OBPAEXOT
Annual total of direct health care payments from all other sources to office-based physician assistants
Description
For all persons, OBPAEXOT captures the sum of direct payments made by all other sources, including other Federal (OBPAEXOF), other State and local (OBPAEXOL, other private (OBPAEXOPR), other public (OBPAEXOPU), and other unclassified sources (OBPAEXOS) made to office-based physician assistants. Payments for over-the-counter drugs and indirect payments not related to specific medical events, such as Medicaid Disproportionate Share and Medicare Direct Medical Education subsidies, are not included in this amount. For more information on how MEPS collects expenditure data, please refer to our user note on medical expenditures.
Related variables
Variables related to total annual health care expenditures by source of payment, total annual health care expenditures by type of medical service, and total annual health care charges are also available. Please refer to our user note on expenditures for a list of these variables.
Codes
OBPAEXOT is a 6-digit numeric variable.
Universe
- 2007-2016: All persons.
Availability
- 2007-2016
Survey Text
| 2016 |
| 2015 |
| 2014 |
| 2013 |
| 2012 |
| 2011 |
| 2010 |
| 2009 |
| 2008 |
| 2007 |
2016
Survey form
view entire document:
text
image
CP11
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[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
=======
ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
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GO TO BOX_05
----------------------------------------------------
CP11OV2
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
=======
ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
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MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
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----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
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----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
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WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
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CP12
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SOFT RANGE CHECK: 1% - 100%
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MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
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DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
=====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
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WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
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SOURCE ROSTER BEHAVIOR SPECIFICATIONS:
1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
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CP13
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
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ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:
1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
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TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
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FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.
DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
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----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------
CP14
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.
DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
=====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who reimbursed or paid anyone in the family back?
PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who reimbursed or paid anyone in the family back?
PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------
2015
Survey form
view entire document:
text
image
CP11
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[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
=======
ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
=======
ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP12
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
=====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:
1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:
1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.
DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------
CP14
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.
DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
=====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who reimbursed or paid anyone in the family back?
PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who reimbursed or paid anyone in the family back?
PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------
2014
Survey form
view entire document:
text
image
CP11
====
=======
=======
====
=====
====
====
=====
====
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
=======
ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
=======
ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP12
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
=====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:
1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:
1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.
DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------
CP14
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.
DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
=====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who reimbursed or paid anyone in the family back?
PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who reimbursed or paid anyone in the family back?
PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------
2013
Survey form
view entire document:
text
image
CP11
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=====
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====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
=======
ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
=======
ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP12
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
=====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:
1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:
1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.
DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------
CP14
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.
DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
=====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who reimbursed or paid anyone in the family back?
PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who reimbursed or paid anyone in the family back?
PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------
2012
Survey form
view entire document:
text
image
CP11
====
=======
=======
====
=====
====
====
=====
====
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
=======
ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
=======
ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP12
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
=====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:
1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:
1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.
DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------
CP14
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.
DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
=====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who reimbursed or paid anyone in the family back?
PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who reimbursed or paid anyone in the family back?
PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------
2011
Survey form
view entire document:
text
image
CP11
====
=======
=======
====
=====
====
====
=====
====
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
=======
ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
=======
ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP12
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
=====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:
1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:
1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.
DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------
CP14
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.
DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
=====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who reimbursed or paid anyone in the family back?
PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who reimbursed or paid anyone in the family back?
PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------
2010
Survey form
view entire document:
text
image
CP11
====
=======
=======
====
=====
====
====
=====
====
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
=======
ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
=======
ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP12
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
=====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:
1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:
1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.
DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------
CP14
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.
DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
=====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who reimbursed or paid anyone in the family back?
PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who reimbursed or paid anyone in the family back?
PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------
2009
Survey form
view entire document:
text
image
CP11
====
=======
=======
====
=====
====
====
=====
====
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
=======
ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
=======
ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP12
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
=====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:
1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:
1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.
DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------
CP14
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.
DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
=====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who reimbursed or paid anyone in the family back?
PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who reimbursed or paid anyone in the family back?
PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------
2008
Survey form
view entire document:
text
image
CP11
====
=======
=======
====
=====
====
====
=====
====
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
=======
ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
=======
ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP12
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
=====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:
1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:
1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.
DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------
CP14
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.
DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
=====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who reimbursed or paid anyone in the family back?
PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who reimbursed or paid anyone in the family back?
PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------
2007
Survey form
view entire document:
text
image
CP11
====
=======
=======
====
=====
====
====
=====
====
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
=======
ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
=======
ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP12
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
=====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:
1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:
1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.
DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------
CP14
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.
DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
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----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
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====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
=====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who reimbursed or paid anyone in the family back?
PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who reimbursed or paid anyone in the family back?
PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------
Weights
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