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pdf2021 MCBS Facility Instrument
Variable Name
MR Screen Name
EX- Expenditures
Question Type
Question Text/Description
Code List
Routing
(01) Continue
(01) BOX EXS2
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
routing
IF COST DATA FROM THE PREVIOUS ROUND REMAINS TO BE COLLECTED, GO TO BOX EXS1A.
ELSE GO TO BOX EXBEG.
BOX EXS1A
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
routing
If PreloadBPRO.ANCLPOST = 0/No, DK, GO TO EX16S1 - ANCLPOST.
ELSE GO TO EX17S1 - ANYANCIL.
ANCLPOST
EX16S1
yes/no
Have all charges for ancillaries been posted for the period from (BP START DATE) to (BP END DATE)?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX EX7BS1
(01) EX17S1 - ANYANCIL
(-8) BOX EX7BS1
(-9) BOX EX7BS1
ANYANCIL
EX17S1
yes/no
Does (SP) have any ancillary charges between (BP START DATE) and (BP END DATE)?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX EX7BS1
(01) EX18S1 - ANCILAMT
(-8) BOX EX7BS1
(-9) BOX EX7BS1
ANCILAMT
EX18S1
dollar
Altogether, what was the total charge for those health-related ancillary services?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) BOX EX7BS1
(-8) BOX EX7BS1
(-9) BOX EX7BS1
BASSMINT
EX20S1PRE
code one
The next questions are about (SP)'s expenditures for room and board while a resident of (FACILITY).
(01) Continue
(01) BOX EX7BS1
BOX EX7BS1
routing
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.
RECDBASP
EX20S1
yes/no
Have you received all of the payments for basic care you expect to receive for (SP) during the [READ BILLING
PERIOD ABOVE] billing period?
(00) NO
(01) YES
(00) BOX EX14S1
(01) EX21AAS1 - ADDSOP1
ADDSOP1
EX21AAS1
yes/no
Do you need to add any Source(s) of Payment for (SP)'s basic care for [READ BILLING PERIOD ABOVE]?
(00) NO
(01) YES
(00) EX21ACS1 - BASRATE
(01) EX21ABS1 - PAYMPLN1
(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) 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
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
EX21ABS1
verbatim
HMO CONTRACT (SPECIFY)
(01) [Continuous answer.]
(01) EX21ACS1 - BASRATE
SOPOS1
EX21ABS1
verbatim
OTHER (SPECIFY)
(01) [Continuous answer.]
(01) EX21ACS1 - BASRATE
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) BOX EX7CS1
(-8) BOX EX7CS1
(-9) BOX EX7CS1
BASRATE
EX21ACS1
Grid
What is the total amount each source paid for [READ BILLING PERIOD ABOVE]?
BOX EX7CS1
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) AND THIS WAS NOT
EXPLAINED THIS ROUND, GO TO EX21BS1 - VEXPTXTB.
ELSE GO TO BOX EX8S1.
Page 1 of 15
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
EX- Expenditures
Question Type
Question Text/Description
Code List
Routing
(01) [Continuous answer.]
(01) BOX EX8S1
(01) MEDICAID WRITE-OFF/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
(01) Continue
(01) BOX EX9AAS1
(01) Continue
(01) BOX EX10S1
(01) Continue
(01) BOX EX11S1
(01) Continue
(01) BOX EX12S1
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
EX21BS1
verbatim
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.
BOX EX8S1
routing
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?
BAS10PCT
EX22S1
code one
BAS10POS
EX22S1
verbatim
OTHER (SPECIFY)
routing
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.
PRESS F1 FOR DEFINITION OF "MEDICAID WRITE-OFF".
BOX EX9S1
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
EX23A1S1
code one
Is Medicaid indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.
BOX EX9AAS1
routing
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 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.
EX23A2S1C
EX23A2S1
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 EX10S1
routing
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
code one
Is Medicaid indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.
BOX EX11S1
routing
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.
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.
Page 2 of 15
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
EX- Expenditures
Question Type
Question Text/Description
BOX EX12S1
routing
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.
CAREPRTB
EX26S1
yes/no
Medicare's payment for this billing period represents less than 10 percent of the total payments for basic care. Is (00) NO
this Medicare payment a Part B payment?
(01) YES
(-8) Don't Know
IF NECESSARY, BACK UP TO CORRECT PAYMENTS.
(-9) Refused
VBPETXTE
EX27S1
verbatim
BOX EX14S1
routing
IF PreloadBPRO.RECDANCP = 0/No or EX17S1 – ANYANCIL = 1/Yes, GO TO EX28S1 - RECDANCP.
ELSE GO TO EX33BS1 - EXSBKCT.
RECDANCP
EX28S1
yes/no
Have you received all the payments you expect to receive for (SP)'s ancillary services during the [READ BILLING (00) NO
PERIOD ABOVE] billing period?
(01) YES
(00) EX33BS1 - EXSBKCT
(01) EX29AAS1 - ADDSOP2
ADDSOP2
EX29AAS1
yes/no
Do you need to add any Source(s) of Payment for (SP)'s ancillary services for [READ BILLING PERIOD
ABOVE]?
(00) NO
(01) YES
(00) EX29ACS1 - ANCRATE
(01) EX29ABS1 - PAYMPLN2
(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) 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
Can you tell me why the Medicare payment is so small?
RECORD VERBATIM BELOW. IF NECESSARY, BACK UP TO CORRECT PAYMENTS.
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.
Code List
(01) [Continuous answer.]
Routing
(00) EX27S1 - VBPETXTE
(01) BOX EX14S1
(-8) EX27S1 - VBPETXTE
(-9) BOX EX14S1
(01) BOX EX14S1
HMOOS2
EX29ABS1
verbatim
HMO CONTRACT (SPECIFY)
(01) [Continuous answer.]
SOPOS2
EX29ABS1
verbatim
OTHER (SPECIFY)
(01) [Continuous answer.]
(01) EX29ACS1 - ANCRATE
Grid
What is the total amount each source paid for [READ BILLING PERIOD ABOVE]?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) BOX EX15S1
(-8) BOX EX15S1
(-9) BOX EX15S1
BOX EX15S1
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 WRITEOFF 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.
ANC10PCT
EX30S1
code one
(01) MEDICAID WRITE-OFF/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
ANC10POS
EX30S1
verbatim
OTHER (SPECIFY)
(01) [Continuous answer.]
(01) BOX EX16S1
routing
(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.
(01) Continue
(01) BOX EX16AAS1
ANCRATE
EX29ACS1
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".
BOX EX16S1
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 EX17S1.
Page 3 of 15
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
EX- Expenditures
Question Type
Question Text/Description
Code List
Routing
(01) Continue
(01) BOX EX17S1
(01) Continue
(01) BOX EX18S1
(01) Continue
(01) EX33BS1 - EXSBKCT
(01) Continue
(01) BOX EX20S1
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?
(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
(01) Continue
(01) EX2 - ANYBASIC
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 EX17S1
routing
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.
EX32AS1C
EX32AS1
code one
Is Medicaid indeed paying for (SP)'s ancillaries?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.
BOX EX18S1
routing
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
THIS IS THE LAST SCREEN FOR THIS BILLING PERIOD WHERE YOU CAN BACK UP TO MAKE
CORRECTIONS.
PRESS "1" TO CONTINUE.
BOX EX20S1
routing
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.
BOX EX21S1
routing
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.
EX34S1
VEXPTXTG
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.
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).
EX1PRECT
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.
Page 4 of 15
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
EX- Expenditures
Question Type
Question Text/Description
The following questions are about (SP)'s basic care between (EX REFERENCE START DATE) and (EX
REFERENCE END DATE).
ANYBASIC
EX2
yes/no
EX2ANAME
EX2A
roster
VEXPTXTA
EX3
verbatim
Was there a charge for (her/his) room and board and basic care between (EX REFERENCE START DATE) and
(EX REFERENCE END DATE)? Please include any charges to (SP), (her/his) family, or a third party, such as
Medicaid, Medicare, or a legal guardian.
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.
Why were there no charges?
IF ANSWER IS "MEDICAID PAID", BACK UP TO EX2 AND ENTER "1".
Code List
Routing
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(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
RECORD VERBATIM.
BOX EX1A
ANCILSEP
EX4
routing
yes/no
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.
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
COMRECDD
EX5
date
DAY
(01) [Continuous answer.]
(01) EX5 - COMRECYY
COMRECYY
EX5
date
YEAR
(01) [Continuous answer.]
(01) BOX EX2AA
BOX EX2AA
routing
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…
(01) monthly,
(02) every two weeks,
(03) every week, or
(04) quarterly?
(91) OTHER
(01) BOX EX2AA1
(02) BOX EX2AA1
(03) BOX EX2AA1
(04) BOX EX2AA1
(91) EX6 - BPLNCROS
BPLNCROS
EX6
verbatim
OTHER (SPECIFY)
(01) [Continuous answer.]
(01) BOX EX2AA1
BOX EX2AA1
routing
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.
(01) Continue
(01) FEX2 - BILLINFO
MONTH
FACILITY HAS UP-TO-DATE RECORDS THROUGH (COMPLETED RECORDS DATE)
EX7PCNT
EX7PRE
code one
LENGTH OF BILLING PERIOD: (LENGTH OF BILLING PERIOD.)
START WITH EARLIEST BILLING PERIOD.
COLLECT BILLING INFORMATION FROM (EX REFERENCE START DATE) THROUGH (EX REFERENCE
END DATE).
PRESS "1" TO CONTINUE.
BILLINFO
BPBEGDATE
FEX2
code one
(01) ALL BILLING AND THEN ALL PAYMENT
INFORMATION
Do you prefer to report billing information for all billing periods before reporting any payment information or do
(02) BILLING AND PAYMENT INFORMATION BY
you prefer to report billing and then payment information for a billing period, then billing and payment information
BILLING PERIOD
for each remaining billing period?
(-8) Don't Know
(-9) Refused
BOX EX3A
routing
GO TO EX8 - BPBEGDATE.
EX8
Date
ENTER THE START AND END DATES FOR THE (NEXT) BILLING PERIOD.
ENTER DATES IN "MM DD YY" FORMAT.
(01) BOX EX3AB2
(02) BOX EX3A
(-8) BOX EX3A
(-9) EXEND - EXENDCNT
(01) [Continuous answer.]
(01) EX8 - BPENDDATE
(01) [Continuous answer.]
(01) BOX EX3A2
BP START DATE[: (BILLSTARTDATE)]
BPENDDATE
EX8
Date
BP END DATE[: (BILLENDDATE)]
BOX EX3A2
routing
GO TO EX9 - BILLDAYS.
Page 5 of 15
2021 MCBS Facility Instrument
Variable Name
BILLDAYS
MR Screen Name
EX9
BOX EX3
EX- Expenditures
Question Type
Numeric
routing
EX10CODE
EX10
Code one
EX10OS
EX10
Code one
Question Text/Description
Between (BP START DATE) and (BP END DATE), how many days was (SP) billed for care?
PRESS F1 FOR HELP ENTERING FLAT-RATE BILLING.
EX10A
code all
Can you tell me why I have a discrepancy between the number of days in this billing period, that is, (DAYS IN
BILLING PERIOD) and the number of days for which (SP) was billed, that is, (DAYS BILLED)?
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
OTHER (SPECIFY)
Can you tell me why I have this discrepancy?
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
EX10AOS
EX10A
verbatim
OTHER (SPECIFY)
BOX EX3B
routing
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
Routing
(01) [Continuous answer.]
(01) BOX EX3
(01) SP DISCHARGED TO COMMUNITY
(02) SP SENT TO HOSPITAL
(03) SP DECEASED
(04) SP ADMITTED AFTER BP START DATE
(05) SP DISCHARGED TO ANOTHER NH
(91) OTHER
(-8) Don't Know
(-9) Refused
(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) [Continuous answer.]
(01) BOX EX3B
(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) EX11 - BRATDAYS
(02) EX11 - BRATDAYS
(03) EX11 - BRATDAYS
(91) EX11 - BRATUNOS
(-8) EX11 - BRATDAYS
(-9) EX11 - BRATDAYS
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.
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
Code List
[PROBE: If more than one rate was billed, let's start with the first rate within the billing period.]
What is the amount?
BRATUNIT
EX11
Quantity Unit
Is that per day, per month, per quarter, or some other amount of time?
(01) DAY
(02) MONTH
(03) QUARTER
(91) OTHER
(-8) Don't Know
(-9) Refused
BRATUNOS
EX11
verbatim
OTHER (SPECIFY)
(01) [Continuous answer.]
(01) EX11 - BRATDAYS
BRATDAYS
EX11
Numeric
How many days were billed at that rate?
(01) [Continuous answer.]
(01) BOX EX4
BOX EX4
routing
IF ALL BILLED DAYS IN THE BILLING PERIOD HAVE BEEN ACCOUNTED FOR, GO TO BOX EX5.
ELSE GO TO BOX EX3B.
BOX EX5
routing
IF SP BILLED SEPARATELY FOR ANCILLARIES, GO TO EX15PRE - EX15PRCT.
ELSE GO TO BOX EX7B.
(01) Continue
(01) EX16 - ANCLPOST
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
EX15PRE
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.
ANCLPOST
EX16
yes/no
Have all charges for ancillaries been posted for the period from (BP START DATE) to (BP END DATE)?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX EX7B
(01) EX17 - ANYANCIL
(-8) BOX EX7B
(-9) BOX EX7B
ANYANCIL
EX17
yes/no
Does (SP) have any ancillary charges between (BP START DATE) and (BP END DATE)?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX EX7B
(01) EX18 - ANCILAMT
(-8) BOX EX7B
(-9) BOX EX7B
Page 6 of 15
2021 MCBS Facility Instrument
Variable Name
ANCILAMT
MR Screen Name
EX- Expenditures
Question Type
Question Text/Description
Code List
Routing
Altogether, what was the total charge for those health-related ancillary services?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) BOX EX7B
(-8) BOX EX7B
(-9) BOX EX7B
EX18
dollar
BOX EX7B
routing
GO TO EX20 - RECDBASP
(00) NO
(01) YES
(00) BOX EX14
(01) EX21AA - ADDSOP1
(00) NO
(01) YES
(00) EX21AC - BASRATE
(01) EX21AB - PAYMPLN1
(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) 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
RECDBASP
EX20
yes/no
Have you received all of the payments for basic care you expect to receive for (SP) during the [READ BILLING
PERIOD ABOVE] billing period?
ADDSOP1
EX21AA
yes/no
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
EX21AB
verbatim
HMO CONTRACT (SPECIFY)
(01) [Continuous answer.]
(01) EX21AC - BASRATE
SOPOS1
EX21AB
verbatim
OTHER (SPECIFY)
(01) [Continuous answer.]
(01) EX21AC - BASRATE
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) BOX EX7C
(-8) BOX EX7C
(-9) BOX EX7C
(01) [Continuous answer.]
(01) BOX EX8
BASRATE
EX21AC
Grid
What is the total amount each source paid for [READ BILLING PERIOD ABOVE]?
BOX EX7C
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) 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.
BOX EX8
routing
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.
BAS10PCT
EX22
code one
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".
(01) MEDICAID WRITE-OFF/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
BAS10POS
EX22
verbatim
OTHER (SPECIFY)
(01) [Continuous answer.]
(01) BOX EX9
BOX EX9
routing
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.
(01) Continue
(01) 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.
EX23A1C
EX23A1
code one
Is Medicaid indeed paying for (SP)'s care?
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 EX10.
Page 7 of 15
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
EX- Expenditures
Question Type
Question Text/Description
Code List
Routing
(01) Continue
(01) BOX EX10
(01) Continue
(01) BOX EX11
(01) Continue
(01) BOX EX12
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.
EX23A2C
EX23A2
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 EX10
routing
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.
EX24AC
EX24A
code one
Is Medicaid indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.
BOX EX11
routing
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.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.
BOX EX12
routing
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.
CAREPRTB
EX26
yes/no
Medicare's payment for this billing period represents less than 10 percent of the total payments for basic care. Is (00) NO
this Medicare payment a Part B payment?
(01) YES
(-8) Don't Know
IF NECESSARY, BACK UP TO CORRECT PAYMENTS.
(-9) Refused
VBPETXTE
EX27
Verbatim Text
BOX EX14
routing
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.
RECDANCP
EX28
yes/no
Have you received all the payments you expect to receive for (SP)'s ancillary services during the [READ BILLING (00) NO
PERIOD ABOVE] billing period?
(01) YES
(00) EX33B - EXABKCT
(01) EX29AA - ADDSOP2
ADDSOP2
EX29AA
yes/no
Do you need to add any Source(s) of Payment for (SP)'s ancillary services for [READ BILLING PERIOD
ABOVE]?
(00) NO
(01) YES
(00) EX29AC - ANCRATE
(01) EX29AB - PAYMPLN2
(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) 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
Can you tell me why the Medicare payment is so small?
RECORD VERBATIM BELOW. IF NECESSARY, BACK UP TO CORRECT PAYMENTS.
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.
(01) [Continuous answer.]
(00) EX27 - VBPETXTE
(01) BOX EX14
(-8) EX27 - VBPETXTE
(-9) BOX EX14
(01) BOX EX14
Page 8 of 15
2021 MCBS Facility Instrument
EX- Expenditures
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
HMOOS2
EX29AB
Verbatim Text
HMO CONTRACT (SPECIFY)
(01) [Continuous answer.]
(01) EX29AC - ANCRATE
SOPOS2
EX29AB
Verbatim Text
OTHER (SPECIFY)
(01) [Continuous answer.]
(01) EX29AC - ANCRATE
Grid
What is the total amount each source paid for [READ BILLING PERIOD ABOVE]?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) BOX EX15
(-8) BOX EX15
(-9) BOX EX15
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.
(01) MEDICAID WRITE-OFF/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
(01) Continue
(01) BOX EX17
(01) Continue
(01) BOX EX18
(01) Continue
(01) EX33B - EXABKCT
ANCRATE
EX29AC
BOX EX15
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?
ANC10PCT
EX30
code one
ANC10POS
EX30
verbatim text
OTHER (SPECIFY)
routing
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.
PRESS F1 FOR DEFINITION OF "MEDICAID WRITE-OFF".
BOX EX16
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.
EX31A1C
EX31A1
code one
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 EX 17.
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.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.
BOX EX17
routing
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.
EX32AC
EX32A
code one
Is Medicaid indeed paying for (SP)'s ancillaries?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.
BOX EX18
routing
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.
Page 9 of 15
2021 MCBS Facility Instrument
Variable Name
EXABKCT
MR Screen Name
EX33B
EX- Expenditures
Question Type
code one
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) SP DISCHARGED TO COMMUNITY
(02) SP SENT TO HOSPITAL
(03) SP DECEASED
(04) SP ADMITTED AFTER BP START DATE
(05) SP DISCHARGED TO ANOTHER NH
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) BOX EX3BB2
(02) BOX EX3BB2
(03) BOX EX3BB2
(04) BOX EX3BB2
(05) BOX EX3BB2
(91) EX10B2 - EX10OS
(-8) BOX EX3BB2
(-9) BOX EX3BB2
(01) [Continuous answer.]
(01) BOX EX3BB2
(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 EX3BB2
(02) BOX EX3BB2
(03) BOX EX3BB2
(04) BOX EX3BB2
(05) BOX EX3BB2
(91) EX10AB2 - EX10AOS
(-8) BOX EX3BB2
(-9) BOX EX3BB2
(01) [Continuous answer.]
(01) BOX EX3BB2
PRESS "1" TO CONTINUE.
BOX EX20
routing
IF AMOUNTS BILLED FOR ALL BILLING PERIODS HAVE NOT BEEN COLLECTED, GO TO BOX EX3A.
ELSE GO TO BOX EX21.
BOX EX21
routing
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.
USENOLTC
EX34
yes/no
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?
VEXPTXTG
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
ECAIDECO
Can you explain this to me?
RECORD VERBATIM BELOW.
GO TO EX8B2 - BPBEGDATE.
ENTER THE START AND END DATES FOR THE (NEXT) BILLING PERIOD.
BPBEGDATE
EX8B2
Date
BPENDDATE
EX8B2
Date
BOX EX3A2B2
routing
GO TO EX9B2 - BILLDAYS.
routing
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.
BOX EX3B2
EX10CODE
EX10B2
code all
EX10OS
EX10B2
Verbatim Text
BP START DATE[: (BILLSTARTDATE)]
ENTER THE START AND END DATES FOR THE (NEXT) BILLING PERIOD.
BP END DATE[: (BILLENDDATE)]
Can you tell me why I have a discrepancy between the number of days in this billing period, that is, (DAYS IN
BILLING PERIOD) and the number of days for which (SP) was billed, that is, (DAYS BILLED)?
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
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.
EX10ACOD
EX10AB2
code all
Can you tell me why I have this discrepancy?
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
EX10AOS
EX10AB2
Verbatim Text
OTHER (SPECIFY)
BOX EX3BB2
routing
GO TO EX11B2 - BRATRATE.
Page 10 of 15
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
EX- Expenditures
Question Type
Question Text/Description
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.]
Code List
Routing
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) EX11B2 - BRATUNIT
(-8) EX11B2 - BRATUNIT
(-9) EX11B2 - BRATUNIT
(01) EX11B2 - BRATDAYS
(02) EX11B2 - BRATDAYS
(03) EX11B2 - BRATDAYS
(91) EX11B2 - BRATUNOS
(-8) EX11B2 - BRATDAYS
(-9) EX11B2 - BRATDAYS
What is the amount?
BRATUNIT
EX11B2
Quantity Unit
Is that per day, per month, per quarter, or some other amount of time?
(01) DAY
(02) MONTH
(03) QUARTER
(91) OTHER
(-8) Don't Know
(-9) Refused
BRATUNOS
EX11B2
Quantity Unit
OTHER (SPECIFY)
(01) [Continuous answer.]
(01) EX11B2 - BRATDAYS
BRATDAYS
EX11B2
Quantity Unit
How many days were billed at that rate?
(01) [Continuous answer.]
(01) BOX EX4B2
BOX EX4B2
routing
IF ALL BILLED DAYS IN THE BILLING PERIOD HAVE BEEN ACCOUNTED FOR, GO TO BOX EX5B2.
ELSE GO TO BOX EX3BB2.
BOX EX5B2
routing
IF SP BILLED SEPARATELY FOR ANCILLARIES, GO TO EX15PREB2 - EX15PRCT.
ELSE GO TO BOX EX6B2.
(01) Continue
(01) EX16B2 - ANCLPOST
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.
ANCLPOST
EX16B2
yes/no
Have all charges for ancillaries been posted for the period from (BP START DATE) to (BP END DATE)?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX EX6B2
(01) EX17B2 - ANYANCIL
(-8) BOX EX6B2
(-9) BOX EX6B2
ANYANCIL
EX17B2
Yes/No
Does (SP) have any ancillary charges between (BP START DATE) and (BP END DATE)?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX EX6B2
(01) EX18B2 - ANCILAMT
(-8) BOX EX6B2
(-9) BOX EX6B2
ANCILAMT
EX18B2
dollar
Altogether, what was the total charge for those health-related ancillary services?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) BOX EX6B2
(-8) BOX EX6B2
(-9) BOX EX6B2
BOX EX6B2
routing
IF AMOUNTS BILLED FOR ALL BILLING PERIODS HAVE NOT BEEN COLLECTED, GO TO BOX EX3AB2.
ELSE GO TO BOX EX6BB2.
BOX EX6BB2
routing
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.
BOX EX7BB2
routing
GO TO EX20B2 - RECDBASP.
(00) NO
(01) YES
(00) BOX EX14B2
(01) EX21AAB2 - ADDSOP1
(00) NO
(01) YES
(00) EX21ACB2 - BASRATE
(01) EX21ABB2 - PAYMPLN1
(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) 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) [Continuous answer.]
(01) EX21ACB2 - BASRATE
RECDBASP
EX20B2
yes/no
Have you received all of the payments for basic care you expect to receive for (SP) during the [READ BILLING
PERIOD ABOVE] billing period?
ADDSOP1
EX21AAB2
yes/no
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
EX21ABB2
code all
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
IF NO RESPONSES ARE AVAILABLE, BACK UP AND CORRECT YOUR RESPONSE.
HMOOS1
EX21ABB2
Verbatim Text
HMO CONTRACT (SPECIFY)
Page 11 of 15
2021 MCBS Facility Instrument
EX- Expenditures
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
SOPOS1
EX21ABB2
Verbatim Text
OTHER (SPECIFY)
(01) [Continuous answer.]
(01) EX21ACB2 - BASRATE
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) BOX EX7CB2
(-8) BOX EX7CB2
(-9) BOX EX7CB2
(01) [Continuous answer.]
(01) BOX EX8B2
(01) MEDICAID WRITE-OFF/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 10B2
(01) Continue
(01) BOX EX11B2
BASRATE
EX21ACB2
Grid
What is the total amount each source paid for [READ BILLING PERIOD ABOVE]?
BOX EX7CB2
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.
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
EX21BB2
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.
BOX EX8B2
routing
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?
BAS10PCT
EX22B2
code one
BAS10POS
EX22B2
verbatim text
OTHER (SPECIFY)
BOX EX9B2
routing
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.
PRESS F1 FOR DEFINITION OF "MEDICAID WRITE-OFF".
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.
EX23A1B2C
EX23A1B2
code one
Is Medicaid indeed paying for (SP)'s care?
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 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.
BOX EX10B2
routing
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.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.
Page 12 of 15
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
BOX EX11B2
EX- Expenditures
Question Type
Question Text/Description
routing
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.
Code List
Routing
(01) Continue
(01) 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.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.
BOX EX12B2
routing
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.
CAREPRTB
EX26B2
yes/no
Medicare's payment for this billing period represents less than 10 percent of the total payments for basic care. Is (00) NO
this Medicare payment a Part B payment?
(01) YES
(-8) Don't Know
IF NECESSARY, BACK UP TO CORRECT PAYMENTS.
(-9) Refused
(00) EX27B2 - VBPETXTE
(01) BOX EX14B2
(-8) EX27B2 - VBPETXTE
(-9) BOX EX14B2
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) BOX EX14B2
BOX EX14B2
routing
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.
RECDANCP
EX28B2
yes/no
Have you received all the payments you expect to receive for (SP)'s ancillary services during the [READ BILLING (00) NO
PERIOD ABOVE] billing period?
(01) YES
(00) EX33BB2 - EXBBKCT
(01) EX29AAB2 - ADDSOP2
ADDSOP2
EX29AAB2
yes/no
Do you need to add any Source(s) of Payment for (SP)'s ancillary services for [READ BILLING PERIOD
ABOVE]?
(00) NO
(01) YES
(00) EX29ACB2 - ANCRATE
(01) EX29ABB2 - PAYMPLN2
(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) 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
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.
(01) [Continuous answer.]
HMOOS2
EX29ABB2
Verbatim Text
HMO CONTRACT (SPECIFY)
(01) [Continuous answer.]
(01) EX29ACB2 - ANCRATE
SOPOS2
EX29ABB2
Verbatim Text
OTHER (SPECIFY)
(01) [Continuous answer.]
(01) EX29ACB2 - ANCRATE
Grid
What is the total amount each source paid for [READ BILLING PERIOD ABOVE]?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) BOX EX15B2
(-8) BOX EX15B2
(-9) BOX EX15B2
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.
(01) MEDICAID WRITE-OFF/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
ANCRATE
EX29ACB2
BOX EX15B2
ANC10PCT
EX30B2
code one
ANC10POS
EX30B2
Verbatim Text
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".
OTHER (SPECIFY)
Page 13 of 15
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
BOX EX16B2
EX- Expenditures
Question Type
Question Text/Description
routing
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.
Code List
Routing
(01) Continue
(01) BOX EX16AAB2
(01) Continue
(01) BOX EX17B2
(01) Continue
(01) BOX EX18B2
(01) Continue
(01) EX33BB2 - EXBBKCT
(01) Continue
(01) BOX EX20B2
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.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.
BOX EX16AAB2
routing
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 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.
EX31A2B2C
EX31A2B2
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 EX17B2
routing
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.
EX32AB2C
EX32AB2
code one
Is Medicaid indeed paying for (SP)'s ancillaries?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.
BOX EX18B2
routing
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.
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.
EXBBKCT
THIS IS THE LAST SCREEN FOR THIS BILLING PERIOD .
EX33BB2
code one
BOX EX20B2
routing
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.
BOX EX21B2
routing
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.
USENOLTC
EX34B2
yes/no
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?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) EX35B2 - VEXPTXTG
(01) BOX EX21AB2
(-8) BOX EX21AB2
(-9) BOX EX21AB2
VEXPTXTG
EX35B2
Verbatim Text
Can you explain this to me?
RECORD VERBATIM BELOW.
(01) [Continuous answer.]
(01) BOX EX21AB2
PRESS "1" TO CONTINUE.
Page 14 of 15
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
EX- Expenditures
Question Type
Question Text/Description
BOX EX21AB2
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 EX35AB2 - ECAIDECO.
ELSE GO TO EXEND - EXENDCNT.
ECAIDECO
EX35AB2
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?
EXENDCNT
EXEND
code one
(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.
Code List
Routing
(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
PRESS "1" TO RETURN TO NAVIGATION SCREEN.
BOX EXEND
routing
GO TO NAVIGATOR
Page 15 of 15
| File Type | application/pdf |
| File Title | Medicare Current Beneficiary Survey Section Specifications for EX |
| Subject | Medicare beneficiaries, MCBS facility instrument, 2021, Expenditures, EX |
| Author | NORC |
| File Modified | 2021-09-08 |
| File Created | 2021-09-03 |