BLAISE NAME: EvpvWhereBill
Context Header: [PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV][OME ITEM GROUP NAME] [EVN-DT/REF-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP]]
Question Text:

To whom was the bill sent?
RECORD VERBATIM.

1 CP100 (CP1095)
REFUSED RF CP100 (CP1095)
DON'T KNOW DK CP100 (CP1095)

BLAISE NAME: EvpvWhereBillTp
Context Header: [PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [OME ITEM GROUP NAME] [EVN-DT/REF-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP]]
Question Text:

INTERVIEWER: SELECT TYPE OF ORGANIZATION TO WHOM BILL WAS SENT:
HELP: F1

HMO 1 BOX_50 (CP1096)
VA (VETERANS ADMINISTRATION)/CHAMPVA 2 BOX_50 (CP1096)
TRICARE 3 BOX_50 (CP1096)
OTHER MILITARY 4 BOX_50 (CP1096)
PUBLIC ASSISTANCE/MEDICAID/SCHIP 5 BOX_50 (CP1096)
WORKER'S COMPENSATION 6 BOX_50 (CP1096)
PRIVATE INSURANCE COMPANY 7 BOX_50 (CP1096)
INDIAN HEALTH SERVICE (IHS) 8 BOX_50 (CP1096)
OTHER 91 BOX_50 (CP1096)
REFUSED RF BOX_50 (CP1096)
DON'T KNOW DK BOX_50 (CP1096)

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-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]
To whom was the bill sent?
RECORD VERBATIM. TO CONTINUE PRESS TAB AND THEN ENTER, OR SELECT NEXT PAGE.

[Enter Text] ........................... [CP07OV1]
----------------------------------------------------
[NAME OF PRESCRIBED MEDICINE]: DISPLAY THE NAMEOF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT FOR THIS EVENT.
[OME ITEM GROUP NAME]: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT.
DISPLAY ?GLASSES OR CONTACT LENSES? IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS ?1? (GLASSES OR CONTACT LENSES).
DISPLAY ?AMBULANCE SERVICES? IF THE OM ITEM GROUP IS ?4? (AMBULANCE SERVICES).
DISPLAY ?ORTHOPEDIC ITEMS? IF THE OM ITEM GROUP IS ?5? (ORTHOPEDIC ITEMS).
DISPLAY ?HEARING DEVICES? IF THE OM ITEM GROUP IS ?6? (HEARING DEVICES).
DISPLAY ?PROSTHESES? IF THE OM ITEM GROUP IS ?7? (PROSTHESES).
DISPLAY ?BATHROOM AIDS? IF THE OM ITEM GROUP IS ?8? (BATHROOM AIDS).
DISPLAY ?MEDICAL EQUIPMENT? IF THE OM ITEM GROUP IS ?9? (MEDICAL EQUIPMENT).
DISPLAY ?DISPOSABLE SUPPLIES? IF THE OM ITEM GROUP IS ?10? (DISPOSABLE SUPPLIES).
DISPLAY ?ALTERATIONS OR MODIFICATIONS? IF THE OM ITEM GROUP IS ?11? (ALTERATIONS/MODIFICATIONS).
DISPLAY [TEXT FROM OTHER SPECIFY] IF THE OM ITEM GROUP IS ?91? (OTHER).
FOR ?TEXT FROM OTHER SPECIFY?, DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP]/FLAT FEE GROUP: [NAME OF FLAT FEE EVENT GROUP]]
Let me be sure I recorded this correctly. The total charge for the services received at home during [MONTH] was [$ AMOUNT].
Is that correct?

YES .................................... 1 [CP11]
NO ..................................... 2
REF ................................... -7 [CP11]
DK .................................... -8 [CP11]
----------------------------------------------------
[$ AMOUNT]: DISPLAY AMOUNT ENTERED AT CP09OV.
----------------------------------------------------
----------------------------------------------------
IF CODED ?2? (NO), DISPLAY THE FOLLOWING MESSAGE: ?USE BACKUP TO CORRECT TOTAL CHARGE FOR THIS MONTH.?
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-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 of the [[AMT TOT CH]/total charge] did anyone in the family pay ?out-of-pocket,? that is, before any reimbursements?
IF AMOUNT PAID IS NOTHING, DK, OR REF, SELECT ?DOLLARS?, THEN ENTER 0, DK, OR RF.
IS ANSWER IN DOLLARS OR PERCENT?

DOLLARS ................................ 1 [CP11OV1]
PERCENT ................................ 2 [CP11OV2]
[Code One]
HELP AVAILABLE FOR INFORMATION ON AMOUNTS TO INCLUDE.
----------------------------------------------------
[[AMT TOT CH]/total charge]: DISPLAY ?[AMT TOT CH]? IF AN AMOUNT IS GIVEN FOR THE TOTAL CHARGE AT CP09OV. DISPLAY ?total charge? IF CP08 IS CODED ?2? (NO), ?-7? (REFUSED), ?-8? (DON?T KNOW), OR IS NOT ASKED.
[AMT TOT CH]: DISPLAY THE DOLLAR AMOUNT ENTERED AT CP09OV.
----------------------------------------------------
----------------------------------------------------
[NAME OF PRESCRIBED MEDICINE]: DISPLAY THE NAME OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT FOR THIS EVENT.
[OME ITEM GROUP NAME]: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT.
DISPLAY ?GLASSES OR CONTACT LENSES? IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS ?1? (GLASSES OR CONTACT LENSES).
DISPLAY ?AMBULANCE SERVICES? IF THE OM ITEM GROUP IS ?4? (AMBULANCE SERVICES).
DISPLAY ?ORTHOPEDIC ITEMS? IF THE OM ITEM GROUP IS ?5? (ORTHOPEDIC ITEMS).
DISPLAY ?HEARING DEVICES? IF THE OM ITEM GROUP IS ?6? (HEARING DEVICES).
DISPLAY ?PROSTHESES? IF THE OM ITEM GROUP IS ?7? (PROSTHESES).
DISPLAY ?BATHROOM AIDS? IF THE OM ITEM GROUP IS ?8? (BATHROOM AIDS).
DISPLAY ?MEDICAL EQUIPMENT? IF THE OM ITEM GROUP IS ?9? (MEDICAL EQUIPMENT).
DISPLAY ?DISPOSABLE SUPPLIES? IF THE OM ITEM GROUP IS ?10? (DISPOSABLE SUPPLIES).
DISPLAY ?ALTERATIONS OR MODIFICATIONS? IF THE OM ITEM GROUP IS ?11? (ALTERATIONS/MODIFICATIONS).
DISPLAY [TEXT FROM OTHER SPECIFY] IF THE OM ITEM GROUP IS ?91? (OTHER).
FOR ?TEXT FROM OTHER SPECIFY?, DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-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]
To whom was the bill sent?
RECORD VERBATIM. TO CONTINUE PRESS TAB AND THEN ENTER, OR SELECT NEXT PAGE.

[Enter Text] ........................... [CP07OV1]
[NAME OF PRESCRIBED MEDICINE]: DISPLAY THE NAME OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT FOR THIS EVENT.
[OME ITEM GROUP NAME]: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT.
DISPLAY 'GLASSES OR CONTACT LENSES' IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS '1' (GLASSES OR CONTACT LENSES).
DISPLAY 'AMBULANCE SERVICES' IF THE OM ITEM GROUP IS '4' (AMBULANCE SERVICES).
DISPLAY 'ORTHOPEDIC ITEMS' IF THE OM ITEM GROUP IS '5' (ORTHOPEDIC ITEMS).
DISPLAY 'HEARING DEVICES' IF THE OM ITEM GROUP IS '6' (HEARING DEVICES).
DISPLAY 'PROSTHESES' IF THE OM ITEM GROUP IS '7' (PROSTHESES).
DISPLAY 'BATHROOM AIDS' IF THE OM ITEM GROUP IS '8' (BATHROOM AIDS).
DISPLAY 'MEDICAL EQUIPMENT' IF THE OM ITEM GROUP IS '9' (MEDICAL EQUIPMENT).
DISPLAY 'DISPOSABLE SUPPLIES' IF THE OM ITEM GROUP IS '10' (DISPOSABLE SUPPLIES).
DISPLAY 'ALTERATIONS OR MODIFICATIONS' IF THE OM ITEM GROUP IS '11' (ALTERATIONS/ MODIFICATIONS).
DISPLAY [TEXT FROM OTHER SPECIFY] IF THE OM ITEM GROUP IS '91' (OTHER).
FOR 'TEXT FROM OTHER SPECIFY', DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-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]
INTERVIEWER: SELECT TYPE OF ORGANIZATION TO WHOM BILL WAS SENT:

HMO .................................... 1 [BOX_04]
VA (VETERANS ADMINISTRATION)/CHAMPVA.... 2 [BOX_04]
TRICARE ................................ 3 [CP08]
OTHER MILITARY ......................... 4 [BOX_04]
PUBLIC ASSISTANCE/MEDICAID/SCHIP ....... 5 [BOX_04]
INDIAN HEALTH SERVICE (IHS) ............ 8 [BOX_04]
WORKER'S COMPENSATION .................. 6 [BOX_04]
PRIVATE INSURANCE COMPANY .............. 7 [BOX_04]
OTHER ................................. 91 [CP08]
REF ................................... -7 [CP08]
DK .................................... -8 [CP08]
[Code One]
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
INDIAN HEALTH SERVICE (IHS) WAS INTRODUCED IN PANEL 12 ROUND 3. STARTING IN PANEL 13, IT WILL BE AVAILABLE IN ALL ROUNDS. IT IS DISPLAYED ON THE PICK LIST BETWEEN PUBLIC ASSISTANCE AND WORKER'S COMPENSATION.
----------------------------------------------------
BEGINNING IN PANEL 13, ROUND 1, THE RESPONSE CATEGORIES AT CP07OV1 GROUP VA AND CHAMPVA TOGETHER RATHER THAN TRICARE AND CHAMPVA AS PAST ROUNDS HAVE DONE.
CATEGORIES 2 AND 3 AT CP07OV1 FOR ALL ROUNDS OF PANEL 12 READ:
'VA (VETERANS ADMINISTRATION)' 'TRICARE/CHAMPVA'
CATEGORIES 2 AND 3 AT CP07OV1 FOR ALL ROUNDS OF PANEL 13 AND BEYOND READ:
'VA (VETERANS ADMINISTRATION)/CHAMPVA' 'TRICARE'
----------------------------------------------------

[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP]]
Let me be sure I recorded this correctly. The total charge for the services received at home during [MONTH] was [$ AMOUNT].
Is that correct?

YES .................................... 1 [CP11]
NO ..................................... 2
REF ................................... -7 [CP11]
DK .................................... -8 [CP11]
----------------------------------------------------
[$ AMOUNT]: DISPLAY AMOUNT ENTERED AT CP09OV.
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), DISPLAY THE FOLLOWING MESSAGE:
'USE BACKUP TO CORRECT TOTAL CHARGE FOR THIS MONTH.'
----------------------------------------------------

[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 of the [[AMT TOT CH]/total charge] did anyone in the family pay 'out-of-pocket,' that is, before any reimbursements?
IF AMOUNT PAID IS NOTHING, DK, OR REF, SELECT 'DOLLARS', THEN ENTER 0, DK, OR RF.
IS ANSWER IN DOLLARS OR PERCENT?

DOLLARS ................................ 1 [CP11OV1]
PERCENT ................................ 2 [CP11OV2]
[Code One]
HELP AVAILABLE FOR INFORMATION ON AMOUNTS TO INCLUDE.
----------------------------------------------------
[[AMT TOT CH]/total charge]: DISPLAY '[AMT TOT CH]' IF AN AMOUNT IS GIVEN FOR THE TOTAL CHARGE AT CP09OV. DISPLAY 'total charge' IF CP08 IS CODED '2' (NO), '-7' (REFUSED), '-8' (DON'T KNOW OR IS NOT ASKED.
[AMT TOT CH]: DISPLAY THE DOLLAR AMOUNT ENTERED AT CP09OV.
----------------------------------------------------
[NAME OF PRESCRIBED MEDICINE]: DISPLAY THE NAME OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT FOR THIS EVENT.
[OME ITEM GROUP NAME]: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT.
DISPLAY 'GLASSES OR CONTACT LENSES' IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS '1' (GLASSES OR CONTACT LENSES).
DISPLAY 'AMBULANCE SERVICES' IF THE OM ITEM GROUP IS '4' (AMBULANCE SERVICES).
DISPLAY 'ORTHOPEDIC ITEMS' IF THE OM ITEM GROUP IS '5' (ORTHOPEDIC ITEMS).
DISPLAY 'HEARING DEVICES' IF THE OM ITEM GROUP IS '6' (HEARING DEVICES).
DISPLAY 'PROSTHESES' IF THE OM ITEM GROUP IS '7' (PROSTHESES).
DISPLAY 'BATHROOM AIDS' IF THE OM ITEM GROUP IS '8' (BATHROOM AIDS).
DISPLAY 'MEDICAL EQUIPMENT' IF THE OM ITEM GROUP IS '9' (MEDICAL EQUIPMENT).
DISPLAY 'DISPOSABLE SUPPLIES' IF THE OM ITEM GROUP IS '10' (DISPOSABLE SUPPLIES).
DISPLAY 'ALTERATIONS OR MODIFICATIONS' IF THE OM ITEM GROUP IS '11' (ALTERATIONS/ MODIFICATIONS).
DISPLAY [TEXT FROM OTHER SPECIFY] IF THE OM ITEM GROUP IS '91' (OTHER).
FOR 'TEXT FROM OTHER SPECIFY', DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-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]
To whom was the bill sent?

RECORD VERBATIM. TO CONTINUE PRESS TAB AND THEN ENTER, OR SELECT NEXT PAGE.
[Enter Text] ........................... [CP07OV1]
----------------------------------------------------
[NAME OF PRESCRIBED MEDICINE]: DISPLAY THE NAME OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT FOR THIS EVENT.

[OME ITEM GROUP NAME]: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT.

DISPLAY 'GLASSES OR CONTACT LENSES' IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS '1' (GLASSES OR CONTACT LENSES).

DISPLAY 'AMBULANCE SERVICES' IF THE OM ITEM GROUP IS '4' (AMBULANCE SERVICES).

DISPLAY 'ORTHOPEDIC ITEMS' IF THE OM ITEM GROUP IS '5' (ORTHOPEDIC ITEMS).

DISPLAY 'HEARING DEVICES' IF THE OM ITEM GROUP IS '6' (HEARING DEVICES).

DISPLAY 'PROSTHESES' IF THE OM ITEM GROUP IS '7' (PROSTHESES).

DISPLAY 'BATHROOM AIDS' IF THE OM ITEM GROUP IS '8' (BATHROOM AIDS).

DISPLAY 'MEDICAL EQUIPMENT' IF THE OM ITEM GROUP IS '9' (MEDICAL EQUIPMENT).

DISPLAY 'DISPOSABLE SUPPLIES' IF THE OM ITEM GROUP IS '10' (DISPOSABLE SUPPLIES).

DISPLAY 'ALTERATIONS OR MODIFICATIONS' IF THE OM ITEM GROUP IS '11' (ALTERATIONS/ MODIFICATIONS).

DISPLAY [TEXT FROM OTHER SPECIFY] IF THE OM ITEM GROUP IS '91' (OTHER).

FOR 'TEXT FROM OTHER SPECIFY', DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-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]
INTERVIEWER: SELECT TYPE OF ORGANIZATION TO WHOM BILL WAS SENT:

HMO .................................... 1 [BOX_04]
VA (VETERANS ADMINISTRATION)/CHAMPVA.... 2 [BOX_04]
TRICARE ................................ 3 [CP08]
OTHER MILITARY ......................... 4 [BOX_04]
PUBLIC ASSISTANCE/MEDICAID/SCHIP ....... 5 [BOX_04]
INDIAN HEALTH SERVICE (IHS) ............ 8 [BOX_04]
WORKER'S COMPENSATION .................. 6 [BOX_04]
PRIVATE INSURANCE COMPANY .............. 7 [BOX_04]
OTHER ................................. 91 [CP08]
REF ................................... -7 [CP08]
DK .................................... -8 [CP08]
[Code One]
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
INDIAN HEALTH SERVICE (IHS) WAS INTRODUCED IN PANEL 12 ROUND 3. STARTING IN PANEL 13, IT WILL BE AVAILABLE IN ALL ROUNDS. IT IS DISPLAYED ON THE PICK LIST BETWEEN PUBLIC ASSISTANCE AND WORKER'S COMPENSATION.
----------------------------------------------------
----------------------------------------------------
BEGINNING IN PANEL 13, ROUND 1, THE RESPONSE CATEGORIES AT CP07OV1 GROUP VA AND CHAMPVA
TOGETHER RATHER THAN TRICARE AND CHAMPVA AS PAST ROUNDS HAVE DONE.

CATEGORIES 2 AND 3 AT CP07OV1 FOR ALL ROUNDS OF PANEL 12 READ:

'VA (VETERANS ADMINISTRATION)' 'TRICARE/CHAMPVA'

CATEGORIES 2 AND 3 AT CP07OV1 FOR ALL ROUNDS OF PANEL 13 AND BEYOND READ:

'VA (VETERANS ADMINISTRATION)/CHAMPVA' 'TRICARE'
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP]/FLAT FEE GROUP: [NAME OF FLAT FEE EVENT GROUP]]
Let me be sure I recorded this correctly. The total charge for the services received at home during [MONTH] was [$ AMOUNT]. Is that correct?

YES .................................... 1 [CP11]
NO ..................................... 2
REF ................................... -7 [CP11]
DK .................................... -8 [CP11]
----------------------------------------------------
[$ AMOUNT]: DISPLAY AMOUNT ENTERED AT CP09OV.
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), DISPLAY THE FOLLOWING MESSAGE: 'USE BACKUP TO CORRECT TOTAL CHARGE FOR THIS MONTH.'
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-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 of the [[AMT TOT CH]/total charge] did anyone in the family pay 'out-of-pocket,' that is, before any reimbursements?

IF AMOUNT PAID IS NOTHING, DK, OR REF, SELECT 'DOLLARS', THEN ENTER 0,
DK, OR RF.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1 [CP11OV1]
PERCENT ................................ 2 [CP11OV2]
[Code One]
HELP AVAILABLE FOR INFORMATION ON AMOUNTS TO INCLUDE.
----------------------------------------------------
[[AMT TOT CH]/total charge]: DISPLAY '[AMT TOT CH]' IF AN AMOUNT IS GIVEN FOR THE TOTAL CHARGE AT CP09OV. DISPLAY 'total charge' IF CP08 IS CODED '2' (NO), '-7' (REFUSED), '-8' (DON'T KNOW),OR IS NOT ASKED.

[AMT TOT CH]: DISPLAY THE DOLLAR AMOUNT ENTERED AT CP09OV.
----------------------------------------------------
----------------------------------------------------
[NAME OF PRESCRIBED MEDICINE]: DISPLAY THE NAME OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT FOR THIS EVENT.

[OME ITEM GROUP NAME]: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT.

DISPLAY 'GLASSES OR CONTACT LENSES' IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS '1' (GLASSES OR CONTACT LENSES).

DISPLAY 'AMBULANCE SERVICES' IF THE OM ITEM GROUP IS '4' (AMBULANCE SERVICES).

DISPLAY 'ORTHOPEDIC ITEMS' IF THE OM ITEM GROUP IS '5' (ORTHOPEDIC ITEMS).

DISPLAY 'HEARING DEVICES' IF THE OM ITEM GROUP IS '6' (HEARING DEVICES).

DISPLAY 'PROSTHESES' IF THE OM ITEM GROUP IS '7' (PROSTHESES).

DISPLAY 'BATHROOM AIDS' IF THE OM ITEM GROUP IS '8' (BATHROOM AIDS).

DISPLAY 'MEDICAL EQUIPMENT' IF THE OM ITEM GROUP IS '9' (MEDICAL EQUIPMENT).

DISPLAY 'DISPOSABLE SUPPLIES' IF THE OM ITEM GROUP IS '10' (DISPOSABLE SUPPLIES).

DISPLAY 'ALTERATIONS OR MODIFICATIONS' IF THE OM ITEM GROUP IS '11' (ALTERATIONS/ MODIFICATIONS).

DISPLAY [TEXT FROM OTHER SPECIFY] IF THE OM ITEM GROUP IS '91' (OTHER).

FOR 'TEXT FROM OTHER SPECIFY', DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-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]
To whom was the bill sent?

RECORD VERBATIM. TO CONTINUE PRESS TAB AND THEN ENTER, OR SELECT NEXT PAGE.
[Enter Text] ........................... [CP07OV1]
----------------------------------------------------
[NAME OF PRESCRIBED MEDICINE]: DISPLAY THE NAME OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT FOR THIS EVENT.

[OME ITEM GROUP NAME]: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT.

DISPLAY 'GLASSES OR CONTACT LENSES' IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS '1' (GLASSES OR CONTACT LENSES).

DISPLAY 'AMBULANCE SERVICES' IF THE OM ITEM GROUP IS '4' (AMBULANCE SERVICES).

DISPLAY 'ORTHOPEDIC ITEMS' IF THE OM ITEM GROUP IS '5' (ORTHOPEDIC ITEMS).

DISPLAY 'HEARING DEVICES' IF THE OM ITEM GROUP IS '6' (HEARING DEVICES).

DISPLAY 'PROSTHESES' IF THE OM ITEM GROUP IS '7' (PROSTHESES).

DISPLAY 'BATHROOM AIDS' IF THE OM ITEM GROUP IS '8' (BATHROOM AIDS).

DISPLAY 'MEDICAL EQUIPMENT' IF THE OM ITEM GROUP IS '9' (MEDICAL EQUIPMENT).

DISPLAY 'DISPOSABLE SUPPLIES' IF THE OM ITEM GROUP IS '10' (DISPOSABLE SUPPLIES).

DISPLAY 'ALTERATIONS OR MODIFICATIONS' IF THE OM ITEM GROUP IS '11' (ALTERATIONS/MODIFICATIONS).

DISPLAY [TEXT FROM OTHER SPECIFY] IF THE OM ITEM GROUP IS '91' (OTHER).

FOR 'TEXT FROM OTHER SPECIFY', DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-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]
INTERVIEWER: SELECT TYPE OF ORGANIZATION TO WHOM BILL WAS SENT:
HMO .................................... 1 [BOX_04]
VA (VETERANS ADMINISTRATION)/CHAMPVA.... 2 [BOX_04]
TRICARE ................................ 3 [CP08]
OTHER MILITARY ......................... 4 [BOX_04]
PUBLIC ASSISTANCE/MEDICAID/SCHIP ....... 5 [BOX_04]
INDIAN HEALTH SERVICE (IHS) ............ 8 [BOX_04]
WORKER'S COMPENSATION .................. 6 [BOX_04]
PRIVATE INSURANCE COMPANY .............. 7 [BOX_04]
OTHER ................................. 91 [CP08]
REF ................................... -7 [CP08]
DK .................................... -8 [CP08]
[Code One]
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
INDIAN HEALTH SERVICE (IHS) WAS INTRODUCED IN PANEL 12 ROUND 3. STARTING IN PANEL 13, IT WILL BE AVAILABLE IN ALL ROUNDS. IT IS DISPLAYED ON THE PICK LIST BETWEEN PUBLIC ASSISTANCE AND WORKER'S COMPENSATION.
----------------------------------------------------
----------------------------------------------------
BEGINNING IN PANEL 13, ROUND 1, THE RESPONSE CATEGORIES AT CP07OV1 GROUP VA AND CHAMPVA TOGETHER RATHER THAN TRICARE AND CHAMPVA AS PAST ROUNDS HAVE DONE.

CATEGORIES 2 AND 3 AT CP07OV1 FOR ALL ROUNDS OF PANEL 12 READ:

'VA (VETERANS ADMINISTRATION)' 'TRICARE/CHAMPVA'

CATEGORIES 2 AND 3 AT CP07OV1 FOR ALL ROUNDS OF PANEL 13 AND BEYOND READ:

'VA (VETERANS ADMINISTRATION)/CHAMPVA' 'TRICARE'
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP]]
Let me be sure I recorded this correctly. The total charge for the services received at home during [MONTH] was [$ AMOUNT]. Is that correct?

YES .................................... 1 [CP11]
NO ..................................... 2
REF ................................... -7 [CP11]
DK .................................... -8 [CP11]
----------------------------------------------------
[$ AMOUNT]: DISPLAY AMOUNT ENTERED AT CP09OV.
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), DISPLAY THE FOLLOWING MESSAGE:
'USE BACKUP TO CORRECT TOTAL CHARGE FOR THIS MONTH.'
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-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 of the [[AMT TOT CH]/total charge] did anyone in the family pay 'out-of-pocket,' that is, before any reimbursements?

IF AMOUNT PAID IS NOTHING, DK, OR REF, SELECT 'DOLLARS', THEN ENTER 0, DK, OR RF.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1 [CP11OV1]
PERCENT ................................ 2 [CP11OV2]
[Code One]
HELP AVAILABLE FOR INFORMATION ON AMOUNTS TO INCLUDE.
----------------------------------------------------
[[AMT TOT CH]/total charge]: DISPLAY '[AMT TOT CH]' IF AN AMOUNT IS GIVEN FOR THE TOTAL CHARGE AT CP09OV. DISPLAY 'total charge' IF CP08 IS CODED '2' (NO), '-7' (REFUSED), '-8' (DON'T KNOW), OR IS NOT ASKED.

[AMT TOT CH]: DISPLAY THE DOLLAR AMOUNT ENTERED AT CP09OV.
----------------------------------------------------
----------------------------------------------------
[OME ITEM GROUP NAME]: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT.

DISPLAY 'GLASSES OR CONTACT LENSES' IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS '1' (GLASSES OR CONTACT LENSES).

DISPLAY 'AMBULANCE SERVICES' IF THE OM ITEM GROUP IS '4' (AMBULANCE SERVICES).

DISPLAY 'ORTHOPEDIC ITEMS' IF THE OM ITEM GROUP IS '5' (ORTHOPEDIC ITEMS).

DISPLAY 'HEARING DEVICES' IF THE OM ITEM GROUP IS '6' (HEARING DEVICES).

DISPLAY 'PROSTHESES' IF THE OM ITEM GROUP IS '7' (PROSTHESES).

DISPLAY 'BATHROOM AIDS' IF THE OM ITEM GROUP IS '8' (BATHROOM AIDS).

DISPLAY 'MEDICAL EQUIPMENT' IF THE OM ITEM GROUP IS '9' (MEDICAL EQUIPMENT).

DISPLAY 'DISPOSABLE SUPPLIES' IF THE OM ITEM GROUP IS '10' (DISPOSABLE SUPPLIES).

DISPLAY 'ALTERATIONS OR MODIFICATIONS' IF THE OM ITEM GROUP IS '11' (ALTERATIONS/MODIFICATIONS).

DISPLAY [TEXT FROM OTHER SPECIFY] IF THE OM ITEM GROUP IS '91' (OTHER).

FOR 'TEXT FROM OTHER SPECIFY', DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-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]
To whom was the bill sent?

RECORD VERBATIM. TO CONTINUE PRESS TAB AND THEN ENTER, OR SELECT NEXT PAGE.
[Enter Text] ........................... [CP07OV1]
----------------------------------------------------
[NAME OF PRESCRIBED MEDICINE]: DISPLAY THE NAME OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT FOR THIS EVENT.

[OME ITEM GROUP NAME]: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT.

DISPLAY 'GLASSES OR CONTACT LENSES' IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS '1' (GLASSES OR CONTACT LENSES).

DISPLAY 'AMBULANCE SERVICES' IF THE OM ITEM GROUP IS '4' (AMBULANCE SERVICES).

DISPLAY 'ORTHOPEDIC ITEMS' IF THE OM ITEM GROUP IS '5' (ORTHOPEDIC ITEMS).

DISPLAY 'HEARING DEVICES' IF THE OM ITEM GROUP IS '6' (HEARING DEVICES).

DISPLAY 'PROSTHESES' IF THE OM ITEM GROUP IS '7' (PROSTHESES).

DISPLAY 'BATHROOM AIDS' IF THE OM ITEM GROUP IS '8' (BATHROOM AIDS).

DISPLAY 'MEDICAL EQUIPMENT' IF THE OM ITEM GROUP IS '9' (MEDICAL EQUIPMENT).

DISPLAY 'DISPOSABLE SUPPLIES' IF THE OM ITEM GROUP IS '10' (DISPOSABLE SUPPLIES).

DISPLAY 'ALTERATIONS OR MODIFICATIONS' IF THE OM ITEM GROUP IS '11' (ALTERATIONS/MODIFICATIONS).

DISPLAY [TEXT FROM OTHER SPECIFY] IF THE OM ITEM GROUP IS '91' (OTHER).

FOR 'TEXT FROM OTHER SPECIFY', DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-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]
INTERVIEWER: SELECT TYPE OF ORGANIZATION TO WHOM BILL WAS SENT:

HMO .................................... 1 [BOX_04]
VA (VETERANS ADMINISTRATION)/CHAMPVA.... 2 [BOX_04]
TRICARE ................................ 3 [CP08]
OTHER MILITARY ......................... 4 [BOX_04]
PUBLIC ASSISTANCE/MEDICAID/SCHIP ....... 5 [BOX_04]
INDIAN HEALTH SERVICE (IHS) ............ 8 [BOX_04]
WORKER'S COMPENSATION .................. 6 [BOX_04]
PRIVATE INSURANCE COMPANY .............. 7 [BOX_04]
OTHER ................................. 91 [CP08]
REF ................................... -7 [CP08]
DK .................................... -8 [CP08]
[Code One]
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
INDIAN HEALTH SERVICE (IHS) WAS INTRODUCED IN PANEL 12 ROUND 3. STARTING IN PANEL 13, IT WILL BE AVAILABLE IN ALL ROUNDS. IT IS DISPLAYED ON THE PICK LIST BETWEEN PUBLIC ASSISTANCE AND WORKER'S COMPENSATION.
----------------------------------------------------
----------------------------------------------------
BEGINNING IN PANEL 13, ROUND 1, THE RESPONSE CATEGORIES AT CP07OV1 GROUP VA AND CHAMPVA TOGETHER RATHER THAN TRICARE AND CHAMPVA AS PAST ROUNDS HAVE DONE.

CATEGORIES 2 AND 3 AT CP07OV1 FOR ALL ROUNDS OF PANEL 12 READ:

'VA (VETERANS ADMINISTRATION)' 'TRICARE/CHAMPVA'

CATEGORIES 2 AND 3 AT CP07OV1 FOR ALL ROUNDS OF PANEL 13 AND BEYOND READ:

'VA (VETERANS ADMINISTRATION)/CHAMPVA' 'TRICARE'
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP]]
Let me be sure I recorded this correctly. The total charge for the services received at home during [MONTH] was [$ AMOUNT]. Is that correct?

YES .................................... 1 [CP11]
NO ..................................... 2
REF ................................... -7 [CP11]
DK .................................... -8 [CP11]
----------------------------------------------------
[$ AMOUNT]: DISPLAY AMOUNT ENTERED AT CP09OV.
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), DISPLAY THE FOLLOWING MESSAGE:
'USE BACKUP TO CORRECT TOTAL CHARGE FOR THIS MONTH.'
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-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 of the [[AMT TOT CH]/total charge] did anyone in the family pay 'out-of-pocket,' that is, before any reimbursements?

IF AMOUNT PAID IS NOTHING, DK, OR REF, SELECT 'DOLLARS', THEN ENTER 0, DK, OR RF.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1 [CP11OV1]
PERCENT ................................ 2 [CP11OV2]
[Code One]
HELP AVAILABLE FOR INFORMATION ON AMOUNTS TO INCLUDE.
----------------------------------------------------
[[AMT TOT CH]/total charge]: DISPLAY '[AMT TOT CH]' IF AN AMOUNT IS GIVEN FOR THE TOTAL CHARGE AT CP09OV. DISPLAY 'total charge' IF CP08 IS CODED '2' (NO), '-7' (REFUSED), '-8' (DON'T KNOW), OR IS NOT ASKED.

[AMT TOT CH]: DISPLAY THE DOLLAR AMOUNT ENTERED AT CP09OV.
----------------------------------------------------
----------------------------------------------------
[OME ITEM GROUP NAME]: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT.

DISPLAY 'GLASSES OR CONTACT LENSES' IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS '1' (GLASSES OR CONTACT LENSES).

DISPLAY 'AMBULANCE SERVICES' IF THE OM ITEM GROUP IS '4' (AMBULANCE SERVICES).

DISPLAY 'ORTHOPEDIC ITEMS' IF THE OM ITEM GROUP IS '5' (ORTHOPEDIC ITEMS).

DISPLAY 'HEARING DEVICES' IF THE OM ITEM GROUP IS '6' (HEARING DEVICES).

DISPLAY 'PROSTHESES' IF THE OM ITEM GROUP IS '7' (PROSTHESES).

DISPLAY 'BATHROOM AIDS' IF THE OM ITEM GROUP IS '8' (BATHROOM AIDS).

DISPLAY 'MEDICAL EQUIPMENT' IF THE OM ITEM GROUP IS '9' (MEDICAL EQUIPMENT).

DISPLAY 'DISPOSABLE SUPPLIES' IF THE OM ITEM GROUP IS '10' (DISPOSABLE SUPPLIES).

DISPLAY 'ALTERATIONS OR MODIFICATIONS' IF THE OM ITEM GROUP IS '11' (ALTERATIONS/MODIFICATIONS).

DISPLAY [TEXT FROM OTHER SPECIFY] IF THE OM ITEM GROUP IS '91' (OTHER).

FOR 'TEXT FROM OTHER SPECIFY', DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-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 was the total charge, including any amounts that may be paid by health insurance or other sources?
[Do not include any services billed for separately such as physician charges or other services.] [Include charges for procedures such as x-rays, lab tests, or diagnostic procedures that are listed separately on the [hospital] bill [or statement].]
IF WORKING FROM DOCUMENTATION, ENTER TOTAL CHARGES. DO NOT DEDUCT DISCOUNTS OR DISALLOWED OR DENIED CHARGES.
[SELECT 'INCLUDED WITH OTHER CHARGES' IF THIS IS A FLAT FEE SITUATION.]

AMOUNT ................................. 1 [CP09OV]
INCLUDED WITH OTHER CHARGES ........... 95
[Code One]

HELP AVAILABLE FOR DEFINITION OF WHAT MAKES UP TOTAL CHARGE AND FLAT FEE.

----------------------------------------------------
DISPLAY 'Do not include any services billed for billed for separately such as physician charges or other services.' IF EVENT TYPE IS HS, ER, OR OP. OTHERWISE, USE A NULL DISPLAY.

DISPLAY 'Include charges for procedures such as x-rays, lab tests, or diagnostic procedures that are listed separately on the [hospital] bill [or statement]'. IF CP05 IS CODED '1' (YES, AND DOCUMENTATION AVAILABLE) AND EVENT TYPE IS NOT PM. OTHERWISE, USE A NULL DISPLAY.

DISPLAY 'hospital' IF EVENT TYPE IS HS, ER, OR OP.
OTHERWISE, USE A NULL DISPLAY. DISPLAY 'or statement' IF EVENT TYPE IS MV, DN, OM, HH OR EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP.
OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY INTERVIEWER INSTRUCTION 'SELECT "INCLUDED WITH OTHER CHARGES? IF THIS IS A FLAT FEE SITUATION' IF EVENT-PROVIDER PAIR DOES NOT REPRESENT A FLAT FEE GROUP. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
[OME ITEM GROUP NAME]: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT.

DISPLAY 'GLASSES OR CONTACT LENSES' IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS '1' (GLASSES OR CONTACT LENSES).

DISPLAY 'AMBULANCE SERVICES' IF THE OM ITEM GROUP IS '4' (AMBULANCE SERVICES).

DISPLAY 'ORTHOPEDIC ITEMS' IF THE OM ITEM GROUP IS '5' (ORTHOPEDIC ITEMS).

DISPLAY 'HEARING DEVICES' IF THE OM ITEM GROUP IS '6' (HEARING DEVICES).

DISPLAY 'PROSTHESES' IF THE OM ITEM GROUP IS '7' (PROSTHESES).
DISPLAY 'BATHROOM AIDS' IF THE OM ITEM GROUP IS '8' (BATHROOM AIDS).

DISPLAY 'MEDICAL EQUIPMENT' IF THE OM ITEM GROUP IS '9' (MEDICAL EQUIPMENT).

DISPLAY 'DISPOSABLE SUPPLIES' IF THE OM ITEM GROUP IS '10' (DISPOSABLE SUPPLIES).

DISPLAY 'ALTERATIONS OR MODIFICATIONS' IF THE OM ITEM GROUP IS '11' (ALTERATIONS/MODIFICATIONS).

DISPLAY [TEXT FROM OTHER SPECIFY] IF THE OM ITEM GROUP IS '91' (OTHER).

FOR 'TEXT FROM OTHER SPECIFY', DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.
----------------------------------------------------
----------------------------------------------------
IF 'INCLUDED WITH OTHER CHARGES' DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A PM EVENT.'
----------------------------------------------------
----------------------------------------------------
IF 'INCLUDED WITH OTHER CHARGES' IS SELECTED AND THE EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A FLAT FEE GROUP.'
----------------------------------------------------
----------------------------------------------------
IF 'INCLUDED WITH OTHER CHARGES' IS SELECTED AND THE EVENT-PROVIDER PAIR REPRESENTS A REPEAT VISIT STEM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A REPEAT VISIT GROUP.'
----------------------------------------------------
----------------------------------------------------
IF 'INCLUDED WITH OTHER CHARGES' IS SELECTED AND THE EVENT TYPE IS NOT PM AND THE EVENT-PROVIDER PAIR DOES NOT REPRESENT A FLAT FEE GROUP OR A REPEAT VISIT GROUP, ASK THE FLAT FEE (FF) SECTION.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-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]
To whom was the bill sent?
RECORD VERBATIM. TO CONTINUE PRESS TAB AND THEN ENTER, OR SELECT NEXT PAGE.

[Enter Text] ........................... [CP07OV1]
----------------------------------------------------
[NAME OF PRESCRIBED MEDICINE]: DISPLAY THE NAME OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT FOR THIS EVENT.

[OME ITEM GROUP NAME]: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT.

DISPLAY 'GLASSES OR CONTACT LENSES' IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS '1' (GLASSES OR CONTACT LENSES).

DISPLAY 'AMBULANCE SERVICES' IF THE OM ITEM GROUP IS '4' (AMBULANCE SERVICES).

DISPLAY 'ORTHOPEDIC ITEMS' IF THE OM ITEM GROUP IS '5' (ORTHOPEDIC ITEMS).

DISPLAY 'HEARING DEVICES' IF THE OM ITEM GROUP IS '6' (HEARING DEVICES).

DISPLAY 'PROSTHESES' IF THE OM ITEM GROUP IS '7' (PROSTHESES).

DISPLAY 'BATHROOM AIDS' IF THE OM ITEM GROUP IS '8' (BATHROOM AIDS).

DISPLAY 'MEDICAL EQUIPMENT' IF THE OM ITEM GROUP IS '9' (MEDICAL EQUIPMENT).

DISPLAY 'DISPOSABLE SUPPLIES' IF THE OM ITEM GROUP IS '10' (DISPOSABLE SUPPLIES).

DISPLAY 'ALTERATIONS OR MODIFICATIONS' IF THE OM ITEM GROUP IS '11' (ALTERATIONS/MODIFICATIONS).

DISPLAY [TEXT FROM OTHER SPECIFY] IF THE OM ITEM GROUP IS '91' (OTHER).

FOR 'TEXT FROM OTHER SPECIFY', DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-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]
INTERVIEWER: SELECT TYPE OF ORGANIZATION TO WHOM BILL WAS SENT:

HMO .................................... 1 [BOX_04]
VA (VETERANS ADMINISTRATION)/CHAMPVA.... 2 [BOX_04]
TRICARE ................................ 3 [CP08]
OTHER MILITARY ......................... 4 [BOX_04]
PUBLIC ASSISTANCE/MEDICAID/SCHIP ....... 5 [BOX_04]
INDIAN HEALTH SERVICE (IHS) ............ 8 [BOX_04]
WORKER'S COMPENSATION .................. 6 [BOX_04]
PRIVATE INSURANCE COMPANY .............. 7 [BOX_04]
OTHER ................................. 91 [CP08]
REF ................................... -7 [CP08]
DK .................................... -8 [CP08]
[Code One]
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
INDIAN HEALTH SERVICE (IHS) WAS INTRODUCED IN PANEL 12 ROUND 3. STARTING IN PANEL 13, IT WILL BE AVAILABLE IN ALL ROUNDS. IT IS DISPLAYED ON THE PICK LIST BETWEEN PUBLIC ASSISTANCE AND WORKER'S COMPENSATION.
----------------------------------------------------
----------------------------------------------------
BEGINNING IN PANEL 13, ROUND 1, THE RESPONSE CATEGORIES AT CP07OV1 GROUP VA AND CHAMPVA TOGETHER RATHER THAN TRICARE AND CHAMPVA AS PAST ROUNDS HAVE DONE.

CATEGORIES 2 AND 3 AT CP07OV1 FOR ALL ROUNDS OF PANEL 12 READ:

'VA (VETERANS ADMINISTRATION)' 'TRICARE/CHAMPVA'

CATEGORIES 2 AND 3 AT CP07OV1 FOR ALL ROUNDS OF PANEL 13 AND BEYOND READ:

'VA (VETERANS ADMINISTRATION)/CHAMPVA' 'TRICARE'
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP]/FLAT FEE GROUP: [NAME OF FLAT FEE EVENT GROUP]]
Let me be sure I recorded this correctly. The total charge for the services received at home during [MONTH] was [$ AMOUNT].
Is that correct?

YES .................................... 1 [CP11]
NO ..................................... 2
REF ................................... -7 [CP11]
DK .................................... -8 [CP11]
----------------------------------------------------
[$ AMOUNT]: DISPLAY AMOUNT ENTERED AT CP09OV.
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), DISPLAY THE FOLLOWING MESSAGE:
'USE BACKUP TO CORRECT TOTAL CHARGE FOR THIS MONTH.'
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-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 of the [[AMT TOT CH]/total charge] did anyone in the family pay 'out-of-pocket,' that is, before any reimbursements?
IF AMOUNT PAID IS NOTHING, DK, OR REF, SELECT 'DOLLARS', THEN ENTER 0, DK, OR RF.
IS ANSWER IN DOLLARS OR PERCENT?

DOLLARS ................................ 1 [CP11OV1]
PERCENT ................................ 2 [CP11OV2]
[Code One]
HELP AVAILABLE FOR INFORMATION ON AMOUNTS TO INCLUDE.
----------------------------------------------------
[[AMT TOT CH]/total charge]: DISPLAY '[AMT TOT CH]' IF AN AMOUNT IS GIVEN FOR THE TOTAL CHARGE AT CP09OV. DISPLAY 'total charge' IF CP08 IS CODED '2' (NO), '-7' (REFUSED), '-8' (DON'T KNOW), OR IS NOT ASKED.

[AMT TOT CH]: DISPLAY THE DOLLAR AMOUNT ENTERED AT CP09OV.
----------------------------------------------------
----------------------------------------------------
[OME ITEM GROUP NAME]: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT.

DISPLAY 'GLASSES OR CONTACT LENSES' IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS '1' (GLASSES OR CONTACT LENSES).

DISPLAY 'AMBULANCE SERVICES' IF THE OM ITEM GROUP IS '4' (AMBULANCE SERVICES).

DISPLAY 'ORTHOPEDIC ITEMS' IF THE OM ITEM GROUP IS '5' (ORTHOPEDIC ITEMS).

DISPLAY 'HEARING DEVICES' IF THE OM ITEM GROUP IS '6' (HEARING DEVICES).

DISPLAY 'PROSTHESES' IF THE OM ITEM GROUP IS '7' (PROSTHESES).

DISPLAY 'BATHROOM AIDS' IF THE OM ITEM GROUP IS '8' (BATHROOM AIDS).

DISPLAY 'MEDICAL EQUIPMENT' IF THE OM ITEM GROUP IS '9' (MEDICAL EQUIPMENT).

DISPLAY 'DISPOSABLE SUPPLIES' IF THE OM ITEM GROUP IS '10' (DISPOSABLE SUPPLIES).

DISPLAY 'ALTERATIONS OR MODIFICATIONS' IF THE OM ITEM GROUP IS '11' (ALTERATIONS/MODIFICATIONS).

DISPLAY [TEXT FROM OTHER SPECIFY] IF THE OM ITEM GROUP IS '91' (OTHER).

FOR 'TEXT FROM OTHER SPECIFY', DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-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]
To whom was the bill sent?
RECORD VERBATIM. TO CONTINUE PRESS TAB AND THEN ENTER, OR SELECT NEXT PAGE.

[Enter Text] ........................... [CP07OV1]
----------------------------------------------------
[NAME OF PRESCRIBED MEDICINE]: DISPLAY THE NAME OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT FOR THIS EVENT.

[OME ITEM GROUP NAME]: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT.

DISPLAY 'GLASSES OR CONTACT LENSES' IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS '1' (GLASSES OR CONTACT LENSES).

DISPLAY 'AMBULANCE SERVICES' IF THE OM ITEM GROUP IS '4' (AMBULANCE SERVICES).

DISPLAY 'ORTHOPEDIC ITEMS' IF THE OM ITEM GROUP IS '5' (ORTHOPEDIC ITEMS).

DISPLAY 'HEARING DEVICES' IF THE OM ITEM GROUP IS '6' (HEARING DEVICES).

DISPLAY 'PROSTHESES' IF THE OM ITEM GROUP IS '7' (PROSTHESES).

DISPLAY 'BATHROOM AIDS' IF THE OM ITEM GROUP IS '8' (BATHROOM AIDS).

DISPLAY 'MEDICAL EQUIPMENT' IF THE OM ITEM GROUP IS '9' (MEDICAL EQUIPMENT).

DISPLAY 'DISPOSABLE SUPPLIES' IF THE OM ITEM GROUP IS '10' (DISPOSABLE SUPPLIES).

DISPLAY 'ALTERATIONS OR MODIFICATIONS' IF THE OM ITEM GROUP IS '11' (ALTERATIONS/MODIFICATIONS).

DISPLAY [TEXT FROM OTHER SPECIFY] IF THE OM ITEM GROUP IS '91' (OTHER).

FOR 'TEXT FROM OTHER SPECIFY', DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-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]
INTERVIEWER: SELECT TYPE OF ORGANIZATION TO WHOM BILL WAS SENT:

HMO .................................... 1 [BOX_04]
VA (VETERANS ADMINISTRATION)/CHAMPVA.... 2 [BOX_04]
TRICARE ................................ 3 [CP08]
OTHER MILITARY ......................... 4 [BOX_04]
PUBLIC ASSISTANCE/MEDICAID/SCHIP ....... 5 [BOX_04]
INDIAN HEALTH SERVICE (IHS) ............ 8 [BOX_04]
WORKER'S COMPENSATION .................. 6 [BOX_04]
PRIVATE INSURANCE COMPANY .............. 7 [BOX_04]
OTHER ................................. 91 [CP08]
REF ................................... -7 [CP08]
DK .................................... -8 [CP08]
[Code One]
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
INDIAN HEALTH SERVICE (IHS) WAS INTRODUCED IN PANEL 12 ROUND 3. STARTING IN PANEL 13, IT WILL BE AVAILABLE IN ALL ROUNDS. IT IS DISPLAYED ON THE PICK LIST BETWEEN PUBLIC ASSISTANCE AND WORKER'S COMPENSATION.
----------------------------------------------------
----------------------------------------------------
BEGINNING IN PANEL 13, ROUND 1, THE RESPONSE CATEGORIES AT CP07OV1 GROUP VA AND CHAMPVA TOGETHER RATHER THAN TRICARE AND CHAMPVA AS PAST ROUNDS HAVE DONE.

CATEGORIES 2 AND 3 AT CP07OV1 FOR ALL ROUNDS OF PANEL 12 READ:

'VA (VETERANS ADMINISTRATION)' 'TRICARE/CHAMPVA'

CATEGORIES 2 AND 3 AT CP07OV1 FOR ALL ROUNDS OF PANEL 13 AND BEYOND READ:

'VA (VETERANS ADMINISTRATION)/CHAMPVA' 'TRICARE'
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP]]
Let me be sure I recorded this correctly. The total charge for the services received at home during (MONTH) was [$ AMOUNT]. Is that correct?

YES .................................... 1 [CP11]
NO ..................................... 2
REF ................................... -7 [CP11]
DK .................................... -8 [CP11]
----------------------------------------------------
[$ AMOUNT]: DISPLAY AMOUNT ENTERED AT CP09OV.
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), DISPLAY THE FOLLOWING MESSAGE:
'USE BACKUP TO CORRECT TOTAL CHARGE FOR THIS MONTH.'
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-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 of the [[AMT TOT CH]/total charge] did anyone in the family pay 'out-of-pocket,' that is, before any reimbursements?
IF AMOUNT PAID IS NOTHING, DK, OR REF, SELECT 'DOLLARS', THEN ENTER 0, DK, OR RF.
IS ANSWER IN DOLLARS OR PERCENT?

DOLLARS ................................ 1 [CP11OV1]
PERCENT ................................ 2 [CP11OV2]
[Code One]
HELP AVAILABLE FOR INFORMATION ON AMOUNTS TO INCLUDE.
----------------------------------------------------
[[AMT TOT CH]/total charge]: DISPLAY '[AMT TOT CH]' IF AN AMOUNT IS GIVEN FOR THE TOTAL CHARGE AT CP09OV. DISPLAY 'total charge' IF CP08 IS CODED '2' (NO), '-7' (REFUSED), '-8' (DON'T KNOW), OR IS NOT ASKED.

[AMT TOT CH]: DISPLAY THE DOLLAR AMOUNT ENTERED AT CP09OV.
----------------------------------------------------
----------------------------------------------------
[OME ITEM GROUP NAME]: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT.

DISPLAY 'GLASSES OR CONTACT LENSES' IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS '1' (GLASSES OR CONTACT LENSES).

DISPLAY 'AMBULANCE SERVICES' IF THE OM ITEM GROUP IS '4' (AMBULANCE SERVICES).

DISPLAY 'ORTHOPEDIC ITEMS' IF THE OM ITEM GROUP IS '5' (ORTHOPEDIC ITEMS).

DISPLAY 'HEARING DEVICES' IF THE OM ITEM GROUP IS '6' (HEARING DEVICES).

DISPLAY 'PROSTHESES' IF THE OM ITEM GROUP IS '7' (PROSTHESES).

DISPLAY 'BATHROOM AIDS' IF THE OM ITEM GROUP IS '8' (BATHROOM AIDS).

DISPLAY 'MEDICAL EQUIPMENT' IF THE OM ITEM GROUP IS '9' (MEDICAL EQUIPMENT).

DISPLAY 'DISPOSABLE SUPPLIES' IF THE OM ITEM GROUP IS '10' (DISPOSABLE SUPPLIES).

DISPLAY 'ALTERATIONS OR MODIFICATIONS' IF THE OM ITEM GROUP IS '11' (ALTERATIONS/MODIFICATIONS).

DISPLAY [TEXT FROM OTHER SPECIFY] IF THE OM ITEM GROUP IS '91' (OTHER).

FOR 'TEXT FROM OTHER SPECIFY', DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-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]
To whom was the bill sent?
RECORD VERBATIM. TO CONTINUE PRESS TAB AND THEN ENTER, OR SELECT NEXT PAGE.

[Enter Text] ........................... [CP07OV1]
----------------------------------------------------
[NAME OF PRESCRIBED MEDICINE]: DISPLAY THE NAME OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT FOR THIS EVENT.

[OME ITEM GROUP NAME]: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT.

DISPLAY 'GLASSES OR CONTACT LENSES' IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS '1' (GLASSES OR CONTACT LENSES).

DISPLAY 'INSULIN' IF THE OM ITEM GROUP IS '2' (INSULIN).
DISPLAY 'AMBULANCE SERVICES' IF THE OM ITEM GROUP IS '4' (AMBULANCE SERVICES).

DISPLAY 'OTHER DIABETIC EQUIPMENT OR SUPPLIES' IF THE OM ITEM GROUP IS '3' (OTHER DIABETIC EQUIPMENT OR SUPPLIES).

DISPLAY 'ORTHOPEDIC ITEMS' IF THE OM ITEM GROUP IS '5' (ORTHOPEDIC ITEMS).

DISPLAY 'HEARING DEVICES' IF THE OM ITEM GROUP IS '6' (HEARING DEVICES).

DISPLAY 'PROSTHESES' IF THE OM ITEM GROUP IS '7' (PROSTHESES).

DISPLAY 'BATHROOM AIDS' IF THE OM ITEM GROUP IS '8' (BATHROOM AIDS).

DISPLAY 'MEDICAL EQUIPMENT' IF THE OM ITEM GROUP IS '9' (MEDICAL EQUIPMENT).

DISPLAY 'DISPOSABLE SUPPLIES' IF THE OM ITEM GROUP IS '10' (DISPOSABLE SUPPLIES).

DISPLAY 'ALTERATIONS OR MODIFICATIONS' IF THE OM ITEM GROUP IS '11' (ALTERATIONS/MODIFICATIONS).

DISPLAY [TEXT FROM OTHER SPECIFY] IF THE OM ITEM GROUP IS '91' (OTHER).

FOR 'TEXT FROM OTHER SPECIFY', DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP]]
INTERVIEWER: SELECT TYPE OF ORGANIZATION TO WHOM BILL WAS SENT:

HMO .................................... 1 [BOX_04]
VA (VETERANS ADMINISTRATION)/CHAMPVA.... 2 [BOX_04]
TRICARE ................................ 3 [CP08]
OTHER MILITARY ......................... 4 [BOX_04]
PUBLIC ASSISTANCE/MEDICAID/SCHIP ....... 5 [BOX_04]
INDIAN HEALTH SERVICE (IHS) ............ 8 [BOX_04]
WORKER'S COMPENSATION .................. 6 [BOX_04]
PRIVATE INSURANCE COMPANY .............. 7 [BOX_04]
OTHER ................................. 91 [CP08]
REF ................................... -7 [CP08]
DK .................................... -8 [CP08]
[Code One]
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
INDIAN HEALTH SERVICE (IHS) WAS INTRODUCED IN PANEL 12 ROUND 3. STARTING IN PANEL 13, IT WILL BE AVAILABLE IN ALL ROUNDS. IT IS DISPLAYED ON THE PICK LIST BETWEEN PUBLIC ASSISTANCE AND WORKER'S COMPENSATION.
----------------------------------------------------
----------------------------------------------------
BEGINNING IN PANEL 13, ROUND 1, THE RESPONSE CATEGORIES AT CP07OV1 GROUP VA AND CHAMPVA TOGETHER RATHER THAN TRICARE AND CHAMPVA AS PAST ROUNDS HAVE DONE.

CATEGORIES 2 AND 3 AT CP07OV1 FOR ALL ROUNDS OF PANEL 12 READ:

'VA (VETERANS ADMINISTRATION)' 'TRICARE/CHAMPVA'

CATEGORIES 2 AND 3 AT CP07OV1 FOR ALL ROUNDS OF PANEL 13 AND BEYOND READ:

'VA (VETERANS ADMINISTRATION)/CHAMPVA' 'TRICARE'
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP]]
Let me be sure I recorded this correctly. The total charge for the services received at home from (PROVIDER) during (MONTH) for (PERSON) was [$ AMOUNT]. Is that correct?

YES .................................... 1 [CP11]
NO ..................................... 2
REF ................................... -7 [CP11]
DK .................................... -8 [CP11]
----------------------------------------------------
[$ AMOUNT]: DISPLAY AMOUNT ENTERED AT CP09OV.
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), DISPLAY THE FOLLOWING MESSAGE:
'USE BACKUP TO CORRECT TOTAL CHARGE FOR THIS MONTH.'
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-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)]? Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, SELECT 'DOLLARS', THEN ENTER 0, DK, OR RF.
IS ANSWER IN DOLLARS OR PERCENT?

DOLLARS ................................ 1 [CP11OV1]
PERCENT ................................ 2 [CP11OV2]
[Code One]
HELP AVAILABLE FOR INFORMATION ON AMOUNTS TO INCLUDE.
----------------------------------------------------
[[AMT TOT CH]/total charge]: DISPLAY '[AMT TOT CH]' IF AN AMOUNT IS GIVEN FOR THE TOTAL CHARGE AT CP09OV. DISPLAY 'total charge' IF CP08 IS CODED '2' (NO), '-7' (REFUSED), '-8' (DON'T KNOW), OR IS NOT ASKED.

[AMT TOT CH]: DISPLAY THE DOLLAR AMOUNT ENTERED AT CP09OV.
----------------------------------------------------
----------------------------------------------------
(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE): DISPLAY IF EVENT TYPE IS HS.

(PERSON)'s visit to (PROVIDER) on (VISIT DATE):
DISPLAY IF EVENT TYPE IS ER, OP, MV, OR DN.

the last purchase of [NAME OF PRESCRIBED MEDICINE] for (PERSON): DISPLAY IF EVENT TYPE IS PM.

[NAME OF PRESCRIBED MEDICINE]: DISPLAY THE NAME OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT FOR THIS EVENT.

the services for (FLAT FEE GROUP) for (PERSON):
DISPLAY IF EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP.

the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE): DISPLAY IF EVENT TYPE IS OM.

services received at home from (PROVIDER) during (MONTH) for (PERSON): DISPLAY IF EVENT TYPE IS HH.
----------------------------------------------------
----------------------------------------------------
[OME ITEM GROUP NAME]: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT.

DISPLAY 'glasses or contact lenses' IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS '1' (GLASSES OR CONTACT LENSES).

DISPLAY 'insulin' IF THE OM ITEM GROUP IS '2' (INSULIN).

DISPLAY 'other diabetic equipment or supplies' IF THE OM ITEM GROUP IS '3' (OTHER DIABETIC EQUIPMENT OR SUPPLIES).

DISPLAY 'ambulance services' IF THE OM ITEM GROUP IS '4' (AMBULANCE SERVICES).

DISPLAY 'orthopedic items' IF THE OM ITEM GROUP IS '5' (ORTHOPEDIC ITEMS).

DISPLAY 'hearing devices' IF THE OM ITEM GROUP IS '6' (HEARING DEVICES).

DISPLAY 'prostheses' IF THE OM ITEM GROUP IS '7' (PROSTHESES).

DISPLAY 'bathroom aids' IF THE OM ITEM GROUP IS '8' (BATHROOM AIDS).

DISPLAY 'medical equipment' IF THE OM ITEM GROUP IS '9' (MEDICAL EQUIPMENT).

DISPLAY 'disposable supplies' IF THE OM ITEM GROUP IS '10' (DISPOSABLE SUPPLIES).

DISPLAY 'alterations or modifications' IF THE OM ITEM GROUP IS '11' (ALTERATIONS/MODIFICATIONS).

DISPLAY [TEXT FROM OTHER SPECIFY] IF THE OM ITEM GROUP IS '91' (OTHER).

FOR 'TEXT FROM OTHER SPECIFY', DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-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)]? Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, SELECT 'DOLLARS', THEN ENTER 0, DK, OR RF.

IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1 [CP11OV1]
PERCENT ................................ 2 [CP11OV2]
[Code One]
HELP AVAILABLE FOR INFORMATION ON AMOUNTS TO INCLUDE.
----------------------------------------------------
DISPLAY [NAME OF MEDICAL CARE PROVIDER] IN THE HEADER IF THE EVENT TYPE IS NOT 'PM' (PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
OTHERWISE, USE NULL VALUE.

DISPLAY [EVN-DT] IN THE HEADER IF EVENT TYPE IS NOT 'PM' (PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).

DISPLAY [REF-DT] IN THE HEADER IF EVENT TYPE IS 'PM' (PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).

DISPLAY 'REPEAT VISIT: [NAME OF REPEAT VISIT GROUP]' IN THE HEADER IF THIS EVENT IS A REPEAT VISIT STEM.

DISPLAY 'FLAT FEE GROUP: [NAME OF FLAT FEE EVENT GROUP]' IN THE HEADER IF THIS EVENT IS A FLAT FEE STEM.

[[AMT TOT CH]/total charge]: DISPLAY '[AMT TOT CH]' IF AN AMOUNT IS GIVEN FOR THE TOTAL CHARGE AT CP09OV. DISPLAY 'total charge' IF CP08 IS CODED '2' (NO), '-7' (REFUSED), '-8' (DON'T KNOW), OR IS NOT ASKED.

[AMT TOT CH]: DISPLAY THE DOLLAR AMOUNT ENTERED AT CP09OV.
----------------------------------------------------
----------------------------------------------------
(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE): DISPLAY IF EVENT TYPE IS HS.

(PERSON)'s visit to (PROVIDER) on (VISIT DATE):
DISPLAY IF EVENT TYPE IS ER, OP, MV, OR DN.

the last purchase of [NAME OF PRESCRIBED MEDICINE] for (PERSON): DISPLAY IF EVENT TYPE IS PM.

[NAME OF PRESCRIBED MEDICINE]: DISPLAY THE NAME OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT FOR THIS EVENT.

the services for (FLAT FEE GROUP) for (PERSON):
DISPLAY IF EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP.

the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE): DISPLAY IF EVENT TYPE IS OM.
----------------------------------------------------
----------------------------------------------------
[OME ITEM GROUP NAME]: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT.

DISPLAY 'glasses or contact lenses' IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS '1' (GLASSES OR CONTACT LENSES).

DISPLAY 'ambulance services' IF THE OM ITEM GROUP IS '4' (AMBULANCE SERVICES).

DISPLAY 'orthopedic items' IF THE OM ITEM GROUP IS '5' (ORTHOPEDIC ITEMS).

DISPLAY 'hearing devices' IF THE OM ITEM GROUP IS '6' (HEARING DEVICES).

DISPLAY 'prostheses' IF THE OM ITEM GROUP IS '7' (PROSTHESES).

DISPLAY 'bathroom aids' IF THE OM ITEM GROUP IS '8' (BATHROOM AIDS).

DISPLAY 'medical equipment' IF THE OM ITEM GROUP IS '9' (MEDICAL EQUIPMENT).

DISPLAY 'disposable supplies' IF THE OM ITEM GROUP IS '10' (DISPOSABLE SUPPLIES).

DISPLAY 'alterations or modifications' IF THE OM ITEM GROUP IS '11' (ALTERATIONS/MODIFICATIONS).

DISPLAY [TEXT FROM OTHER SPECIFY] IF THE OM ITEM GROUP IS '91' (OTHER).

FOR 'TEXT FROM OTHER SPECIFY', DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.

FOR '[START DATE]', DISPLAYED IN THE CONTEXT HEADER, DISPLAY THE START DATE OF THE CURRENT ROUND FOR OM EVENTS THAT ARE 'REGULAR' GROUP TYPE (EV02A=1 OR NOT ASKED) AND DISPLAY 'JAN 01' FOR OM EVENTS THAT ARE 'ADDITIONAL' GROUP TYPE (EV02A=2).

services received at home from (PROVIDER) during
(MONTH) for (PERSON): DISPLAY IF EVENT TYPE IS HH.
----------------------------------------------------

[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...........]
To whom was the bill sent?
RECORD VERBATIM:

[Enter Text]

INTERVIEWER: ENTER CODE FOR TYPE OF ORGANIZATION TO WHOM BILL WAS SENT:

HMO .................................... 1
VA ..................................... 2
TRICARE/CHAMPVA ........................ 3 [CP08]
OTHER MILITARY ......................... 4
PUBLIC ASSISTANCE/MEDICAID/SCHIP ....... 5
WORKER'S COMPENSATION .................. 6
PRIVATE INSURANCE COMPANY .............. 7
OTHER ................................. 91 [CP08]
REF ................................... -7 [CP08]
DK .................................... -8 [CP08]
[Code One]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.

[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..]]
Let me be sure I recorded this correctly. The total charge for the services received at home from (PROVIDER) during (MONTH) for (PERSON) was [$ AMOUNT].
Is that correct?

YES .................................... 1 [CP11]
NO ..................................... 2
REF ................................... -7 [CP11]
DK .................................... -8 [CP11]
----------------------------------------------------
IF CODED '2' (NO), DISPLAY THE FOLLOWING MESSAGE:
'USE CTRL/B TO CORRECT TOTAL CHARGE FOR THIS MONTH. PRESS ENTER TO CONTINUE.'
----------------------------------------------------

[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)]?
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.

[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...........]
To whom was the bill sent?
RECORD VERBATIM:

[Enter Text]

INTERVIEWER: ENTER CODE FOR TYPE OF ORGANIZATION TO WHOM BILL WAS SENT:

HMO .................................... 1
VA ..................................... 2
TRICARE/CHAMPVA ........................ 3 [CP08]
OTHER MILITARY ......................... 4
PUBLIC ASSISTANCE/MEDICAID/SCHIP ....... 5
WORKER'S COMPENSATION .................. 6
PRIVATE INSURANCE COMPANY .............. 7
OTHER ................................. 91 [CP08]
REF ................................... -7 [CP08]
DK .................................... -8 [CP08]
[Code One]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.

[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..]]
Let me be sure I recorded this correctly. The total charge for the services received at home from (PROVIDER) during (MONTH) for (PERSON) was [$ AMOUNT].
Is that correct?

YES .................................... 1 [CP11]
NO ..................................... 2
REF ................................... -7 [CP11]
DK .................................... -8 [CP11]
----------------------------------------------------
IF CODED '2' (NO), DISPLAY THE FOLLOWING MESSAGE:
'USE CTRL/B TO CORRECT TOTAL CHARGE FOR THIS MONTH. PRESS ENTER TO CONTINUE.'
----------------------------------------------------

[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)]?
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.

[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...........]
To whom was the bill sent?
RECORD VERBATIM:

[Enter Text]

INTERVIEWER: ENTER CODE FOR TYPE OF ORGANIZATION TO WHOM BILL WAS SENT:

HMO .................................... 1
VA ..................................... 2
TRICARE ........ 3 [CP08]
OTHER MILITARY ......................... 4
WELFARE/MEDICAID ....................... 5
WORKER?S COMPENSATION .................. 6
PRIVATE INSURANCE COMPANY .............. 7
OTHER ................................. 91 [CP08]
REF ................................... -7 [CP08]
DK .................................... -8 [CP08]
[Code One]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.

[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..]]
Let me be sure I recorded this correctly. The total charge for the services received at home from (PROVIDER) during (MONTH) for (PERSON) was [$ AMOUNT].
Is that correct?

YES .................................... 1 [CP11]
NO ..................................... 2
REF ................................... -7 [CP11]
DK .................................... -8 [CP11]
----------------------------------------------------
IF CODED ?2? (NO), DISPLAY THE FOLLOWING MESSAGE:
?USE CTRL/B TO CORRECT TOTAL CHARGE FOR THIS MONTH. PRESS ENTER TO CONTINUE.?
----------------------------------------------------

[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)]?
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.

[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)]?
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.

[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...........]
To whom was the bill sent?
RECORD VERBATIM:

[Enter Text]

INTERVIEWER: ENTER CODE FOR TYPE OF ORGANIZATION TO WHOM BILL WAS SENT:

HMO .................................... 1
VA ..................................... 2
TRICARE ........ 3 [CP08]
OTHER MILITARY ......................... 4
WELFARE/MEDICAID ....................... 5
WORKER'S COMPENSATION .................. 6
PRIVATE INSURANCE COMPANY .............. 7
OTHER ................................. 91 [CP08]
REF ................................... -7 [CP08]
DK .................................... -8 [CP08]
[Code One]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.

[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..]]
Let me be sure I recorded this correctly. The total charge for the services received at home from (PROVIDER) during (MONTH) for (PERSON) was [$ AMOUNT].
Is that correct?

YES .................................... 1 [CP11]
NO ..................................... 2
REF ................................... -7 [CP11]
DK .................................... -8 [CP11]
----------------------------------------------------
IF CODED '2' (NO), DISPLAY THE FOLLOWING MESSAGE:
'USE CTRL/B TO CORRECT TOTAL CHARGE FOR THIS MONTH. PRESS ENTER TO CONTINUE.'
----------------------------------------------------

[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)]?
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.

[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...........]
To whom was the bill sent?
RECORD VERBATIM:

[Enter Text]

INTERVIEWER: ENTER CODE FOR TYPE OF ORGANIZATION TO WHOM BILL WAS SENT:

HMO .................................... 1
VA ..................................... 2
TRICARE (CHAMPUS/CHAMPVA) .............. 3 [CP08]
OTHER MILITARY ......................... 4
WELFARE/MEDICAID ....................... 5
WORKER'S COMPENSATION .................. 6
PRIVATE INSURANCE COMPANY .............. 7
OTHER ................................. 91 [CP08]
REF ................................... -7 [CP08]
DK .................................... -8 [CP08]
[Code One]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.

[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..]]
Let me be sure I recorded this correctly. The total charge for the services received at home from (PROVIDER) during (MONTH) for (PERSON) was [$ AMOUNT].
Is that correct?

YES .................................... 1 [CP11]
NO ..................................... 2
REF ................................... -7 [CP11]
DK .................................... -8 [CP11]
----------------------------------------------------
IF CODED '2' (NO), DISPLAY THE FOLLOWING MESSAGE:
'USE CTRL/B TO CORRECT TOTAL CHARGE FOR THIS MONTH. PRESS ENTER TO CONTINUE.'
----------------------------------------------------

[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)]?
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.

[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...........]
To whom was the bill sent?
RECORD VERBATIM:

[Enter Text]

INTERVIEWER: ENTER CODE FOR TYPE OF ORGANIZATION TO WHOM BILL WAS SENT:

HMO .................................... 1
VA ..................................... 2
CHAMPUS/CHAMPVA ........................ 3 [CP08]
OTHER MILITARY ......................... 4
WELFARE/MEDICAID ....................... 5
WORKER'S COMPENSATION .................. 6
PRIVATE INSURANCE COMPANY .............. 7
OTHER ................................. 91 [CP08]
REF ................................... -7 [CP08]
DK .................................... -8 [CP08]
[Code One]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.

----------------------------------------------------
IF:
- EVENT TYPE IS OM, HH, OR PM
OR
- EVENT TYPE IS HS AND THE EVENT-PROVIDER PAIR IS NOT FLAGGED AS 'SEPARATELY BILLING'
OR
- THIS EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP, GO TO CP11
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO CP10
----------------------------------------------------

[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..]]
Do you know the total charge 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)]?
[CODE '95' IF THIS IS A FLAT FEE SITUATION.]

YES .................................... 1 [CP09]
NO ..................................... 2
INCLUDED WITH OTHER CHARGES ........... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF TOTAL CHARGE AND FLAT FEE.
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT TYPE OF THE EVENT-PROVIDER PAIR IS PM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A PM EVENT. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A FLAT FEE GROUP. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT-PROVIDER PAIR REPRESENTS A REPEAT VISIT STEM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A REPEAT VISIT GROUP. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT TYPE IS NOT PM AND THE EVENT-PROVIDER PAIR DOES NOT REPRESENT A FLAT FEE GROUP OR A REPEAT VISIT GROUP, ASK THE FLAT FEE (FF) SECTION.
----------------------------------------------------
----------------------------------------------------
IF:
CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW)
AND
(EVENT TYPE IS OM, HH, OR PM
OR
EVENT TYPE IS HS AND THE EVENT-PROVIDER PAIR IS NOT FLAGGED AS 'SEPARATELY BILLING'
OR
THIS EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP), GO TO CP11
----------------------------------------------------
----------------------------------------------------
IF:
CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW)
AND
EVENT TYPE IS ER, OP, MV, DN, OR EVENT-PROVIDER PAIR IS FLAGGED AS 'SEPARATELY BILLING', GO TO CP10
----------------------------------------------------

[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?

DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.

ENTER PERCENT:

[Enter % Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------

[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...........]
To whom was the bill sent?
RECORD VERBATIM:

[Enter Text]

INTERVIEWER: ENTER CODE FOR TYPE OF ORGANIZATION TO WHOM BILL WAS SENT:

HMO .................................... 1
VA ..................................... 2
CHAMPUS/CHAMPVA ........................ 3 [CP08]
OTHER MILITARY ......................... 4
WELFARE/MEDICAID ....................... 5
WORKER'S COMPENSATION .................. 6
PRIVATE INSURANCE COMPANY .............. 7
OTHER ................................. 91 [CP08]
REF ................................... -7 [CP08]
DK .................................... -8 [CP08]
[Code One]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.

[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..]]
Let me be sure I recorded this correctly. The total charge for the services received at home from (PROVIDER) during (MONTH) for (PERSON) was [$ AMOUNT].
Is that correct?

YES .................................... 1 [CP11]
NO ..................................... 2
REF ................................... -7 [CP11]
DK .................................... -8 [CP11]
----------------------------------------------------
IF CODED '2' (NO), DISPLAY THE FOLLOWING MESSAGE:
'USE CTRL/B TO CORRECT TOTAL CHARGE FOR THIS MONTH. PRESS ENTER TO CONTINUE.'
----------------------------------------------------

[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?

DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.

ENTER PERCENT:

[Enter % Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------

[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...........]
To whom was the bill sent?
RECORD VERBATIM:

[Enter Text]

[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..]]
Let me be sure I recorded this correctly. The total charge for the services received at home from (PROVIDER) during (MONTH) for (PERSON) was [$ AMOUNT].
Is that correct?

YES .................................... 1 [CP11]
NO ..................................... 2
REF ................................... -7 [CP11]
DK .................................... -8 [CP11]
----------------------------------------------------
IF CODED '2' (NO), DISPLAY THE FOLLOWING MESSAGE:
'USE CTRL/B TO CORRECT TOTAL CHARGE FOR THIS MONTH. PRESS ENTER TO CONTINUE.'
----------------------------------------------------

[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?

DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.

[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?

DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.