO EX15PREB2 - EX15PRCT.
ELSE GO TO BOX EX6B2.
The next questions are about health-related services received by (SP) for which there was a
separate charge, that is, your (facility/home)'s ancillary services.

EX15PRCT

EX15PREB2

code one

(Please do not include non-health-related services such as hairdressing, television, or telephone).
PRESS F1 FOR EXAMPLES OF NON-HEALTH-RELATED ANCILLARIES.
PRESS "1" TO CONTINUE.

Variable Name

ANCLPOST

ANYANCIL

ANCILAMT

MR Screen Name

EX16B2

EX17B2

EX18B2

BOX EX6B2

Question type

yes/no

Yes/No

Question text/description
Have all charges for ancillaries been posted for the period from (BP START DATE) to (BP END
DATE)?

Does (SP) have any ancillary charges between (BP START DATE) and (BP END DATE)?

dollar

Altogether, what was the total charge for those health-related ancillary services?

routing

IF AMOUNTS BILLED FOR ALL BILLING PERIODS HAVE NOT BEEN COLLECTED, GO TO BOX EX3AB2.
ELSE GO TO BOX EX6BB2.

BOX EX6BB2

routing

BOX EX7BB2

routing

RECDBASP

EX20B2

yes/no

ADDSOP1

EX21AAB2

yes/no

EX21ABB2

code all

GO TO EX20B2 - RECDBASP.
Have you received all of the payments for basic care you expect to receive for (SP) during the
[READ BILLING PERIOD ABOVE] billing period?
Do you need to add any Source(s) of Payment for (SP)'s basic care for [READ BILLING PERIOD
ABOVE]?

SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
IF NO RESPONSES ARE AVAILABLE, BACK UP AND CORRECT YOUR RESPONSE.

HMOOS1
SOPOS1

EX21ABB2
EX21ABB2

Verbatim Text
Verbatim Text

HMO CONTRACT (SPECIFY)
OTHER (SPECIFY)

BASRATE

EX21ACB2

Grid

What is the total amount each source paid for [READ BILLING PERIOD ABOVE]?

routing

IF MEDICARE IS IDENTIFIED AS A SOURCE OF PAYMENT FOR BASIC CARE AND THERE IS NO STAY IN
A HOSPITAL BETWEEN (BP START DATE - 60 DAYS) AND (BP END DATE + 60 DAYS) DATE AND THIS
WAS NOT EXPLAINED THIS ROUND, GO TO EX21BB2 - VEXPTXTB.
ELSE GO TO BOX EX8B2.

BOX EX7CB2

Routing

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

(00) BOX EX6B2
(01) EX17B2 - ANYANCIL
(-8) BOX EX6B2
(-9) BOX EX6B2

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

(00) BOX EX6B2
(01) EX18B2 - ANCILAMT
(-8) BOX EX6B2
(-9) BOX EX6B2

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) BOX EX6B2
(-8) BOX EX6B2
(-9) BOX EX6B2

(00) NO
(01) YES
(00) NO
(01) YES
(01) MEDICAID
(02) PRIVATE PAY OR SP/FAMILY
INCOME
(03) SOCIAL SECURITY
(04) SP/FAMILY INCOME
(05) PRIVATE INSURANCE
(06) PENSION
(07) MEDICARE
(08) VA CONTRACT
(09) HMO CONTRACT
(10) SUPPLEMENTAL SECURITY
INCOME (SSI)
(91) OTHER
(01) [Continuous answer.]
(01) [Continuous answer.]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(00) BOX EX14B2
(01) EX21AAB2 - ADDSOP1
(00) EX21ACB2 - BASRATE
(01) EX21ABB2 - PAYMPLN1
(01) EX21ACB2 - BASRATE
(02) EX21ACB2 - BASRATE
(03) EX21ACB2 - BASRATE
(04) EX21ACB2 - BASRATE
(05) EX21ACB2 - BASRATE
(06) EX21ACB2 - BASRATE
(07) EX21ACB2 - BASRATE
(08) EX21ACB2 - BASRATE
(09) EX21ABB2 - HMOOS1
(10) EX21ACB2 - BASRATE
(91) EX21ABB2 - SOPOS1
(-8) EX21ACB2 - BASRATE
(-9) EX21ACB2 - BASRATE
(01) EX21ACB2 - BASRATE
(01) EX21ACB2 - BASRATE
(01) BOX EX7CB2
(-8) BOX EX7CB2
(-9) BOX EX7CB2

IF THERE ARE ANY BILLING PERIODS FOR WHICH BILLED DAYS > 0 AND FOR WHICH PAYMENT
DATA HAS NOT ALREADY BEEN COLLECTED, GO TO BOX EX7BB2.
ELSE GO TO BOX EX21B2.

What Source(s) of Payment do you need to add for (SP)'s basic care for [READ BILLING PERIOD
ABOVE]?
PAYMPLN1

Code list

Variable Name

MR Screen Name

Question type

Question text/description

Code list

Routing

(01) [Continuous answer.]

(01) BOX EX8B2

(01) MEDICAID WRITEOFF/ADJUSTMENT
(02) OTHER WRITE-OFF/ADJUSTMENT
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) BOX EX9B2
(02) BOX EX9B2
(91) EX22B2 - BAS10POS
(-8) BOX EX9B2
(-9) BOX EX9B2

(01) [Continuous answer.]

(01) BOX EX9B2

(01) Continue

(01) BOX EX9AAB2

(01) Continue

(01) BOX EX9AB2 BOX 10B2

Medicare has been reported as a payment source for basic care for (SP) for [READ BILLING PERIOD
ABOVE], but I have not recorded any preceding hospital stays for (him/her).
Please tell me why Medicare paid for (SP) during this billing period.
VEXPTXTB

EX21BB2

Verbatim Text
RECORD VERBATIM BELOW. IF NECESSARY, BACK UP TO CORRECT.
IF HOSPITAL STAY IS REPORTED, RECORD DATES OF STAY BELOW.

BOX EX8B2

BAS10PCT

EX22B2

routing

code one

IF BPER.BASICAMT = DK, RF OR BPER.BASICPAY = DK OR ((BASICPAY >= BASICAMT*0.9) AND
(BASICPAY <= BASICAMT*1.1)) OR (MEDICAID IS A SOURCE OF PAYMENT AND (BASICPAY >=
BASICAMT*0.7) AND (BASICPAY <= BASICAMT*1.1)) OR (A WRITE-OFF WAS PREVIOUSLY
REPORTED AND EX22B2 - BAS10PCT WAS ASKED THIS ROUND AND (BASICPAY >= BASICAMT*0.7)
AND (BASICPAY <= BASICAMT*1.1)), GO TO BOX EX9B2.
ELSE GO TO EX22B2 - BAS10PCT.
There seems to be a difference between what (FACILITY) billed between (BP START DATE) and (BP
END DATE) and the payments received. The total amount billed I have entered for this billing
period is (TOTAL AMOUNT BILLED FOR THIS BILLING PERIOD) and the total payments for the
period are (SUM OF EX21 PAYMENTS). Why is that?
PRESS F1 FOR DEFINITION OF "MEDICAID WRITE-OFF".

BAS10POS

EX22B2

verbatim text

BOX EX9B2

routing

OTHER (SPECIFY)
IF (MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICAID CERTIFIED
AND FACILITY HAS NEVER CONFIRMED), GO TO EX23A1B2 - EX23A1B2C.
ELSE GO TO BOX EX9AAB2.
I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not
certified by Medicaid but I have identified Medicaid as a payment source.
Is Medicaid indeed paying for (SP)'s care?

EX23A1B2C

EX23A1B2

code one
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

BOX EX9AAB2

routing

IF (MEDICARE IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICARE CERTIFED
AND FACILITY HAS NEVER CONFIRMED), GO TO EX23A2B2 - EX23A2B2C.
ELSE GO TO BOX EX9AB2 BOX EX10B2.
I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not
certified by Medicare but I have identified Medicare as a payment source.

EX23A2B2C

EX23A2B2

code one

Is Medicare indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

Variable Name

MR Screen Name

BOX EX9AB2

ECAIDNUM

ECAIDVR1

EX23AB2

EX23BB2

BOX EX10B2

Question type

routing

text

yes/no

routing

Question text/description

Code list

Routing

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) EX23BB2 - ECAIDVR1
(-8)BOX EX10B2
(-9)BOX EX10B2

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

(00) BOX EX10B2
(01) BOX EX10B2
(-8) BOX EX10B2
(-9) BOX EX10B2

(01) Continue

(01) BOX EX11B2

(01) Continue

(01) BOX EX12B2

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

(00) EX27B2 - VBPETXTE
(01) BOX EX14B2
(-8) EX27B2 - VBPETXTE
(-9) BOX EX14B2

IF (THIS IS THE FIRST TIME MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE FOR AN SP WHOSE
MEDICAID STATUS IN THIS ROUND IS "PENDING" OR WHOSE MEDICAID NUMBER IS UNKNOWN),
GO TO EX23AB2 - ECAIDNUM.
ELSE GO TO BOX EX11B2.

Please tell me (SP)'s [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] ID number.

I'd like to verify the [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] ID number that I have
recorded. I have entered (MEDICAID ID NUMBER). Is this correct?
IF EX23AB2 - ECAIDNUM = DK, RF OR EX23BB2 - ECAIDVR1 = DK, RF, IF THIS IS THE FIRST TIME
MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE FOR AN SP WHOSE MEDICAID STATUS IN THIS
ROUND IS "NO" GO TO EX24AB2 - EX24AB2C.
ELSE GO TO BOX EX11B2.
Earlier, I recorded that (SP) was not a Medicaid recipient, but I have identified Medicaid as a
source of payment.

EX24AB2C

EX24AB2

code one

Is Medicaid indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.

BOX EX11B2

routing

IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.
IF MEDICAID IS NOT IDENTIFIED AS A PAYMENT SOURCE FOR THE CURRENT BILLING PERIOD BUT
APPEARS IN THE PRECEDING BILLING PERIOD, GO TO EX25B2 - EX25B2C.
ELSE GO TO BOX EX12B2.
It seems that I might have made a mistake in identifying the various sources of payment for (SP)'s
care. Earlier, I recorded that (his/her) basic charges from a previous billing period were paid by
Medicaid, and in this billing period, Medicaid is no longer a payment source.

EX25B2C

EX25B2

code one

Is Medicaid indeed no longer paying for (her/his) care?
IF YES, PRESS '1' TO CONTINUE.

BOX EX12B2

routing

IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.
IF MEDICARE IS IDENTIFIED AS A PAYMENT SOURCE AND THE AMOUNT PAID BY MEDICARE
REPRESENTS LESS THAN 10 PERCENT OF THE TOTAL PAYMENTS RECEIVED FOR THE BILLING
PERIOD, GO TO EX26B2 - CAREPRTB.
ELSE GO TO BOX EX14B2.
Medicare's payment for this billing period represents less than 10 percent of the total payments
for basic care. Is this Medicare payment a Part B payment?

CAREPRTB

EX26B2

yes/no
IF NECESSARY, BACK UP TO CORRECT PAYMENTS.

Variable Name

MR Screen Name

Question type

Question text/description

Code list

Routing

VBPETXTE

EX27B2

Verbatim Text

Can you tell me why the Medicare payment is so small?
RECORD VERBATIM BELOW. IF NECESSARY, BACK UP TO CORRECT PAYMENTS.

(01) [Continuous answer.]

(01) BOX EX14B2

(00) NO
(01) YES
(00) NO
(01) YES
(01) MEDICAID
(02) PRIVATE PAY OR SP/FAMILY
INCOME
(03) SOCIAL SECURITY
(04) SP/FAMILY INCOME
(05) PRIVATE INSURANCE
(06) PENSION
(07) MEDICARE
(08) VA CONTRACT
(09) HMO CONTRACT
(10) SUPPLEMENTAL SECURITY
INCOME (SSI)
(91) OTHER
(01) [Continuous answer.]
(01) [Continuous answer.]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(00) EX33BB2 - EXBBKCT
(01) EX29AAB2 - ADDSOP2
(00) EX29ACB2 - ANCRATE
(01) EX29ABB2 - PAYMPLN2
(01) EX29ACB2 - ANCRATE
(02) EX29ACB2 - ANCRATE
(03) EX29ACB2 - ANCRATE
(04) EX29ACB2 - ANCRATE
(05) EX29ACB2 - ANCRATE
(06) EX29ACB2 - ANCRATE
(07) EX29ACB2 - ANCRATE
(08) EX29ACB2 - ANCRATE
(09) EX29ABB2 - HMOOS2
(10) EX29ACB2 - ANCRATE
(91) EX29ABB2 - SOPOS2
(-8) EX29ACB2 - ANCRATE
(-9) EX29ACB2 - ANCRATE
(01) EX29ACB2 - ANCRATE
(01) EX29ACB2 - ANCRATE
(01) BOX EX15B2
(-8) BOX EX15B2
(-9) BOX EX15B2

(01) MEDICAID WRITEOFF/ADJUSTMENT
(02) OTHER WRITE-OFF/ADJUSTMENT
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) BOX EX16B2
(02) BOX EX16B2
(91) EX30B2 - ANC10POS
(-8) BOX EX16B2
(-9) BOX EX16B2

(01) [Continuous answer.]

(01) BOX EX16B2

BOX EX14B2

routing

RECDANCP

EX28B2

yes/no

ADDSOP2

EX29AAB2

yes/no

IF SP HAS ANY ANCILLARY CHARGES BETWEEN THE BILLING PERIOD START DATE AND THE BILLING
PERIOD END DATE, GO TO EX28B2 - RECDANCP.
ELSE GO TO EX33BB2 - EXBBKCT.
Have you received all the payments you expect to receive for (SP)'s ancillary services during the
[READ BILLING PERIOD ABOVE] billing period?
Do you need to add any Source(s) of Payment for (SP)'s ancillary services for [READ BILLING
PERIOD ABOVE]?

What Source(s) of Payment do you need to add for (SP)'s ancillary services for [READ BILLING
PERIOD ABOVE]?
PAYMPLN2

EX29ABB2

code all

SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
IF NO RESPONSES ARE AVAILABLE, BACK UP AND CORRECT YOUR RESPONSE.

HMOOS2
SOPOS2

EX29ABB2
EX29ABB2

Verbatim Text
Verbatim Text

HMO CONTRACT (SPECIFY)
OTHER (SPECIFY)

ANCRATE

EX29ACB2

Grid

What is the total amount each source paid for [READ BILLING PERIOD ABOVE]?

routing

IF EX18B2 - .ANCILAMT = DK, RF OR BPER.ANCILPAY = DK OR ((BPER.ANCILPAY >= EX18B2 ANCILAMT*0.9) AND (BPER.ANCILPAY <= EX18B2 - ANCILAMT*1.1)) OR (MEDICAID IS A SOURCE
OF PAYMENT AND (BPER.ANCILPAY >= EX18B2 - ANCILAMT*0.7) AND (BPER.ANCILPAY <= EX18B2 ANCILAMT*1.1)) OR (A WRITE-OFF WAS PREVIOUSLY REPORTED AND EX30B2 - ANC10PCT WAS
ASKED THIS BP ROUND AND (BPER.ANCILPAY >= EX18B2 - ANCILAMT*0.7) AND (BPER.ANCILPAY
<= EX18B2 - ANCILAMT*1.1)), GO TO BOX EX16B2.
ELSE GO TO EX30B2 - ANC10PCT.

BOX EX15B2

ANC10PCT

EX30B2

code one

There seems to be a difference between what (FACILITY) billed for ancillary services between (BP
START DATE) and (BP END DATE) and the payments received. The total amount billed I have
entered for [READ BILLING PERIOD ABOVE] is (TOTAL AMOUNT BILLED FOR BILLING PERIOD) and
the total payments for the period are (SUM OF ANCILLARY PAYMENTS). Why is that?
PRESS F1 FOR DEFINITION OF "MEDICAID WRITE-OFF".

ANC10POS

EX30B2

Verbatim Text

BOX EX16B2

routing

OTHER (SPECIFY)
IF (MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICAID CERTIFIED
AND FACILITY HAS NEVER CONFIRMED), GO TO EX31A1B2 - EX31A1B2C.
ELSE GO TO BOX EX16AAB2.

Variable Name

MR Screen Name

Question type

Question text/description

Code list

Routing

(01) Continue

(01) BOX EX16AAB2

(01) Continue

(01) BOX EX16AB2 BOX EX17B2

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) EX31BB2 - ECAIDVR2
(-8) BOX EX17B2
(-9) BOX EX17B2

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

(00) BOX EX17B2
(01) BOX EX17B2
(-8) BOX EX17B2
(-9) BOX EX17B2

(01) Continue

(01) BOX EX18B2

I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not
certified by Medicaid but I have identified Medicaid as a payment source.
EX31A1B2C

EX31A1B2

code one

Is Medicaid indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.

EX31A2B2C

BOX EX16AAB2

routing

EX31A2B2

code one

IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.
IF (MEDICARE IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICARE CERTIFED
AND FACILITY HAS NEVER CONFIRMED), GO TO EX31A2B2 - EX31A2B2C.
ELSE GO TO BOX EX16AB2 BOX EX17B2 .
I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not
certified by Medicare but I have identified Medicare as a payment source.
Is Medicare indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.

BOX EX16AB2

ECAIDNM3

ECAIDVR2

EX32AB2C

EX31AB2

EX31BB2

routing

text

yes/no

BOX EX17B2

routing

EX32AB2

code one

IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.
IF (THIS IS THE FIRST TIME MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE FOR AN SP WHOSE
MEDICAID STATUS IN THIS ROUND IS "PENDING" OR WHOSE MEDICAID NUMBER IS UNKNOWN),
GO TO EX31AB2 - ECAIDNM3.
ELSE GO TO BOX EX18B2.

Please tell me (SP)'s [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] ID number.

I'd like to verify the [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] ID number that I have
recorded. I have entered (MEDICAID ID NUMBER). Is this correct?
IF EX31AB2 - ECAIDNM3 = DK, RF OR EX31BB2 - ECAIDVR2 = DK, RF, IF THIS IS THE FIRST TIME
MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE FOR AN SP WHOSE MEDICAID STATUS IN THIS
ROUND IS "NO" GO TO EX32AB2 - EX32AB2C.
ELSE GO TO BOX EX18B2.
Earlier, I recorded that (SP) was not a Medicaid recipient but I have identified Medicaid as a source
of payment.
Is Medicaid indeed paying for (SP)'s ancillaries?
IF YES, PRESS '1' TO CONTINUE.

BOX EX18B2

routing

IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.
IF MEDICAID IS NOT IDENTIFIED AS PAYMENT SOURCE FOR ANCILLARIES FOR THE CURRENT
BILLING PERIOD BUT APPEARS IN THE PRECEDING PERIOD (INCLUDING IF THE BILLING PERIOD
OCCURRED IN THE PREVIOUS ROUND), GO TO EX33B2 - EX33B2C.
ELSE GO TO EX33BB2 - EXBBKCT.

Variable Name

MR Screen Name

Question type

Question text/description

Code list

Routing

(01) Continue

(01) EX33BB2 - EXBBKCT

(01) Continue

(01) BOX EX20B2

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

(00) EX35B2 - VEXPTXTG
(01) BOX EX21AB2
(-8) BOX EX21AB2
(-9) BOX EX21AB2

(01) [Continuous answer.]

(01) BOX EX21AB2

(01) STILL PENDING
(02) DENIED
(-8) Don't Know
(-9) Refused

(01) EXEND - EXENDCNT
(02) EXEND - EXENDCNT
(-8) EXEND - EXENDCNT
(-9) EXEND - EXENDCNT

(01) Continue

(01) BOX EXEND

It seems that I might have made a mistake in identifying the various sources of payment for (SP)'s
care. Earlier, I recorded that (his/her) charges for ancillaries in a previous billing period were paid
by Medicaid, and in this billing period, Medicaid is no longer a payment source.
EX33B2C

EX33B2

code one

Is Medicaid indeed no longer paying for (his/her) ancillary services?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.
THIS IS THE LAST SCREEN FOR THIS BILLING PERIOD .

EXBBKCT

EX33BB2

code one

BOX EX20B2

routing

BOX EX21B2

routing

USENOLTC

EX34B2

yes/no

VEXPTXTG

EX35B2

Verbatim Text

BOX EX21AB2

routing

ECAIDECO

EX35AB2

code one

PRESS "1" TO CONTINUE.
IF THERE ARE ANY ADDITIONAL BILLING PERIODS FOR WHICH BILLED DAYS > 0 AND FOR WHICH
PAYMENT DATA HAS NOT ALREADY BEEN COLLECTED, GO TO BOX EX7BB2.
ELSE GO TO BOX EX21B2.
IF PRIVATE PAY HAS NEVER BEEN REPORTED AS A SOURCE OF PAYMENT AND SP WAS COVERED
BY A LONG-TERM CARE POLICY, GO TO EX34B2 - USENOLTC.
ELSE GO TO BOX EX21AB2.
Earlier I was told that (SP) had long-term care insurance from (NAME OF FIRST LTC INSURANCE
COMPANY REPORTED). Is it correct that this policy paid for none of (his/her) care?
Can you explain this to me?
RECORD VERBATIM BELOW.
IF IT IS PENDING WHETHER SP HAS BEEN COVERED BY MEDICAID FROM CRIN-1 AND MEDICAID
HAS NEVER BEEN REPORTED AS A SOURCE OF PAYMENT, GO TO EX35AB2 - ECAIDECO.
ELSE GO TO EXEND - EXENDCNT.
The last time I was here, I collected information that (SP)'s [(PREFERRED NAME(S) FOR
MEDICAID)/MEDICAID] eligibility status was pending. Is it still pending or has [(PREFERRED
NAME(S) FOR MEDICAID)/MEDICAID] been denied?
(Thank you for your time, I will need to talk to this person to complete these questions.)
(YOU HAVE COMPLETED THE EXPENDITURES SECTION FOR THIS SP.)

EXENDCNT

EXEND

code one
PRESS "1" TO RETURN TO NAVIGATION SCREEN.

BOX EXEND

routing

GO TO NAVIGATOR