[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]]
Has any [other] source already paid for any of the charges for [this hospital stay/this visit/the last purchase of [NAME OF PRESCRIBED MEDICINE]/the services for [FLAT FEE GROUP]/the [OME ITEM GROUP NAME]/ the services received at home]?
By other source, we mean a private insurance company, an HMO, Medicare, Medicaid, or any other public program that may have paid.

YES .................................... 1 [CP12A]
NO ..................................... 2 [BOX_06]
REF ................................... -7 [BOX_06]
DK .................................... -8 [BOX_06]
HELP AVAILABLE 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 OR 0% WAS ENTERED AT CP11OV1 OR CP11OV2.
OTHERWISE USE A NULL DISPLAY.
----------------------------------------------------
DISPLAY 'this hospital stay' IF EVENT TYPE IS HS.
DISPLAY 'this visit' IF EVENT TYPE IS ER, OP, MV, OR DN.
DISPLAY 'the last purchase of [NAME OF PRESCRIBED MEDICINE]' IF EVENT TYPE IS PM.
[NAME OF PRESCRIBED MEDICINE]: DISPLAY THE NAME OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT FOR THIS EVENT.
DISPLAY 'the services for [FLAT FEE GROUP]' IF EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP.
FOR [FLAT FEE GROUP], DISPLAY THE NAME OF THE FLAT FEE GROUP SELECTED AT FF02 OR ENTERED AT FF03.
DISPLAY 'the [OME ITEM GROUP NAME]' IF EVENT TYPE IS OM.
DISPLAY 'the services received at home' 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 '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 did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
IF ONLY PERCENT KNOWN, ENTER F5 FOR DOLLAR AMOUNT PAID AND THEN ENTER PERCENT.

TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLAR AMOUNT 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]
HELP AVAILABLE FOR A DEFINITION OF PAYMENTS MADE DIRECTLY TO PROVIDER.
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT
DISPLAY THE RESPONSE TO CP11 IN THE 'DOLLAR AMOUNT PAID' OR 'PERCENT AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN THE 'DOLLAR AMOUNT PAID' COLUMN. IF THE RESPONSE TO CP11 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN THE 'PERCENT AMOUNT PAID' COLUMN. IF THE DOLLAR AMOUNT AT CP11 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH COLUMNS. IF DOLLAR AMOUNT AT CP11 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTHCOLUMNS.
----------------------------------------------------
[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.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
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 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. NOTE THAT THE SCREEN WILL REQUIRE AN AMOUNT FOR PERSON/FAMILY IN THE DOLLAR COLUMN IN ORDER TO PROCEED. THIS DOLLAR AMOUNT MAY BE ENTERED BY THE INTERVIEWER OR CALCULATED BY CAPI BASED ON % OF TOTAL CHARGE WHERE TOTAL CHARGE IS KNOWN. |
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.
----------------------------------------------------
----------------------------------------------------
SOFT CHECK:
$0 - $10,000
----------------------------------------------------
----------------------------------------------------
CONTINUE WITH BOX_06
----------------------------------------------------
ROSTER DETAILS:
TITLE: EVNT_SOP_1
COL # 1 HEADER: SOURCE OF PAYMENT INSTRUCTIONS: DISPLAY PAYMENT SOURCE NAME (PAYM.REIMNAM/PAYF.REIMNAM)
COL # 2 HEADER: DOLLAR AMOUNT PAID INSTRUCTIONS: ENTER $ AMOUNT PAID (PAYM.AMTPAID/PAYF.AMTPAID)
COL # 3 HEADER: PERCENT AMOUNT PAID INSTRUCTIONS: ENTER % AMOUNT PAID (PAYM.PCTPAID/PAYF.PCTPAID)
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION:
DISPLAY THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER FOR ENTRY.
----------------------------------------------------
----------------------------------------------------
ROSTER BEHAVIOR:
1. SOURCE COLUMN IS PROTECTED; NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
2. THE PERSON/FAMILY AMOUNT MAY BE CHANGED OR CORRECTED.
3. THE INTERVIEWER CAN ENTER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
4. THE AMOUNT PAID COLUMNS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
5. WHEN THE 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.
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
----------------------------------------------------
ROSTER FILTER:
DISPLAY ALL SOURCES SELECTED AT CP12A FOR THIS EVENT-PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------

[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]]
Has any [other] source already paid for any of the charges for [this hospital stay/this visit/the last purchase of [NAME OF PRESCRIBED MEDICINE]/the services for [FLAT FEE GROUP]/the [OME ITEM GROUP NAME]/ the services received at home]? By other source, we mean a private insurance company, an HMO, Medicare, Medicaid, or any other public program that may have paid.

YES .................................... 1 [CP12A]
NO ..................................... 2 [BOX_06]
REF ................................... -7 [BOX_06]
DK .................................... -8 [BOX_06]
HELP AVAILABLE 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 OR 0% WAS ENTERED AT CP11OV1 OR CP11OV2. OTHERWISE USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'this hospital stay' IF EVENT TYPE IS HS.

DISPLAY 'this visit' IF EVENT TYPE IS ER, OP, MV, OR DN.

DISPLAY 'the last purchase of [NAME OF PRESCRIBED MEDICINE]' IF EVENT TYPE IS PM.

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

DISPLAY 'the services for [FLAT FEE GROUP]' IF EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP.

FOR [FLAT FEE GROUP], DISPLAY THE NAME OF THE FLAT FEE GROUP SELECTED AT FF02 OR ENTERED AT FF03.

DISPLAY 'the [OME ITEM GROUP NAME]' IF EVENT TYPE IS OM.

DISPLAY 'the services received at home' 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 '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 did (SOURCE) pay?

ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
IF ONLY PERCENT KNOWN, ENTER F5 FOR DOLLAR AMOUNT PAID AND THEN ENTER PERCENT.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT CP13_02. DOLLAR AMOUNT 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]
HELP AVAILABLE FOR A DEFINITION OF PAYMENTS MADE DIRECTLY TO PROVIDER.
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'DOLLAR AMOUNT PAID' OR 'PERCENT AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN THE 'DOLLAR AMOUNT PAID' COLUMN. IF THE RESPONSE TO CP11 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN THE 'PERCENT AMOUNT PAID' COLUMN. IF THE DOLLAR AMOUNT AT CP11 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH COLUMNS. IF DOLLAR AMOUNT AT CP11 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH COLUMNS.
----------------------------------------------------
----------------------------------------------------
[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.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
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 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. NOTE THAT THE SCREEN WILL REQUIRE AN AMOUNT FOR PERSON/FAMILY IN THE DOLLAR COLUMN IN ORDER TO PROCEED. THIS DOLLAR AMOUNT MAY BE ENTERED BY THE INTERVIEWER OR CALCULATED BY CAPI BASED ON % OF TOTAL CHARGE WHERE TOTAL CHARGE IS KNOWN.

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.
----------------------------------------------------
----------------------------------------------------
SOFT CHECK:
$0 - $10,000
----------------------------------------------------
----------------------------------------------------
CONTINUE WITH BOX_06
----------------------------------------------------
----------------------------------------------------
ROSTER DETAILS:
TITLE: EVNT_SOP_1

COL # 1 HEADER: SOURCE OF PAYMENT
INSTRUCTIONS: DISPLAY PAYMENT SOURCE NAME (PAYM.REIMNAM/PAYF.REIMNAM)

COL # 2 HEADER: DOLLAR AMOUNT PAID
INSTRUCTIONS: ENTER $ AMOUNT PAID (PAYM.AMTPAID/PAYF.AMTPAID)

COL # 3 HEADER: PERCENT AMOUNT PAID
INSTRUCTIONS: ENTER % AMOUNT PAID (PAYM.PCTPAID/PAYF.PCTPAID)
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION:
DISPLAY THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER FOR ENTRY.
----------------------------------------------------
----------------------------------------------------
ROSTER BEHAVIOR:
1. SOURCE COLUMN IS PROTECTED; NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.

2. THE PERSON/FAMILY AMOUNT MAY BE CHANGED OR CORRECTED.

3. THE INTERVIEWER CAN ENTER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.

4. THE AMOUNT PAID COLUMNS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.

5. WHEN THE 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.

6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
----------------------------------------------------
----------------------------------------------------
ROSTER FILTER:
DISPLAY ALL SOURCES SELECTED AT CP12A FOR THIS EVENT-PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------

[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]]
Has any [other] source already paid for any of the charges for [this hospital stay/this visit/the last purchase of [NAME OF PRESCRIBED MEDICINE]/the services for [FLAT FEE GROUP]/the [OME ITEM GROUP NAME]/ the services received at home]? By other source, we mean a private insurance company, an HMO, Medicare, Medicaid, or any other public program that may have paid.

YES .................................... 1 [CP12A]
NO ..................................... 2 [BOX_06]
REF ................................... -7 [BOX_06]
DK .................................... -8 [BOX_06]
HELP AVAILABLE 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 OR 0% WAS ENTERED AT CP11OV1 OR CP11OV2. OTHERWISE USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'this hospital stay' IF EVENT TYPE IS HS.

DISPLAY 'this visit' IF EVENT TYPE IS ER, OP, MV, OR DN.

DISPLAY 'the last purchase of [NAME OF PRESCRIBED MEDICINE]' IF EVENT TYPE IS PM.

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

DISPLAY 'the services for [FLAT FEE GROUP]' IF EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP.

FOR [FLAT FEE GROUP], DISPLAY THE NAME OF THE FLAT FEE GROUP SELECTED AT FF02 OR ENTERED AT FF03.

DISPLAY 'the [OME ITEM GROUP NAME]' IF EVENT TYPE IS OM.

DISPLAY 'the services received at home' 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 '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 did (SOURCE) pay?

ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
IF ONLY PERCENT KNOWN, ENTER F5 FOR DOLLAR AMOUNT PAID AND THEN ENTER PERCENT.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT CP13_02. DOLLAR
AMOUNT 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]
HELP AVAILABLE FOR A DEFINITION OF PAYMENTS MADE DIRECTLY TO PROVIDER.
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'DOLLAR AMOUNT PAID' OR 'PERCENT AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN THE 'DOLLAR AMOUNT PAID' COLUMN. IF THE RESPONSE TO CP11 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN THE 'PERCENT AMOUNT PAID' COLUMN. IF THE DOLLAR AMOUNT AT CP11 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH COLUMNS. IF DOLLAR AMOUNT AT CP11 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH COLUMNS.
----------------------------------------------------
----------------------------------------------------
[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.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
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 TOMOVE BETWEEN 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. NOTE THAT THE SCREEN WILL REQUIRE AN AMOUNT FOR PERSON/FAMILY IN THE DOLLAR COLUMN IN ORDER TO PROCEED. THIS DOLLAR AMOUNT MAY BE ENTERED BY THE INTERVIEWER OR CALCULATED BY CAPI BASED ON % OF TOTAL CHARGE WHERE TOTAL CHARGE IS KNOWN.
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.
----------------------------------------------------
----------------------------------------------------
SOFT CHECK:
$0 - $10,000
----------------------------------------------------
----------------------------------------------------
CONTINUE WITH BOX_06
----------------------------------------------------
----------------------------------------------------
ROSTER DETAILS:
TITLE: EVNT_SOP_1

COL # 1 HEADER: SOURCE OF PAYMENT
INSTRUCTIONS: DISPLAY PAYMENT SOURCE NAME (PAYM.REIMNAM/PAYF.REIMNAM)

COL # 2 HEADER: DOLLAR AMOUNT PAID
INSTRUCTIONS: ENTER $ AMOUNT PAID (PAYM.AMTPAID/PAYF.AMTPAID)

COL # 3 HEADER: PERCENT AMOUNT PAID
INSTRUCTIONS: ENTER % AMOUNT PAID (PAYM.PCTPAID/PAYF.PCTPAID)
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION:
DISPLAY THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER FOR ENTRY.
----------------------------------------------------
----------------------------------------------------
ROSTER BEHAVIOR:
1. SOURCE COLUMN IS PROTECTED; NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.

2. THE PERSON/FAMILY AMOUNT MAY BE CHANGED OR CORRECTED.

3. THE INTERVIEWER CAN ENTER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.

4. THE AMOUNT PAID COLUMNS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.

5. WHEN THE 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.

6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
----------------------------------------------------
----------------------------------------------------
ROSTER FILTER:
DISPLAY ALL SOURCES SELECTED AT CP12A FOR THIS EVENT-PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------

[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]]
Has any [other] source already paid for any of the charges for [this hospital stay/this visit/the last purchase of [NAME OF PRESCRIBED MEDICINE]/the services for [FLAT FEE GROUP]/the [OME ITEM GROUP NAME]/the services received at home]? By other source, we mean a private insurance company, an HMO, Medicare, Medicaid, or any other public program that may have paid.

YES .................................... 1 [CP12A]
NO ..................................... 2 [BOX_06]
REF ................................... -7 [BOX_06]
DK .................................... -8 [BOX_06]
HELP AVAILABLE 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 OR 0% WAS ENTERED AT CP11OV1 OR CP11OV2. OTHERWISE USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'this hospital stay' IF EVENT TYPE IS HS.

DISPLAY 'this visit' IF EVENT TYPE IS ER, OP, MV, OR DN.

DISPLAY 'the last purchase of [NAME OF PRESCRIBED MEDICINE]' IF EVENT TYPE IS PM.

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

DISPLAY 'the services for [FLAT FEE GROUP]' IF EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP.

FOR [FLAT FEE GROUP], DISPLAY THE NAME OF THE FLAT FEE GROUP SELECTED AT FF02 OR ENTERED AT FF03.

DISPLAY 'the [OME ITEM GROUP NAME]' IF EVENT TYPE IS OM.

DISPLAY 'the services received at home' 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 '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 did (SOURCE) pay?

ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
IF ONLY PERCENT KNOWN, ENTER F5 FOR DOLLAR AMOUNT PAID AND THEN ENTER PERCENT.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT CP13_02. DOLLAR
AMOUNT 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]
HELP AVAILABLE FOR A DEFINITION OF PAYMENTS MADE DIRECTLY TO PROVIDER.
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'DOLLAR AMOUNT PAID' OR 'PERCENT AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN THE 'DOLLAR AMOUNT PAID' COLUMN. IF THE RESPONSE TO CP11 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN THE 'PERCENT AMOUNT PAID' COLUMN. IF THE DOLLAR AMOUNT AT CP11 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH COLUMNS. IF DOLLAR AMOUNT AT CP11 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH COLUMNS.
----------------------------------------------------
----------------------------------------------------
[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.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
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 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. NOTE THAT THE SCREEN WILL REQUIRE AN AMOUNT FOR PERSON/FAMILY IN THE DOLLAR COLUMN IN ORDER TO PROCEED. THIS DOLLAR AMOUNT MAY BE ENTERED BY THE INTERVIEWER OR CALCULATED BY CAPI BASED ON % OF TOTAL CHARGE WHERE TOTAL CHARGE IS KNOWN.
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.
----------------------------------------------------
----------------------------------------------------
SOFT CHECK:
$0 - $10,000
----------------------------------------------------
----------------------------------------------------
CONTINUE WITH BOX_06
----------------------------------------------------
----------------------------------------------------
ROSTER DETAILS:
TITLE: EVNT_SOP_1

COL # 1 HEADER: SOURCE OF PAYMENT
INSTRUCTIONS: DISPLAY PAYMENT SOURCE NAME (PAYM.REIMNAM/PAYF.REIMNAM)

COL # 2 HEADER: DOLLAR AMOUNT PAID
INSTRUCTIONS: ENTER $ AMOUNT PAID (PAYM.AMTPAID/PAYF.AMTPAID)

COL # 3 HEADER: PERCENT AMOUNT PAID
INSTRUCTIONS: ENTER % AMOUNT PAID (PAYM.PCTPAID/PAYF.PCTPAID)
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION:
DISPLAY THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER FOR ENTRY.
----------------------------------------------------
----------------------------------------------------
ROSTER BEHAVIOR:
1. SOURCE COLUMN IS PROTECTED; NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.

2. THE PERSON/FAMILY AMOUNT MAY BE CHANGED OR CORRECTED.

3. THE INTERVIEWER CAN ENTER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.

4. THE AMOUNT PAID COLUMNS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.

5. WHEN THE 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.

6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
----------------------------------------------------
----------------------------------------------------
ROSTER FILTER:
DISPLAY ALL SOURCES SELECTED AT CP12A FOR THIS EVENT-PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------

[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]]
Has any [other] source already paid for any of the charges for [this hospital stay/this visit/the last purchase of [NAME OF PRESCRIBED MEDICINE]/the services for [FLAT FEE GROUP]/the [OME ITEM GROUP NAME]/the services received at home]? By other source, we mean a private insurance company, an HMO, Medicare, Medicaid, or any other public program that may have paid.

YES .................................... 1 [CP12A]
NO ..................................... 2 [BOX_06]
REF ................................... -7 [BOX_06]
DK .................................... -8 [BOX_06]

HELP AVAILABLE 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 OR 0% WAS ENTERED AT CP11OV1 OR CP11OV2. OTHERWISE USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'this hospital stay' IF EVENT TYPE IS HS.

DISPLAY 'this visit' IF EVENT TYPE IS ER, OP, MV, OR DN.

DISPLAY 'the last purchase of [NAME OF PRESCRIBED MEDICINE]' IF EVENT TYPE IS PM.

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

DISPLAY 'the services for [FLAT FEE GROUP]' IF EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP.

FOR [FLAT FEE GROUP], DISPLAY THE NAME OF THE FLAT FEE GROUP SELECTED AT FF02 OR ENTERED AT FF03.

DISPLAY 'the [OME ITEM GROUP NAME]' IF EVENT TYPE IS OM.

DISPLAY 'the services received at home' 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 '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 did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
IF ONLY PERCENT KNOWN, ENTER F5 FOR DOLLAR AMOUNT PAID AND THEN ENTER PERCENT.

TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT CP13_02. DOLLAR AMOUNT 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]

HELP AVAILABLE FOR A DEFINITION OF PAYMENTS MADE DIRECTLY TO PROVIDER.

----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'DOLLAR AMOUNT PAID' OR 'PERCENT AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN THE 'DOLLAR AMOUNT PAID' COLUMN. IF THE RESPONSE TO CP11 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN THE 'PERCENT AMOUNT PAID' COLUMN. IF THE DOLLAR AMOUNT AT CP11 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH COLUMNS. IF DOLLAR AMOUNT AT CP11 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH COLUMNS.
----------------------------------------------------
----------------------------------------------------
[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 OMITEM 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.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
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 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. NOTE THAT THE SCREEN WILL REQUIRE AN AMOUNT FOR PERSON/FAMILY IN THE DOLLAR COLUMN IN ORDER TO PROCEED. THIS DOLLAR AMOUNT MAY BE ENTERED BY THE INTERVIEWER OR CALCULATED BY CAPI BASED ON % OF TOTAL CHARGE WHERE TOTAL CHARGE IS KNOWN.
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.
----------------------------------------------------
----------------------------------------------------
SOFT CHECK:
$0 - $10,000
----------------------------------------------------
----------------------------------------------------
CONTINUE WITH BOX_06
----------------------------------------------------
----------------------------------------------------
ROSTER DETAILS:
TITLE: EVNT_SOP_1

COL # 1 HEADER: SOURCE OF PAYMENT
INSTRUCTIONS: DISPLAY PAYMENT SOURCE NAME (PAYM.REIMNAM/PAYF.REIMNAM)

COL # 2 HEADER: DOLLAR AMOUNT PAID
INSTRUCTIONS: ENTER $ AMOUNT PAID (PAYM.AMTPAID/PAYF.AMTPAID)

COL # 3 HEADER: PERCENT AMOUNT PAID
INSTRUCTIONS: ENTER % AMOUNT PAID (PAYM.PCTPAID/PAYF.PCTPAID)
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION:
DISPLAY THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER FOR ENTRY.
----------------------------------------------------
----------------------------------------------------
ROSTER BEHAVIOR:
1. SOURCE COLUMN IS PROTECTED; NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.

2. THE PERSON/FAMILY AMOUNT MAY BE CHANGED OR CORRECTED.

3. THE INTERVIEWER CAN ENTER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.

4. THE AMOUNT PAID COLUMNS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.

5. WHEN THE 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.

6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
----------------------------------------------------
----------------------------------------------------
ROSTER FILTER:
DISPLAY ALL SOURCES SELECTED AT CP12A FOR THIS EVENT-PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------

[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]]
Has any [other] source already paid for any of the charges for [this hospital stay/this visit/the last purchase of [NAME OF PRESCRIBED MEDICINE]/the services for [FLAT FEE GROUP]/the [OME ITEM GROUP NAME]/the services received at home]?
By other source, we mean a private insurance company, an HMO, Medicare, Medicaid, or any other public program that may have paid.

YES .................................... 1 [CP12A]
NO ..................................... 2 [BOX_06]
REF ................................... -7 [BOX_06]
DK .................................... -8 [BOX_06]

HELP AVAILABLE 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 OR 0% WAS ENTERED AT CP11OV1 OR CP11OV2. OTHERWISE USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'this hospital stay' IF EVENT TYPE IS HS.

DISPLAY 'this visit' IF EVENT TYPE IS ER, OP, MV, OR DN.

DISPLAY 'the last purchase of [NAME OF PRESCRIBED MEDICINE]' IF EVENT TYPE IS PM.

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

DISPLAY 'the services for [FLAT FEE GROUP]' IF EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP.

FOR [FLAT FEE GROUP], DISPLAY THE NAME OF THE FLAT FEE GROUP SELECTED AT FF02 OR ENTERED AT FF03.

DISPLAY 'the [OME ITEM GROUP NAME]' IF EVENT TYPE IS OM.

DISPLAY 'the services received at home' 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 '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 did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.

TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT CP13_02. DOLLAR AMOUNT 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]

HELP AVAILABLE FOR A DEFINITION OF PAYMENTS MADE DIRECTLY TO PROVIDER.

----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'DOLLAR AMOUNT PAID' OR 'PERCENT AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN THE 'DOLLAR AMOUNT PAID' COLUMN. IF THE RESPONSE TO CP11 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN THE 'PERCENT AMOUNT PAID' COLUMN. IF THE DOLLAR AMOUNT AT CP11 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH COLUMNS. IF DOLLAR AMOUNT AT CP11 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH COLUMNS.
----------------------------------------------------
----------------------------------------------------
[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.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
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 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. NOTE THAT THE SCREEN WILL REQUIRE AN AMOUNT FOR PERSON/FAMILY IN THE DOLLAR COLUMN IN ORDER TO PROCEED. THIS DOLLAR AMOUNT MAY BE ENTERED BY THE INTERVIEWER OR CALCULATED BY CAPI BASED ON % OF TOTAL CHARGE WHERE TOTAL CHARGE IS KNOWN.
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.
----------------------------------------------------
----------------------------------------------------
SOFT CHECK:
$0 - $10,000
----------------------------------------------------
----------------------------------------------------
CONTINUE WITH BOX_06
----------------------------------------------------
----------------------------------------------------
ROSTER DETAILS:
TITLE: EVNT_SOP_1

COL # 1 HEADER: SOURCE OF PAYMENT
INSTRUCTIONS: DISPLAY PAYMENT SOURCE NAME (PAYM.REIMNAM/PAYF.REIMNAM)

COL # 2 HEADER: DOLLAR AMOUNT PAID
INSTRUCTIONS: ENTER $ AMOUNT PAID (PAYM.AMTPAID/PAYF.AMTPAID)

COL # 3 HEADER: PERCENT AMOUNT PAID
INSTRUCTIONS: ENTER % AMOUNT PAID (PAYM.PCTPAID/PAYF.PCTPAID)
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION:
DISPLAY THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER FOR ENTRY.
----------------------------------------------------
----------------------------------------------------
ROSTER BEHAVIOR:
1. SOURCE COLUMN IS PROTECTED; NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.

2. THE PERSON/FAMILY AMOUNT MAY BE CHANGED OR CORRECTED.

3. THE INTERVIEWER CAN ENTER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.

4. THE AMOUNT PAID COLUMNS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.

5. WHEN THE 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.

6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
----------------------------------------------------
----------------------------------------------------
ROSTER FILTER:
DISPLAY ALL SOURCES SELECTED AT CP12A FOR THIS EVENT-PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------

[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]]
Has any [other] source already paid for any of the charges for [this hospital stay/this visit/the last purchase of [NAME OF PRESCRIBED MEDICINE]/the services for (FLAT FEE GROUP)/the [OME ITEM GROUP NAME]/the services received at home]?

YES .................................... 1 [CP12A]
NO ..................................... 2 [BOX_06]
REF ................................... -7 [BOX_06]
DK .................................... -8 [BOX_06]
HELP AVAILABLE 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 OR 0% WAS ENTERED AT CP11OV1 OR CP11OV2. OTHERWISE USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'this hospital stay' IF EVENT TYPE IS HS.

DISPLAY 'this visit' IF EVENT TYPE IS ER, OP, MV, OR DN.

DISPLAY 'the last purchase of [NAME OF PRESCRIBED MEDICINE]' IF EVENT TYPE IS PM.

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

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

DISPLAY 'the [OME ITEM GROUP NAME]' IF EVENT TYPE IS OM.

DISPLAY 'the services received at home' 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 '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 did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TOTAL CHARGE: [$XXXXXXXXX]

ROSTER. SOURCE OF PAYMENT CP13_02. DOLLAR AMOUNT 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]
HELP AVAILABLE FOR A DEFINITION OF PAYMENTS MADE DIRECTLY TO PROVIDER.
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'DOLLAR AMOUNT PAID' OR 'PERCENT AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN THE 'DOLLAR AMOUNT PAID' COLUMN. IF THE RESPONSE TO CP11 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN THE 'PERCENT AMOUNT PAID' COLUMN. IF THE DOLLAR AMOUNT AT CP11 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH COLUMNS. IF DOLLAR AMOUNT AT CP11 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH COLUMNS.
----------------------------------------------------
----------------------------------------------------
[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.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
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 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. NOTE THAT THE SCREEN WILL REQUIRE AN AMOUNT FOR PERSON/FAMILY IN THE DOLLAR COLUMN IN ORDER TO PROCEED. THIS DOLLAR AMOUNT MAY BE ENTERED BY THE INTERVIEWER OR CALCULATED BY CAPI BASED ON % OF TOTAL CHARGE WHERE TOTAL CHARGE IS KNOWN.
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.
----------------------------------------------------
----------------------------------------------------
SOFT CHECK:
$0 - $10,000
----------------------------------------------------
----------------------------------------------------
CONTINUE WITH BOX_06
----------------------------------------------------
----------------------------------------------------
ROSTER DETAILS:
TITLE: EVNT_SOP_1

COL # 1 HEADER: SOURCE OF PAYMENT
INSTRUCTIONS: DISPLAY PAYMENT SOURCE NAME (PAYM.REIMNAM/PAYF.REIMNAM)

COL # 2 HEADER: DOLLAR AMOUNT PAID
INSTRUCTIONS: ENTER $ AMOUNT PAID (PAYM.AMTPAID/PAYF.AMTPAID)

COL # 3 HEADER: PERCENT AMOUNT PAID
INSTRUCTIONS: ENTER % AMOUNT PAID (PAYM.PCTPAID/PAYF.PCTPAID)
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION:
DISPLAY THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER FOR ENTRY.
----------------------------------------------------
----------------------------------------------------
ROSTER BEHAVIOR:
1. SOURCE COLUMN IS PROTECTED; NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.

2. THE PERSON/FAMILY AMOUNT MAY BE CHANGED OR CORRECTED.

3. THE INTERVIEWER CAN ENTER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.

4. THE AMOUNT PAID COLUMNS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.

5. WHEN THE 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.

6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
----------------------------------------------------
----------------------------------------------------
ROSTER FILTER:
DISPLAY ALL SOURCES SELECTED AT CP12A FOR THIS EVENT-PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------

[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]]
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)]?

YES .................................... 1 [CP12A]
NO ..................................... 2 [BOX_06]
REF ................................... -7 [BOX_06]
DK .................................... -8 [BOX_06]
HELP AVAILABLE 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 OR 0% WAS ENTERED AT CP11OV1 OR CP11OV2. OTHERWISE USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. IF EVENT TYPE IS PM OR OM, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)' IF EVENT TYPE IS HS.

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

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

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

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

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

DISPLAY 'the services received at home from (PROVIDER) during (MONTH) for (PERSON)' 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]]
[NAME OF PRESCRIBED MEDICINE] [OME ITEM GROUP NAME]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TOTAL CHARGE: [$XXXXXXXXX]

ROSTER. SOURCE OF PAYMENT CP13_02. DOLLAR AMOUNT 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]
HELP AVAILABLE FOR A DEFINITION OF PAYMENTS MADE DIRECTLY TO PROVIDER.
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'DOLLAR AMOUNT PAID' OR 'PERCENT AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN THE 'DOLLAR AMOUNT PAID' COLUMN. IF THE RESPONSE TO CP11 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN THE 'PERCENT AMOUNT PAID' COLUMN. IF THE DOLLAR AMOUNT AT CP11 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH COLUMNS. IF DOLLAR AMOUNT AT CP11 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH COLUMNS.
----------------------------------------------------
----------------------------------------------------
[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 '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.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
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 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. NOTE THAT THE SCREEN WILL REQUIRE AN AMOUNT FOR PERSON/FAMILY IN THE DOLLAR COLUMN IN ORDER TO PROCEED. THIS DOLLAR AMOUNT MAY BE ENTERED BY THE INTERVIEWER OR CALCULATED BY CAPI BASED ON % OF TOTAL CHARGE WHERE TOTAL CHARGE IS KNOWN.
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.
----------------------------------------------------
----------------------------------------------------
SOFT CHECK:
$0 - $10,000
----------------------------------------------------
----------------------------------------------------
CONTINUE WITH BOX_06
----------------------------------------------------
----------------------------------------------------
ROSTER DETAILS:
TITLE: EVNT_SOP_1

COL # 1 HEADER: SOURCE OF PAYMENT
INSTRUCTIONS: DISPLAY PAYMENT SOURCE NAME (PAYM.REIMNAM/PAYF.REIMNAM)

COL # 2 HEADER: DOLLAR AMOUNT PAID
INSTRUCTIONS: ENTER $ AMOUNT PAID (PAYM.AMTPAID/PAYF.AMTPAID)

COL # 3 HEADER: PERCENT AMOUNT PAID
INSTRUCTIONS: ENTER % AMOUNT PAID (PAYM.PCTPAID/PAYF.PCTPAID)
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION:
DISPLAY THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER FOR ENTRY.
----------------------------------------------------
----------------------------------------------------
ROSTER BEHAVIOR:
1. SOURCE COLUMN IS PROTECTED; NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.

2. THE PERSON/FAMILY AMOUNT MAY BE CHANGED OR CORRECTED.

3. THE INTERVIEWER CAN ENTER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.

4. THE AMOUNT PAID COLUMNS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.

5. WHEN THE 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.

6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
----------------------------------------------------
----------------------------------------------------
ROSTER FILTER:
DISPLAY ALL SOURCES SELECTED AT CP12A FOR THIS EVENT-PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------

[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]]
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)]?

YES .................................... 1 [CP12A]
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
HELP AVAILABLE FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
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.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 OR 0% WAS ENTERED AT CP11OV1 OR CP11OV2. OTHERWISE USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. IF EVENT TYPE IS PM OR OM, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)' IF EVENT TYPE IS HS.

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

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

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

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

DISPLAY 'the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)' 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/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 did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.

TOTAL CHARGE: [$XXXXXXXXX]
--------------------------------------------------------------------
ROSTER. SOURCE OF PAYMENT CP13_02. DOLLAR CP13_03. PERCENT AMOUNT PAID AMOUNT PAID
--------------------------------------------------------------------
PERSON/Family [Display $ Amount] [Display % Amount]
--------------------------------------------------------------------
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
--------------------------------------------------------------------
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
---------------------------------------------------------------------
----------------------------------------------------
DISPLAY [NAME OF MEDICAL CARE PROVIDER] IN THE CONTEXT HEADER IF THE EVENT TYPE IS NOT 'PM' (PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES). OTHERWISE, USE NULL VALUE.

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

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

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

DISPLAY 'FLAT FEE GROUP: [NAME OF FLAT FEE EVENT GROUP]' IN THE CONTEXT HEADER IF THIS EVENT IS A FLAT FEE STEM.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'DOLLAR AMOUNT PAID' OR 'PERCENT AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN THE 'DOLLAR AMOUNT PAID' COLUMN. IF THE RESPONSE TO CP11 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN THE 'PERCENT AMOUNT PAID' COLUMN. IF THE DOLLAR AMOUNT AT CP11 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH COLUMNS. IF DOLLAR AMOUNT AT CP11 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH COLUMNS.
----------------------------------------------------
----------------------------------------------------
[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.

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).
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
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 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. NOTE THAT THE SCREEN WILL REQUIRE AN AMOUNT FOR PERSON/FAMILY IN THE DOLLAR COLUMN IN ORDER TO PROCEED. THIS DOLLAR AMOUNT MAY BE ENTERED BY THE INTERVIEWER OR CALCULATED BY CAPI BASED ON % OF TOTAL CHARGE WHERE TOTAL CHARGE IS KNOWN.
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.
----------------------------------------------------
----------------------------------------------------
SOFT CHECK:
$0 - $10,000
----------------------------------------------------
----------------------------------------------------
CONTINUE WITH CP13OV
----------------------------------------------------
----------------------------------------------------
ROSTER DETAILS:
TITLE: EVNT_SOP_1

COL # 1 HEADER: SOURCE OF PAYMENT
INSTRUCTIONS: DISPLAY PAYMENT SOURCE NAME (PAYM.REIMNAM/PAYF.REIMNAM)

COL # 2 HEADER: DOLLAR AMOUNT PAID
INSTRUCTIONS: ENTER $ AMOUNT PAID (PAYM.AMTPAID/PAYF.AMTPAID)

COL # 3 HEADER: PERCENT AMOUNT PAID
INSTRUCTIONS: ENTER % AMOUNT PAID (PAYM.PCTPAID/PAYF.PCTPAID)
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION:
DISPLAY THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER FOR ENTRY.
----------------------------------------------------
----------------------------------------------------
ROSTER BEHAVIOR:
1. SOURCE COLUMN IS PROTECTED; NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.

2. THE PERSON/FAMILY AMOUNT MAY BE CHANGED OR CORRECTED.

3. THE INTERVIEWER CAN ENTER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.

4. THE AMOUNT PAID COLUMNS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.

5. WHEN THE 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.

6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
----------------------------------------------------
----------------------------------------------------
ROSTER FILTER:
DISPLAY ALL SOURCES SELECTED AT CP12A FOR THIS EVENT-PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------

[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)]?

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 OR 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...........]
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. DOLLAR AMOUNT 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..]]
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)]?

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 OR 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...........]
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_. DOLLAR AMOUNT PAID
CP13_03. PERCENT AMOUND 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?

YES .................................... 1
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...........]
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.
----------------------------------------------------

[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)]?

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 OR 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...........]
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. DOLLAR AMOUNT 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..]]
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)]?

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 OR 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...........]
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. DOLLAR AMOUNT 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 CAREPROVIDER.] [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)]?

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.
----------------------------------------------------

[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]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLAR AMOUNT 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..]]
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.
----------------------------------------------------

[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]

ROSTER. SOURCE OF PAYMENT
CO06_02. DOLLAR AMOUNT PAID
CP13_03. 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]
----------------------------------------------------
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..]]
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.
----------------------------------------------------

[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]

ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLAR AMOUNT 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..]]
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.
----------------------------------------------------

[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]

--------------------------------------------------------------------
ROSTER. SOURCE OF PAYMENT CP13_02. DOLLAR CP13_03. PERCENT AMOUNT PAID 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'.
----------------------------------------------------

[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)]?

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.
----------------------------------------------------

[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]

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).
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