RIC         1  3                                        C RECORD IDENTIFICATION CODE

FILEYR      4  2                                        C YY REFERENCE YEAR OF RECORD

BASEID      6  8  $BSIDFMT                              C UNIQUE IDENTIFICATION NUMBER

                             264,593             LOW-HIGH BASEID Count

EVNTNUM    14  4  $EVNTNUM                              C UNIQUE EVENT IDENTIFIER

                             125,699            C000-C999 EVENT CREATED FROM CLAIM
                             138,894            0000-9999 SURVEY REPORTED EVENT

EVNTTYPE   18  2  $EVNTTYP                              C EVENT TYPE

                                   0                   DU DENTAL
                                   0                   ER EMERGENCY ROOM
                                   0                   IP INPATIENT
                                   0                   IU INSTITUTIONAL UTILIZATION
                             132,700                   MP MEDICAL PROVIDER
                              28,101                   OM OTHER MEDICAL EXPENSE
                                   0                   OP OUTPATIENT
                                   0                   PM PRESCRIBED MEDICINE
                              55,151                   SD SEP BILLING DOCTOR
                              48,641                   SL SEP BILLING LAB

OREVTYPE   20  2  $EVNTTYP                              C ORIGINAL REPORTED EVENT TYPE

                             125,699
                                   0                   DU DENTAL
                                 885                   ER EMERGENCY ROOM
                                 118                   IP INPATIENT
                                   0                   IU INSTITUTIONAL UTILIZATION
                              94,010                   MP MEDICAL PROVIDER
                              19,244                   OM OTHER MEDICAL EXPENSE
                                   0                   OP OUTPATIENT
                                   0                   PM PRESCRIBED MEDICINE
                              18,249                   SD SEP BILLING DOCTOR
                               6,388                   SL SEP BILLING LAB

CLAIMID    22  6                                        N CLAIM THIS SURVEY EVENT MATCHED TO

HMO        28  1  $HMO                                  C EVENT PROVIDED BY AN HMO?

                             248,644                    0 EVENT NOT PROV BY HMO
                              15,949                    1 EVENT PROVIDED BY HMO

EVBEGYY    29  2  EVYY                                  N EVENT BEGIN YEAR

                               5,387                    . INAPPLICABLE
                                  72                   -9 NOT ASCERTAINED
                                 256                   -8 DK
                             258,878                 1-99 YEAR

EVBEGMM    31  2  EVMM                                  N EVENT BEGIN MONTH

                               5,387                    . INAPPLICABLE
                                 155                   -9 NOT ASCERTAINED
                                 606                   -8 DK
                                   1                   -7 REFUSED
                             258,444                 1-12 MONTH
                                   0                   95 STILL IN PROGRESS

EVBEGDD    33  2  EVDD                                  N EVENT BEGIN YEAR

                               5,387                    . INAPPLICABLE
                                 185                   -9 NOT ASCERTAINED
                               6,928                   -8 DK
                                  60                   -7 REFUSED
                                  89                   -5 MULTIPLE VISITS THIS MONTH
                             251,944                 1-31 DAY OF MONTH

SOURCE     35  1  $SOURCE                               C SOURCE OF EVENT: SURVEY, CLAIM, OR BOTH?

                              53,825                    1 SURVEY ONLY
                             125,699                    2 CLAIMS ONLY
                              85,069                    3 BOTH SURVEY & CLAIMS

SITCODE    36  1  $SITCODE                              C COMMUNITY OR FACILITY SETTING?

                                 286                    B BOTH COMM & FACILITY
                             216,922                    C COMMUNITY
                              18,402                    D DEEMED COMMUNITY
                              28,395                    F FACILITY
                                 588                    G DEEMED FACILITY

AMTTOT     37  9                                        N TOTAL PAYMENT

IMPATOT    46  1  IMPFLAG                               N IMPUTATION FLAG: AMT TOTAL PAYMENT

                             196,996                    0 NOT IMPUTED
                              67,597                    1 IMPUTED

AMTCOV     47  9                                        N PORTION OF TOTAL PAY COV BY MEDICARE

AMTNCOV    56  9                                        N PORTION OF TOTAL PAY NOT COV BY MEDICARE

AMTCARE    65  9                                        N AMOUNT PAID BY MEDICARE

IMPSCARE   74  1  IMPFLAG                               N IMPUTATION FLAG: SOP MEDICARE

                             263,861                    0 NOT IMPUTED
                                 732                    1 IMPUTED

IMPACARE   75  1  IMPFLAG                               N IMPUTATION FLAG: AMT MEDICARE

                             256,030                    0 NOT IMPUTED
                               8,563                    1 IMPUTED

AMTCAID    76  9                                        N AMOUNT PAID BY MEDICAID

IMPSCAID   85  1  IMPFLAG                               N IMPUTATION FLAG: SOP MEDICAID

                             241,814                    0 NOT IMPUTED
                              22,779                    1 IMPUTED

IMPACAID   86  1  IMPFLAG                               N IMPUTATION FLAG: AMT MEDICAID

                             213,354                    0 NOT IMPUTED
                              51,239                    1 IMPUTED

AMTHMOM    87  9                                        N AMOUNT PAID BY MEDICARE HMO

IMPSHMOM   96  1  IMPFLAG                               N IMPUTATION FLAG: SOP MEDICARE HMO

                             263,331                    0 NOT IMPUTED
                               1,262                    1 IMPUTED

IMPAHMOM   97  1  IMPFLAG                               N IMPUTATION FLAG: AMT MEDICARE HMO

                             260,257                    0 NOT IMPUTED
                               4,336                    1 IMPUTED

AMTHMOP    98  9                                        N AMOUNT PAID BY PRIVATE HMO

IMPSHMOP  107  1  IMPFLAG                               N IMPUTATION FLAG: SOP PRIVATE HMO

                             262,068                    0 NOT IMPUTED
                               2,525                    1 IMPUTED

IMPAHMOP  108  1  IMPFLAG                               N IMPUTATION FLAG: AMT PRIVATE HMO

                             260,822                    0 NOT IMPUTED
                               3,771                    1 IMPUTED

AMTVA     109  9                                        N AMOUNT PAID BY VETERANS ADM

IMPSVA    118  1  IMPFLAG                               N IMPUTATION FLAG: SOP VETERANS ADM

                             264,555                    0 NOT IMPUTED
                                  38                    1 IMPUTED

IMPAVA    119  1  IMPFLAG                               N IMPUTATION FLAG: AMT VETERANS ADM

                             263,858                    0 NOT IMPUTED
                                 735                    1 IMPUTED

AMTPRVE   120  9                                        N AMOUNT PAID BY PRIV INS (EMPLOYER SPONS)

IMPSPRVE  129  1  IMPFLAG                               N IMPUTATION FLAG: SOP PRIV INS-EMPLOYER

                             242,049                    0 NOT IMPUTED
                              22,544                    1 IMPUTED

IMPAPRVE  130  1  IMPFLAG                               N IMPUTATION FLAG: AMT PRIV INS-EMPLOYER

                             237,896                    0 NOT IMPUTED
                              26,697                    1 IMPUTED

AMTPRVI   131  9                                        N AMOUNT PAID BY PRIV INS (INDIV PURCH)

IMPSPRVI  140  1  IMPFLAG                               N IMPUTATION FLAG: SOP PRIV INS-INDIV PUR

                             239,894                    0 NOT IMPUTED
                              24,699                    1 IMPUTED

IMPAPRVI  141  1  IMPFLAG                               N IMPUTATION FLAG: AMT PRIV INS-INDIV PUR

                             235,982                    0 NOT IMPUTED
                              28,611                    1 IMPUTED

AMTPRVU   142  9                                        N AMOUNT PAID BY PRIV INS (UNKNOWN PURCH)

IMPSPRVU  151  1  IMPFLAG                               N IMPUTATION FLAG: SOP PRIV INS-UNKNOWN

                             261,956                    0 NOT IMPUTED
                               2,637                    1 IMPUTED

IMPAPRVU  152  1  IMPFLAG                               N IMPUTATION FLAG: AMT PRIV INS-UNKNOWN

                             261,956                    0 NOT IMPUTED
                               2,637                    1 IMPUTED

AMTOOP    153  9                                        N AMOUNT PAID BY PERSON/FAMILY

IMPSOOP   162  1  IMPFLAG                               N IMPUTATION FLAG: SOP PAID BY PERSON

                             220,098                    0 NOT IMPUTED
                              44,495                    1 IMPUTED

IMPAOOP   163  1  IMPFLAG                               N IMPUTATION FLAG: AMT PAID BY PERSON

                             203,176                    0 NOT IMPUTED
                              61,417                    1 IMPUTED

AMTDISC   164  9                                        N AMOUNT OF UNCOLLECTED LIABILITIES

IMPSDISC  173  1  IMPFLAG                               N IMPUTATION FLAG: SOP OF UNCOLL LIAB

                             259,581                    0 NOT IMPUTED
                               5,012                    1 IMPUTED

IMPADISC  174  1  IMPFLAG                               N IMPUTATION FLAG: AMT OF UNCOLL LIAB

                             257,464                    0 NOT IMPUTED
                               7,129                    1 IMPUTED

AMTOTH    175  9                                        N AMOUNT PAID BY OTHER SOURCES

IMPSOTH   184  1  IMPFLAG                               N IMPUTATION FLAG: SOP OTHER SOURCES

                             263,715                    0 NOT IMPUTED
                                 878                    1 IMPUTED

IMPAOTH   185  1  IMPFLAG                               N IMPUTATION FLAG: AMT OTHER SOURCES

                             261,957                    0 NOT IMPUTED
                               2,636                    1 IMPUTED

PAMTMED   186  9                                        N TOTAL AMOUNT PAID FOR MEDICAL SERVICES

PAMTSURG  195  9                                        N TOTAL AMOUNT PAID FOR SURGICAL SERVICES

PAMTLABX  204  9                                        N TOTAL AMOUNT PAID FOR LAB/X-RAY

PAMTOM    213  9                                        N TOTAL AMOUNT PAID FOR OTH MED SERVICES

PAMTPM    222  9                                        N TOTAL AMOUNT PAID FOR PRES MEDICINES

PROVSPEC  231  2  PROVSPEC                              N MEDICAL PROVIDER SPECIALTY

                             125,699                    .
                                 211                   -9 NOT ASCERTAINED
                                 478                   -8 DK
                              36,554                   -1 INAPPLICABLE
                                 185                    1 DENTIST/DENTAL PROVIDER
                              78,804                    2 MEDICAL DOCTOR
                                 309                    3 AUDIOLOGIST
                               4,632                    4 CHIROPRACTOR
                                 238                    5 CLINICAL SOCIAL WORKER
                                  35                    6 DIETITIAN-NUTRITIONIST
                                  11                    7 HEARING THERAPIST
                                  55                    8 HOME HEALTH/HEALTH AIDE
                                   4                    9 HOMEMAKER
                                  24                   10 HOSPICE WORKER
                                  47                   11 I.V. THERAPIST
                               1,789                   12 NURSE (RN)
                                  66                   13 NURSE PRACTITIONER (LPN)
                                  19                   14 NURSE'S AIDE
                                 343                   15 OCCUPATIONAL THERAPIST (OT)
                               2,306                   16 OPTOMETRIST
                                 122                   17 OSTEOPATH (DO)
                                 102                   18 PARAMEDIC
                               3,750                   19 PHYSICAL THERAPIST (PT)
                                 107                   20 PHYSICIAN'S ASSISTANT
                               2,750                   21 PODIATRIST (FOOT DOCTOR)
                               1,111                   22 PSYCHOLOGIST
                                  88                   23 RESPIRATORY THERAPIST
                                 562                   24 SOCIAL/CASE WORKER
                                 134                   25 SPEECH THERAPIST
                                 667                   26 THERAPIST (MENTAL HEALTH)
                                 824                   27 X-RAY TECHNICIAN
                               2,567                   91 OTHER MEDICAL PROVIDER

OMETYPE   233  2  OMETYPE                               N TYPE OF OM EVENT

                             255,664                    .
                                  91                   -1 INAPPLICABLE
                                 126                    1 EYEGLASSES
                                   8                    2 HEARING OR SPEECH DEVICE
                               1,249                    3 ORTHOPEDIC
                                 260                    4 DIABETIC
                               1,863                    5 AMBULANCE
                                  70                    6 PROSTHESIS
                                  62                    7 ALTERATION
                               1,138                    8 OXYGEN
                                  42                    9 KIDNEY DIALYSIS
                               4,020                   10 OTHER

ORTHTYPE  235  2  ORTHTYPE                              N TYPE OF ORTHOPEDIC ITEM

                             124,451                    .
                             136,932                   -1 INAPPLICABLE
                                 437                    1 BRACES OR SUPPORTS
                                 276                    2 CANE
                                 168                    3 CORRECTIVE SHOES OR INSERTS
                                  46                    4 CRUTCHES
                                 387                    5 WALKER
                               1,785                    6 WHEELCHAIR
                                 111                   91 OTHER

ALTRTYPE  237  2  ALTRTYPE                              N TYPE OF ALTERATION

                             125,637                    .
                             138,644                   -1 INAPPLICABLE
                                   6                    1 ELEVATOR OR INCLINE CHAIR
                                  83                    2 HANDRAILS (OTHER THAN TUB)
                                  37                    3 RAMPS
                                  61                    4 TUB HANDRAILS
                                  13                    5 TUB SEAT
                                  13                    6 ANY CAR ALTERATION
                                  99                   91 OTHER

OTHRTYPE  239  2  OTHRTYPE                              N TYPE OF OTHER OME

                             121,684                    .
                                   1                   -9 NOT ASCERTAINED
                             132,776                   -1 INAPPLICABLE
                                 358                    1 PORT./RAISED TOILET
                                  65                    2 PORTABLE TUB SEAT
                                 117                    3 SPECIAL CHAIR OR CUSHION
                                 948                    4 HOSPITAL BED
                                 818                    5 OSTOMY SUPPLIES
                               3,892                    6 DEPENDS (DIAPERS)
                                 436                    7 BANDAGES,DRESSINGS,TAPE SUPP.
                               3,498                   91 OTHER

