RIC         1  2                                        C Record Identification Code

VERSION     3  1                                        C Version Number

BASEID      4  8  $BSIDFMT                              C Unique SP Identification Number

                              12,395             LOW-HIGH BASEID Count

EVNTNUM    14  4                                        C Unique event identifier

OREVTYPE   18  2  $EVN2TYP                              C Original reported event type

                                   1                      Missing
                              12,394                   DU Dental
                                   0                   IP Inpatient
                                   0                   IU Institutional utilization
                                   0                   MP Medical provider
                                   0                   OM Other medical expense
                                   0                   OP Outpatient
                                   0                   PM Prescribed medicine
                                   0                   SD Separate billing doctor
                                   0                   SL Separate billing lab

CLAIMID    20  7                                        N Claim this survey event matched to

EVBEGYY    27  2  $EVENTYY                              C Event begin year

                                   6                   -8 Don't know
                              12,389                      Year

EVBEGMM    29  2  $EVENTMM                              C Event begin month

                                 107                   -8 Don't know
                                   0                   95 Still in progress
                              12,288                      Month

EVBEGDD    31  2  $EVENTDD                              C Event begin year

                               3,011                   -8 Don't know
                               9,384                      Day of month

SOURCE     33  1  $SOURCE                               C Source of event: survey, claim, or both?

                              12,393                    1 Survey only
                                   1                    2 Claims only
                                   1                    3 Both survey & claims

SITCODE    34  1  $SITCODE                              C Community or facility setting?

                                   1                    B Both community & facility
                              12,383                    C Community
                                   4                    D Deemed community
                                   0                    F Facility
                                   1                    G Deemed facility
                                   6                    S SNF

AMTTOT     35  9                                        N Total payment

IMPATOT    44  1  IMPFLAG                               N AMTTOT imputed in part or in total?

                               8,218                    0 Not imputed
                               4,177                    1 Imputed

AMTCOV     45  9                                        N Medicare program liability, incl. copays

AMTNCOV    54  9                                        N Total payment not covered by Medicare

AMTCARE    63  9                                        N Amount paid by Medicare

IMPSCARE   72  1  IMPFLAG                               N AMTCARE payment source imputed?

                              12,395                    0 Not imputed
                                   0                    1 Imputed

IMPACARE   73  1  IMPFLAG                               N AMTCARE payment amount imputed?

                              12,395                    0 Not imputed
                                   0                    1 Imputed

AMTCAID    74  9                                        N Amount paid by Medicaid

IMPSCAID   83  1  IMPFLAG                               N AMTCAID payment source imputed?

                              12,390                    0 Not imputed
                                   5                    1 Imputed

IMPACAID   84  1  IMPFLAG                               N AMTCAID payment amount imputed?

                              12,132                    0 Not imputed
                                 263                    1 Imputed

AMTHMOM    85  9                                        N Amount paid by Medicare HMO

IMPSHMOM   94  1  IMPFLAG                               N AMTHMOM payment source imputed?

                              12,100                    0 Not imputed
                                 295                    1 Imputed

IMPAHMOM   95  1  IMPFLAG                               N AMTHMOM payment amount imputed?

                              11,926                    0 Not imputed
                                 469                    1 Imputed

AMTHMOP    96  9                                        N Amount paid by private HMO

IMPSHMOP  105  1  IMPFLAG                               N AMTHMOP payment source imputed?

                              12,199                    0 Not imputed
                                 196                    1 Imputed

IMPAHMOP  106  1  IMPFLAG                               N AMTHMOP payment amount imputed?

                              12,120                    0 Not imputed
                                 275                    1 Imputed

AMTVA     107  9                                        N Amount paid by Veterans Administration

IMPSVA    116  1  IMPFLAG                               N AMTVA payment source imputed?

                              12,393                    0 Not imputed
                                   2                    1 Imputed

IMPAVA    117  1  IMPFLAG                               N AMTVA payment amount imputed?

                              12,296                    0 Not imputed
                                  99                    1 Imputed

AMTPRVE   118  9                                        N Amt paid by employer-sponsored priv ins

IMPSPRVE  127  1  IMPFLAG                               N AMTPRVE payment source imputed?

                              11,876                    0 Not imputed
                                 519                    1 Imputed

IMPAPRVE  128  1  IMPFLAG                               N AMTPRVE payment amount imputed?

                              11,021                    0 Not imputed
                               1,374                    1 Imputed

AMTPRVI   129  9                                        N Amt paid by individually-purch priv ins

IMPSPRVI  138  1  IMPFLAG                               N AMTPRVI payment source imputed?

                              12,225                    0 Not imputed
                                 170                    1 Imputed

IMPAPRVI  139  1  IMPFLAG                               N AMTPRVI payment amount imputed?

                              12,069                    0 Not imputed
                                 326                    1 Imputed

AMTPRVU   140  9                                        N Amt paid by priv ins (unknown purchased)

IMPSPRVU  149  1  IMPFLAG                               N AMTPRVU payment source imputed?

                              12,395                    0 Not imputed
                                   0                    1 Imputed

IMPAPRVU  150  1  IMPFLAG                               N AMTPRVU payment amount imputed?

                              12,395                    0 Not imputed
                                   0                    1 Imputed

AMTOOP    151  9                                        N Amount paid out-of-pocket (OOP)

IMPSOOP   160  1  IMPFLAG                               N AMTOOP payment source imputed?

                              11,077                    0 Not imputed
                               1,318                    1 Imputed

IMPAOOP   161  1  IMPFLAG                               N AMTOOP payment amount imputed?

                              10,242                    0 Not imputed
                               2,153                    1 Imputed

AMTDISC   162  9                                        N Amount of uncollected SP liability

IMPSDISC  171  1  IMPFLAG                               N AMTDISC payment source imputed?

                              11,830                    0 Not imputed
                                 565                    1 Imputed

IMPADISC  172  1  IMPFLAG                               N AMTDISC payment amount imputed?

                              11,411                    0 Not imputed
                                 984                    1 Imputed

AMTOTH    173  9                                        N Amount paid by other payor(s)

IMPSOTH   182  1  IMPFLAG                               N AMTOTH payment source imputed?

                              12,395                    0 Not imputed
                                   0                    1 Imputed

IMPAOTH   183  1  IMPFLAG                               N AMTOTH payment amount imputed?

                              12,345                    0 Not imputed
                                  50                    1 Imputed

DVBRIDGE  184  2  YES4FMT                               N Dental visit service - bridge

                                   1                    . Missing
                                  37                   -9 Not ascertained
                                  24                   -8 Don't know
                                  13                   -1 Inapplicable
                               1,799                    1 Yes
                              10,521                    2 No

DVCLEAN   186  2  YES4FMT                               N Dental visit service - cleaning

                                   1                    . Missing
                                  37                   -9 Not ascertained
                                  24                   -8 Don't know
                                  13                   -1 Inapplicable
                               5,739                    1 Yes
                               6,581                    2 No

DVCROWN   188  2  YES4FMT                               N Dental visit service - crown

                                   1                    . Missing
                                  37                   -9 Not ascertained
                                  24                   -8 Don't know
                                  13                   -1 Inapplicable
                               1,121                    1 Yes
                              11,199                    2 No

DVEXAM    190  2  YES4FMT                               N Dental visit service - examination

                                   1                    . Missing
                                  37                   -9 Not ascertained
                                  24                   -8 Don't know
                                  13                   -1 Inapplicable
                               5,681                    1 Yes
                               6,639                    2 No

DVEXTRAC  192  2  YES4FMT                               N Dental visit service - tooth extraction

                                   1                    . Missing
                                  36                   -9 Not ascertained
                                  24                   -8 Don't know
                                  13                   -1 Inapplicable
                                 879                    1 Yes
                              11,442                    2 No

DVFILLNG  194  2  YES4FMT                               N Dental visit service - filling

                                   1                    . Missing
                                  35                   -9 Not ascertained
                                  24                   -8 Don't know
                                  13                   -1 Inapplicable
                               1,530                    1 Yes
                              10,792                    2 No

DVORTHO   196  2  YES4FMT                               N Dental visit service - orthodontics

                                   1                    . Missing
                                  36                   -9 Not ascertained
                                  25                   -8 Don't know
                                  13                   -1 Inapplicable
                                  86                    1 Yes
                              12,234                    2 No

DVOTHER   198  2  YES4FMT                               N Dental visit service - other

                                   1                    . Missing
                                  37                   -9 Not ascertained
                                  24                   -8 Don't know
                                  13                   -1 Inapplicable
                                 249                    1 Yes
                              12,071                    2 No

DVRTCNAL  200  2  YES4FMT                               N Dental visit service - root canal

                                   1                    . Missing
                                  36                   -9 Not ascertained
                                  24                   -8 Don't know
                                  13                   -1 Inapplicable
                                 350                    1 Yes
                              11,971                    2 No

DVXRAYS   202  2  YES4FMT                               N Dental visit service - X-rays

                                   1                    . Missing
                                  37                   -9 Not ascertained
                                  25                   -8 Don't know
                                  13                   -1 Inapplicable
                               3,684                    1 Yes
                               8,635                    2 No

HMO       204  1  $HMO                                  C Event provided by an HMO?

                               8,605                    0 Event not provided by HMO
                               3,790                    1 Event provided by HMO

