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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP16
====
[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 SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
CP17
====
[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 was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
CP18
====
[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 expect any [other] source to reimburse anyone in the family for what has been paid?
YES .................................... 1
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
CP19
====
[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 does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
====
[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..]]
Does anyone in the family or any other source expect to make additional payments 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)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
====
[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 more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]