RIC         1  2                                        C Record Identification Code

VERSION     3  1                                        C Version Number

BASEID      4  8  $BSIDFMT                              C Unique SP Identification Number

                              10,795             LOW-HIGH BASEID Count

EVNTNUM    14  4                                        C Unique event identifier

OREVTYPE   18  2  $EVN2TYP                              C Original reported event type

                              10,795                   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

                                  11                   -8 Don't know
                              10,784                      Year

EVBEGMM    29  2  $EVENTMM                              C Event begin month

                                 131                   -8 Don't know
                                   0                   95 Still in progress
                              10,664                      Month

EVBEGDD    31  2  $EVENTDD                              C Event begin year

                                   3                   -7 Refused
                               3,430                   -8 Don't know
                               7,362                      Day of month

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

                              10,752                    1 Survey only
                                   0                    2 Claims only
                                  43                    3 Both survey & claims

SITCODE    34  1  $SITCODE                              C Community or facility setting?

                                   5                    B Both community & facility
                              10,787                    C Community
                                   2                    D Deemed community
                                   0                    F Facility
                                   0                    G Deemed facility
                                   1                    S SNF

AMTTOT     35  9                                        N Total payment

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

                               6,170                    0 Not imputed
                               4,625                    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?

                              10,795                    0 Not imputed
                                   0                    1 Imputed

IMPACARE   73  1  IMPFLAG                               N AMTCARE payment amount imputed?

                              10,795                    0 Not imputed
                                   0                    1 Imputed

AMTCAID    74  9                                        N Amount paid by Medicaid

IMPSCAID   83  1  IMPFLAG                               N AMTCAID payment source imputed?

                              10,792                    0 Not imputed
                                   3                    1 Imputed

IMPACAID   84  1  IMPFLAG                               N AMTCAID payment amount imputed?

                              10,467                    0 Not imputed
                                 328                    1 Imputed

AMTHMOM    85  9                                        N Amount paid by Medicare HMO

IMPSHMOM   94  1  IMPFLAG                               N AMTHMOM payment source imputed?

                              10,353                    0 Not imputed
                                 442                    1 Imputed

IMPAHMOM   95  1  IMPFLAG                               N AMTHMOM payment amount imputed?

                              10,109                    0 Not imputed
                                 686                    1 Imputed

AMTHMOP    96  9                                        N Amount paid by private HMO

IMPSHMOP  105  1  IMPFLAG                               N AMTHMOP payment source imputed?

                              10,610                    0 Not imputed
                                 185                    1 Imputed

IMPAHMOP  106  1  IMPFLAG                               N AMTHMOP payment amount imputed?

                              10,473                    0 Not imputed
                                 322                    1 Imputed

AMTVA     107  9                                        N Amount paid by Veterans Administration

IMPSVA    116  1  IMPFLAG                               N AMTVA payment source imputed?

                              10,795                    0 Not imputed
                                   0                    1 Imputed

IMPAVA    117  1  IMPFLAG                               N AMTVA payment amount imputed?

                              10,723                    0 Not imputed
                                  72                    1 Imputed

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

IMPSPRVE  127  1  IMPFLAG                               N AMTPRVE payment source imputed?

                              10,401                    0 Not imputed
                                 394                    1 Imputed

IMPAPRVE  128  1  IMPFLAG                               N AMTPRVE payment amount imputed?

                               9,556                    0 Not imputed
                               1,239                    1 Imputed

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

IMPSPRVI  138  1  IMPFLAG                               N AMTPRVI payment source imputed?

                              10,664                    0 Not imputed
                                 131                    1 Imputed

IMPAPRVI  139  1  IMPFLAG                               N AMTPRVI payment amount imputed?

                              10,455                    0 Not imputed
                                 340                    1 Imputed

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

IMPSPRVU  149  1  IMPFLAG                               N AMTPRVU payment source imputed?

                              10,795                    0 Not imputed
                                   0                    1 Imputed

IMPAPRVU  150  1  IMPFLAG                               N AMTPRVU payment amount imputed?

                              10,795                    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?

                               9,391                    0 Not imputed
                               1,404                    1 Imputed

IMPAOOP   161  1  IMPFLAG                               N AMTOOP payment amount imputed?

                               8,070                    0 Not imputed
                               2,725                    1 Imputed

AMTDISC   162  9                                        N Amount of uncollected SP liability

IMPSDISC  171  1  IMPFLAG                               N AMTDISC payment source imputed?

                              10,219                    0 Not imputed
                                 576                    1 Imputed

IMPADISC  172  1  IMPFLAG                               N AMTDISC payment amount imputed?

                               9,926                    0 Not imputed
                                 869                    1 Imputed

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

IMPSOTH   182  1  IMPFLAG                               N AMTOTH payment source imputed?

                              10,794                    0 Not imputed
                                   1                    1 Imputed

IMPAOTH   183  1  IMPFLAG                               N AMTOTH payment amount imputed?

                              10,747                    0 Not imputed
                                  48                    1 Imputed

DVBRIDGE  184  2  YES4FMT                               N Dental visit service - bridge

                                  53                   -9 Not ascertained
                                  59                   -8 Don't know
                                   1                   -1 Inapplicable
                               1,501                    1 Yes
                               9,181                    2 No

DVCLEAN   186  2  YES4FMT                               N Dental visit service - cleaning

                                  53                   -9 Not ascertained
                                  59                   -8 Don't know
                                   1                   -1 Inapplicable
                               5,438                    1 Yes
                               5,244                    2 No

DVCROWN   188  2  YES4FMT                               N Dental visit service - crown

                                  52                   -9 Not ascertained
                                  60                   -8 Don't know
                                   1                   -1 Inapplicable
                               1,024                    1 Yes
                               9,658                    2 No

DVEXAM    190  2  YES4FMT                               N Dental visit service - examination

                                  52                   -9 Not ascertained
                                  60                   -8 Don't know
                                   1                   -1 Inapplicable
                               5,269                    1 Yes
                               5,413                    2 No

DVEXTRAC  192  2  YES4FMT                               N Dental visit service - tooth extraction

                                  53                   -9 Not ascertained
                                  59                   -8 Don't know
                                   1                   -1 Inapplicable
                                 789                    1 Yes
                               9,893                    2 No

DVFILLNG  194  2  YES4FMT                               N Dental visit service - filling

                                  53                   -9 Not ascertained
                                  59                   -8 Don't know
                                   1                   -1 Inapplicable
                               1,281                    1 Yes
                               9,401                    2 No

DVORTHO   196  2  YES4FMT                               N Dental visit service - orthodontics

                                  53                   -9 Not ascertained
                                  59                   -8 Don't know
                                   1                   -1 Inapplicable
                                 100                    1 Yes
                              10,582                    2 No

DVOTHER   198  2  YES4FMT                               N Dental visit service - other

                                  53                   -9 Not ascertained
                                  59                   -8 Don't know
                                   1                   -1 Inapplicable
                                 440                    1 Yes
                              10,242                    2 No

DVRTCNAL  200  2  YES4FMT                               N Dental visit service - root canal

                                  53                   -9 Not ascertained
                                  59                   -8 Don't know
                                   1                   -1 Inapplicable
                                 322                    1 Yes
                              10,360                    2 No

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

                                  53                   -9 Not ascertained
                                  59                   -8 Don't know
                                   1                   -1 Inapplicable
                               3,435                    1 Yes
                               7,247                    2 No

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

                               6,549                    0 Event not provided by HMO
                               4,246                    1 Event provided by HMO

