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HSIS manual NC Department of Health and Human Services

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					The
North
Carolina
Health
Service
Information
System
v1.13 10/22/2008                            Table of Contents
Page 2 of 208

             Description                                                                      Section
              Change Log------------------------------------------------------------------------ 000

              Introduction- HSIS Log-on ----------------------------------------------------- 010

          00. Patient Alpha Search------------------------------------------------------------- 020

          01. Patient Master--------------------------------------------------------------------- 030

          02. Patient Financial------------------------------------------------------------------ 040

          03. Patient Insurance------------------------------------------------------------------ 050

          04. Patient Address-------------------------------------------------------------------- 060

          07. Child Service Coordination------------------------------------------------------ 070

          08. Maternity Care Coordination Program---------------------------------------- 075

          09. Pregnancy Outcome Summary-------------------------------------------------- 080

          12. Payments /Adjustments---------------------------------------------------------- 090

             Payment Examples                                                                   090a

          13. DEC Supplemental--------------------------------------------------------------- 100

          14. Insurance/Contracts--------------------------------------------------------------- 110

          18. Appointment Function----------------------------------------------------------- 130

          19. Report Processing----------------------------------------------------------------- 140

          28. Forms Alignment----------------------------------------------------------------- 150

          29. Data unit Menu (not included)-------------------------------------------------- 160

          30. Breast Cancer Follow-up-------------------------------------------------------- 170
              BCCCP Breast Cancer Screening And follow-up Data Entry Form

          31. Cervical Cancer Follow-up------------------------------------------------------ 180
              BCCCP Cervical Cancer Screening And follow-up Data Entry Form

          32. DEC Client History of Services (not included)------------------------------- 190

          40. Immunization Registry (see NCIR Manual)---------------------------------- 200

          60. Setup User Access---------------------------------------------------------------- 210
             Privacy Administration Guidelines
             Resetting RACF Passwords
          61. Setup Staff Provider------------------------------------------------------------- 220

          63. Setup Service Group------------------------------------------------------------- 230



         Revised 04/28/03                                      Page 1 of 2
v1.13 10/22/2008                            Table of Contents
Page 3 of 208

             Description                                                                      Section
          64. Setup CPT/Service Rates-------------------------------------------------------- 240

          65. Encounter and Services---------------------------------------------------------- 250

          66. Risk Factors------------------------------------------------------------------------260

          67. Risk Factors II (PAN)------------------------------------------------------------ 270

          68. Billing Inquiry/Billing Only----------------------------------------------------- 280

          69. Company Service Billing-------------------------------------------------------- 290

          70. Dental Encounter and Services--------------------------------------------------300

          87. View Notification Message (not included)------------------------------------ 310

          89 Sliding Fee Scale------------------------------------------------------------------ 320

          95. Medicaid Eligibility Inquiry (not available electronically)------------------ 330

          96. POS (place of service table)----------------------------------------------------- 900a

          97. County of Residence Table----------------------------------------------------- 900b

          98. Program Type Table------------------------------------------------------------- 900c




         Revised 04/28/03                                      Page 2 of 2
v1.13 10/22/2008                                                                       s000a
Page 4 of 208
                             HSIS MANUAL - CHANGE LOG

         Section   Page(s)     Date     Description of Change:

         New release version 1.13 on
         10/21/08
         S220      1          10/21/08 Added ‘ITP’ and ‘SN’ discipline codes
         New release version 1.12 on
         11/01/2007
         S075     4           11/01/07 Added codes for unknown values for Maternal Intake
                                       data fields
         S080     4           11/01/07 Added codes for unknown values for Maternal Data
                                       fields (POS)
         S170     3           11/01/07 Expanded codes to include State funds and/or Federal
                                       funds
         S180     2-8         11/01/07 Expanded codes to include State funds and/or Federal
                                       funds
         S210     6-8         11/01/07 Changed DHHS CSC number
         New release version 1.11 on
         04/23/2007
         S075        1-9      05/10/07 Added new Maternity Care Coordination Program
                                       (MCCP)
         S080        1-14     05/10/07 Replaced existing Pregnancy Outcome Summary screen
                                       set to new screens which will coordinate with MCCP
         S250        8        06/06/06 Added note in reference to 2 new program types
         S900C       1        04/10/06 Added 2 new program types for BCCP
         S230        2        04/10/06 Added 2 new program types for BCCP
         S010        1        03/27/06 Changed DSS CSC number


         New release version 1.10 on
         03/09/2006
         S030       1-8       03/06/06 Updated screen snapshot & requirements for printing
                                       labels with new functionality.
         S140       3         03/06/06 Corrected typo
         S230       2         03/06/06 Updated program types list
         S320       2         03/06/06 Updated program types list
         S900       1         03/06/06         a) Removed program type “CS”.
                                               b) Replaced old program name with current
                                                   name, Childrens Developmental Service
                                                   Agency


         New release version 1.09 on
         2/23/2006



                                             Page 1 of 5
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                             HSIS MANUAL - CHANGE LOG
         Section   Page(s)      Date    Description of Change:

         S120      All       02/23/06 Removed Infant Toddler section. This screen’s
                                      information no longer reported via HSIS.
         S250      4         02/21/06 Changed weight limits
         S270      2
         S030      6         02/21/06 Revised wording for family ID field
         S140      3         02/21/06 Revised label # 3 (folder)


         New release version 1.08 on
         10/24/2005
         S090a    17          10/20/05 Added payment scenario #17
         S250     5           10/19/05 Changed description for Family Planning Contraceptive
                                       Method code 19.


         New release version 1.07 on
         10/10/2005
         S250     1-10        09/22/05 Revised documentation to for changes to FP
                                       contraceptive methods


         New release version 1.06 on
         09/30/2005
         S250     1-10        09/22/05 Revised documentation to show new fields for FPW.
         S140     1-4         09/22/05 Added documentation and screen for lab labels and
                                       revised reports processing screen.
         S130     several     8/08/05 Updated documentation
         S250     7-9         08/25/05 Added note re: referring provider discipline


         New release version 1.05 on
         08/09/2005
         S110     1           08/08/05 Updated for BCBS indicator field.
         S250     8-9         08/8/05 Updated for Behavioral Health service entry
         S220     1-2         7/28/05 Screen revised for Behavioral Health providers


         New release version 1.04 on
         05/26/2005
         S092     all         05/25/05 Revised payment examples – deleted some obsolete
                                       examples that are no longer applicable.
         S250     8           05/24/05 ST & S2 Code descriptions for child health referrals
                                       reversed per documentation from ATN.


                                              Page 2 of 5
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                             HSIS MANUAL - CHANGE LOG
         Section   Page(s)      Date    Description of Change:

         S140      1         03/22/05 Increased 2-up labels CPL from 24 to 30. Added chart
                                      number on folder label. (KEM)
         S170      1         02/24/05 New Breast Cancer Screening Data Entry Form
                                      (Revised 1-Nov. 2002)
         S180      1,2       02/24/05 New Cervical Cancer Screening Data Entry Form
                                      (Revised 1-Nov.-02)
         S250      4         2/02/05 Add 06 = Natural under FP Contra Method Code (KEM)


         New release version 1.03 on
         01/26/05
         S030     3           12/25/04 Corrected the preferred language codes.
         S250     4           12/07/04 Added additional contraceptive codes.
         S250                 12/03/04 Added ‘S900c ‘ to ‘Program Type table’ reference
                                       (kem)
         S000a                12/03/04 Added Reference tables to Table of Contents (kem)
         S900c                12/03/04 Added Program Type Table (kem)
         S050     1-3         11/04/04 Updated HIPPA required fields for ins/med patients
         S280     8           11/01/04 Added instructions for CDSA sites when entering
                                       insurance payments and billing remainder to patient.
         S090     3           11/01/04 Added note for med/ins payments
         S900b    1-2         11/01/04 Added county of residence table (kem chg per ec)
         S900a                10/18/04 Added POS table (kem chg per ec)
         S050         3       10/14/04 Revised codes for RELATIONSHIP TO INSURED
         S170     1–9         09/14/04 Section replacement, revised for coding changes
                                       effective on 1-November-2002
         S180     1 – 10      09/14/04 Section replacement, revised for coding changes
                                       effective on 1-November-2002


         New release version 1.02 on
         8/27/04
         S270     2           08/30/04 1. Screen option 67 name change to RISK FACTORS
                                          II (PAN), previously Med and Lab Service(s).
                                       2. Introduction of new fields for Physical Activity and
                                          Nutrition, PAN, tracking.
                                       3. Expansion of Hematocrit % range captured.
         S030     1, 3        08/24/04 Added new field Language Preference & added valid
                                       codes for entry of Language Preference field
         S320     2           08/16/04 Changed program codes from numbers to alpha
                                       characters. Added note re: state sliding fee scale.
         S080     1           08/01/04 Added screen shot



                                              Page 3 of 5
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                             HSIS MANUAL - CHANGE LOG
         Section   Page(s)    Date     Description of Change:

         S050      3-4       07/07/04 Changed the list of valid values for RELATIONSHIP
                                      TO INSURED from the Professional codeset to the
                                      Dental one.
                                      Values 04,05,07,10,15,23,24,32,33,36,39,40,41,43,53
                                      and G8 were deleted. 76 (Dependent) was added.
         S090      2         07/01/04 Added notes for CDSA program
         S010      1         07/01/04 Added screen shots
         S100      1         07/01/04 Added screen shots
         S110      1         07/01/04 Added screen shot
         S120      1         07/01/04 Added screen shots
         S130      1         07/01/04 Added screen shots
         S140      1         07/01/04 Added screen shots
         S150      1         07/01/04 Added screen shots
         S170      1         07/01/04 Added screen shots
         S180      1         07/01/04 Added screen shots
         S230      1         07/01/04 Added screen shots
         S260      1         07/01/04 Added screen shots
         S270      1         07/01/04 Added screen shots
         S280      1         07/01/04 Added screen shots
         S290      1         07/01/04 Added screen shots
         S070      5         06/29/04 Deleted note in reference to report interval d & e.

         S220      1-2       06/24/04 Added 2 new fields and documentation for entry
         S250      8         06/24/04 Added program type CA for CDSA sites
         S250      5         06/22/04 Added note for maternal health patient type 1
                                      requirements.




                                             Page 4 of 5
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                            HSIS MANUAL - CHANGE LOG

         Section   Page    Date        Description of Change:
                                       (put newest at top of list)
         New release version 1.01 on
         5/26/04
         S280     1         05/20/04   Added screen print for screen for 68C (list screen)
                                       Added instructions for action code ‘P’ for posting
                                       payments.

                   2                   Added instructions for CDSA sites for posting insurance
                                       payments and billing remainder to patients.

                   3                   Changed instructions for billing units – units can be
                                       changed on screen 68A

                   4                   Deleted reference to INS C & INS D


                   7                   Added instructions for entering insurance payments for
                                       Medicaid & Insurance clients & insurance patients that
                                       have bill remainder to ‘P’ for CDSA sites

                   8                   Deleted following fields - ADJUSTMENT GROUP,
                                       ADJUSTMENT REASON, DISCOUNTED AMT,
                                       PATIENT RESP AMT, PATIENT PAID AMT, PAYMENT
                                       ADJUDICATION DATE

                   10-16               Deleted health care claim adjustment reason code table.
         S050      3       05/13/04    Corrected definition of RELATIONSHIP TO
                                       INSURED
         S050      2-3     05/22/04    Added additional Claim Filing Indicators
                                       Changed Ins Program Type CI to C1
         S250      1       05/22/04    Changed screen print – Added Date of Diab Eval
                                       Deleted Health Check Ref

         S250      8       05/22/04    Added instructions for entering S2 & ST modifiers for
                                       Health check referral.
         S240      All     05/22/04    Updated dates to reflect century. Also, added new
                                       options.




                                              Page 5 of 5
                                     HSIS SIGN-ON                                       Sec 010
v1.13 10/22/2008
Page 9 of 208




    The Sips Banner Screen is displayed after you click on the 2370 Icon
    or if you use a dumb terminal it is displayed each time it is turned
    on.
     The Node name is the identification assigned to your PC or dumb terminal and is displayed in the
    upper left, when you connect to the SIPS Banner Screen. Printers are also assigned Node names.
    The Sips HELP DESK telephone number is also displayed on the banner screen. It is 1-800-722-
    3946. When do you call the Sips Help desk?
    • If the banner screen does not display, call the Help Desk.
    • If the terminal lock up- Do Not turn it off, call the Help Desk

    SYSTEM SECURITY –
    Each person accessing SIPS is assigned a RACF USERID, PASSWORD, and each site is assigned a
    BILL CODE.
    Change passwords as often as you like, but at least once every two months. Do not ever repeat a
    password. If your password gets revoked, or more USER IDS are needed, then call the DIRM
    Customer Support Help DESK. The telephone number is 919 855-3200 option #2.




    Revised September, 20001                       1
                                      HSIS SIGN-ON                                      Sec 010
v1.13 10/22/2008
Page 10 of 208




     1.     At the banner screen type: CICSNC25 <ENTER>
            The CICS sign –on screen will be displayed.

    2.      At the CICS sign-on screen enter the following:
            A. User ID number
            B. Bill Code
            C. Password                     <ENTER>

            A message will flash displaying the terminal number you are logged on to and then a blank
            screen will display.

    3.     On the blank screen type: HSIS       <ENTER>

    4.     The HSIS sign-on screen will appear with a default site number. You may change positions
           1,4, and 5. DEPRESS THE ENTER KEY TO CONTINUE.



    Revised September, 20001                        2
                                       HSIS SIGN-ON                                         Sec 010
v1.13 10/22/2008
Page 11 of 208

    5.     The Application Selection Menu will then be displayed. Enter the two position screen option
           number on the fast-path line, then client ID number (must be 9 positions) followed by the date
           of service (enter in mmddyy format).

    6.     Enter the action code: A = Add; C= Change: D= Delete; I = Inquire. Depress Enter to display
           the requested screen.

    7.     Keyboard Functions: F1 = Sign-on screen; F2 = Application Selection Menu

    8.        To exit system (HSIS)

              Dumb Terminal - Press the clear key and then type ‘logoff ’. Note: Key the Logoff
              command over “Processing Complete, Have a Nice Day, then the banner screen will
              display.

              Internet Connection – Click right mouse button on the upper right corner on the ‘X’.
              A Message box will display “Do you want to disconnect session?” Click the left mouse
              button for YES.




    Revised September, 20001                          3
v1.13 10/22/2008
Page 12 of 208


                                         00. PATIENT ALPHA SEARCH                                                S020

    The Patient Alpha Search screen (00) allows the user to browse the patient master file and will display the ID
    number, name, date of birth, race and sex of the selected patient if found on the file.


    HSA007A           NORTH CAROLINA HSIS - PATIENT MASTER ALPHA SEARCH

    NEXT RECORD: COUNTY ___ SCREEN: ____ ID: _____________ DATE: __________ ACTION: ___
    MESSAGE:

    ENTER LAST NAME: ____________________

              FIRST NAME: _______________

             SEX: _

              (MMDDCCYY)
             DOB: ________ PLUS OR MINUS ___ YEARS


    FIELD                                                 EXPLANATION

    NEXT SCREEN (R)                                       Enter `00'

    NEXT ID (O)                                           No entry required.

    NEXT DATE (0)                                         No entry required.

    NEXT ACTION (R)                                       Enter (I = Inquire)

    LAST NAME (R)                                         Enter patient's last name

    FIRST NAME (R)                                        Enter first name

    SEX (R)                                               Enter sex code.
                                                          1= Male; 2 = Female

    DOB (O)                                               Enter date of birth (MMDDCCYY)

    PLUS OR MINUS __ YEARS (O)                            Enter a number of years (0 – 150) if you are uncertain of the
                                                          exact birth date – HSIS will search the range of years and
                                                          return match(es) if birth date is within the entered range of
                                                          years




    Revised 04/28/03                                      Page 1 of 1
v1.13 10/22/2008
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                                             01. Patient Master                                                 S030

                                                         Screen I

    A PATIENT MASTER screen must be completed on a patient before any additional data for the patient can be
    entered. Certain information from the patient master automatically appears on other screens as you access them. For
    this reason, accuracy of data entry on the patient master is very important.

    Only one patient master per person is allowed; however, changes/updates may be necessary. Before adding a new
    Patient Master, HSIS requires you to perform a Patient Alpha Search to assure a Patient Master does not already
    exist. Required entry fields are denoted by (R). Optional entry fields are denoted by (O). A line-by-line
    explanation of each entry follows. See Page 7 for a description of the Partial Patient Master Screen. Applicable
    action codes are A=Add, C=Change, I=Inquire and D=Delete. A patient master cannot be deleted if records of any
    type have been entered for the client (services, appointments, payments, etc).


    HSA010A                HSIS PATIENT MASTER             ADDED:
                                                           CHANGED:
    NEXT RECORD: COUNTY SCREEN 01 ID                    DATE     ACTION A
    MESSAGE: 016 ENTER ADD INFORMATION AND THEN PRESS "ENTER"
         FIELD NAMES HIGHLIGHTED FOR PARTIAL/APPOINTMENT-ONLY ENTRY
     REGISTRATION NAME: LAST ____________________ FIRST _______________ MI _
       MEDICAID NAME: LAST ____________________ FIRST _______________ MI _
     LABEL #: _ SIZE: _ (2) FOR 2-UP (3) FOR 3-UP QTY#: __
     ID NUMBER:        PREV ID: __________ APPT ONLY: _ WIC EDIT: _
     CLIENT STATUS: _ CHART NUM: __________ PREFERRED LANGUAGE: __
     DOB: MMDDCCYY RACE: _ _ _ _ _ HISP/LATINO: _ SEX: _ COUNTY OF RES: ___
     MIGRANT FARMWORKER/DEPENDENT: _            SEASONAL FARMWORKER/DEPENDENT: _
    ENGLISH SPEAKING: _ HOMELESS: _ REFUGEE: _ COUNTRY OF ORIGIN: _ (1,2,9)
    STREET1: ____________________ STREET2: ____________________
    CITY: ______________ STATE: __ ZIP: _____ - ____
    HOME PHONE: ( ___ ) ___ - ____ BUSINESS/ALTERNATE PHONE: ( ___ ) ___ - ____

    IF CHILD, NAME OF PARENT/GUARDIAN AT THIS ADDRESS:
    LAST: ____________________ FIRST: _______________ MI: _ FAMILY ID: _________
    RELATIONSHIP TO PATIENT: _
    MEDICAID: _ (Y,N) NUMBER: __________ MEDICARE: _ (Y,N) NUMBER: ____________
    OTHER INS: _ (Y,N) SELF PAY: _ (Y,N) O/P: _ HEALTH CHOICE: _ SSI: _
    RELEASE OF INFO: _ SIGNATURE ON FILE: _            RESTRICT PHI: _
    OTHER ADDR:                    SCREEN VERIFICATION DATE:



    FIELD                                                           EXPLANATION

    REGISTRATION NAME:                                              Enter no more than 20 characters.
    LAST (R)

    FIRST (R)                                                       Enter no more than 15 characters. DO NOT enter
                                                                    "Baby Boy" or "Baby Girl" as patient’s first name.

    MI    (O)                                                       Enter the patient's middle initial.




    Revised 03/06/06                                   Page 1 of 13
v1.13 10/22/2008
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                                 01. Patient Master                                              S030


    MEDICAID NAME:                                Enter no more than 20 characters. Enter as appears
                                                  on Medicaid card.

    LAST (R)                                      Enter no more than 20 characters.

    FIRST (R)                                     Enter no more than 15 characters.

    MI (O)                                        Enter as middle initial if applicable.

                                                  NOTE: Hyphens and apostrophes are accepted as
                                                  part of the name fields.

                                                  NOTE: The name of a patient eligible for Medicaid
                                                  MUST agree with the name on the Medicaid card to
                                                  avoid denial of payment.

    LABEL # (O)                                   Enter label number as follows:
                                                  1 = Mailing labels
                                                  2 = Lab labels
                                                  3 = Folder labels

    SIZE (O)                                      Enter ‘2’ for 2 up labels and ‘3’ for 3 up labels.
                                                  Lab labels must be requested as 2-up only.

    QTY (O)                                       Enter number of labels required

                                                  LABELS CAN BE PRINTED FROM
                                                  PATIENT MASTERS WITH ACTION –
                                                  A, C, or I

    ID NUMBER (R)                                 NO ENTRY REQUIRED. **

    PREVIOUS ID NUMBER (O)                        NO ENTRY REQUIRED.

                                                  NOTE: System will enter previous number when an
                                                  ID number change is entered.

    ** CLIENT CAN BE ASSIGNED A TEMPORARY ID NUMBER USING THE FOLLOWING FORMULA:
    FIRST INITIAL OF LAST NAME/FIRST INITIAL OF FIRST NAME/DOB/SEX CODE - USE
    FOLLOWING FORMAT FOR DOB AND SEX CODES –MM/DD/YY/SEX CODE – 1=MALE, 2= FEMALE
    – EX: DAN DAVIS DOB JAN. 1,2001 - DD0101011 – IF MULTIPLE BIRTHS USE THE NEXT ODD
    NUMBER FOR MALES AND NEXT EVEN NUMBER FOR FEMALES.

    APPT ONLY (O)                                 NO ENTRY REQUIRED.

    WIC EDIT (O)                                  Valid entry codes are Y=Yes or N=No to indicate if
                                                  WIC REQUIRED when a WIC client.




    Revised 03/06/06                    Page 2 of 13
v1.13 10/22/2008
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                             01. Patient Master                                           S030


    FIELD                                     EXPLANATION

    CLIENT STATUS (O)                         Valid entry codes are::**
                                              M – moved
                                              D – deceased
                                              U – unable to locate

    CHART NUMBER (O)                          Locally assigned number for client chart.

    PREFERRED LANGUAGE (O)                    Valid codes are:

                                              AR = Arabic, CA = Cambodian, CH = Chinese
                                              EN = English, FR = French, FC = French Creole
                                              GE = German, GR = Greek, GU = Gujarati,
                                              HI – Hindi, HM = Hmong, HU = Hungarian, IT =
                                              Italian, JA = Japanese, KO = Korean, LA = Laotian,
                                              MI = Miao, MK = Mon-Khmer, OT = Other, PE =
                                              Persian, PO = Poland, PG =Portugese,
                                              PC = Portugese Creole, RU = Russian, SC = Serbo-
                                              Croatian, SP = Spanish, TA = Tagalog, TH = Thai,
                                              UR = Urdu, VI = Vietnamese


    DATE OF BIRTH (R)                         Enter in MM/DD/YYYY format.
                                              NOTE: The birth date of a patient eligible for
                                              Medicaid MUST agree with the date on the Medicaid
                                              card to avoid denial of payment.

    RACE (R)                                  Enter one of the following codes to specify the
                                              primary race:
                                              1= White, 2= Black, 3= American Ind., 4= Asian,
                                              5= Native Hawaiian/Other Pacific Islander,
                                              6= Unknown

    RACE-2 (O)                                Enter one of the following codes to specify other
                                              race components:
                                              1= White, 2= Black, 3= American Ind., 4= Asian,
                                              5= Native Hawaiian/Other Pacific Islander,
                                              6= Unknown

    RACE-3 (O)                                Enter one of the following codes to specify other
                                              race components:
                                              1= White, 2= Black, 3= American Ind., 4= Asian,
                                              5= Native Hawaiian/Other Pacific Islander,
                                              6= Unknown

    RACE-4 (O)                                Enter one of the following codes to specify other
                                              race components:
                                              1= White, 2= Black, 3= American Ind., 4= Asian,
                                              5= Native Hawaiian/Other Pacific Islander,
                                              6= Unknown




    Revised 03/06/06                Page 3 of 13
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                                           01. Patient Master                                               S030


    RACE-5 (O)                                                 Enter one of the following codes to specify other
                                                               race components:
                                                               1= White, 2= Black, 3= American Ind., 4= Asian,
                                                               5= Native Hawaiian/Other Pacific Islander,
                                                               6= Unknown

    HISPANIC OR LATINO (R)                                     Valid entry codes are Y = Yes or N = No or
                                                               U = Unknown to indicate whether or not the patient is
                                                               Hispanic or Latino. The patient or other informant
                                                               furnishes this information.

                                                               The definition for Hispanic is as follows: Anyone
                                                               born in Spanish speaking country (including Mexico)
                                                               or anyone who has Hispanic parents and wishes to be
                                                               identified as part of that cultural heritage.

    SEX (R)                                                    Enter one of the following codes to specify sex:
                                                               1 = Male 2 = Female



    COUNTY OF RESIDENCE (R)                                    Enter the three-digit HSIS code for the county of the
                                                               patient's residence, not the county where service is
                                                               rendered. Enter 888 when the patient is an out-of-
                                                               state resident.


    ** Moved or gone elsewhere – any client confirmed as residing outside the county or catchment area.
       Deceased – any client confirmed as deceased.
       Unable to locate – no services received within last 6 months, all available telephone numbers no longer
       valid and a postcard or letter has been returned and no other address is known; or a certified, returned
       receipt letter is received; or home visit validates that person does not live at the assumed address.



   MIGRANT FARMWORKER (O)                                       Valid entry codes are Y=Yes, N=No, or blank to
                                                                specify if dependent migrant farmworker. WIC
                                                                may enter 1 for Yes or 2 for No.

   SEASONAL FARMWORKER (O)                                     Valid entry codes are Y=Yes, N=No, or blank to
                                                               specify if dependent seasonal farmworker. WIC may
                                                               enter 1 for Yes or 2 for No.

    ENGLISH SPEAKING (O)                                       Valid entry codes are Y=Yes, N=No, or blank to
                                                               specify if patient speaks English. WIC may enter 1
                                                               for Yes or 2 for No.

    HOMELESS (O)                                               Valid entry codes are Y=Yes, N=No, or blank to
                                                               specify if patient is homeless. WIC may enter 1 for
                                                               Yes or 2 for No.

   FIELD                                                       EXPLANATION



    Revised 03/06/06                                 Page 4 of 13
v1.13 10/22/2008
Page 17 of 208


                                              01. Patient Master                                                  S030



    REFUGEE (O)                                                     Valid entry codes are Y=Yes, N=No, or blank to
                                                                    specify if patient is a refugee. WIC may enter 1 for
                                                                    Yes or 2 for No.

                                                                    NOTE: System will convert all one’s and
                                                                           two's to Y's or N's.

    COUNTRY OF ORIGIN (O)                                           Enter one of the following codes to specify country
                                                                    of origin.
                                                                    1 = Mexico
                                                                    2 = Haiti
                                                                    9= none of the above




    Migrant health field Definitions are as follows:

    Migrant farmworker/dependent - An individual or dependent of an individual whose principal employment is
    agricultural on a seasonal basis and who establishes a temporary abode in NC for that employment. This term
    includes anyone who meets that definition within the past 24 months.

    Seasonal farmworker/dependent - An individual or dependent of an individual whose principal employment is
    agricultural and who is a year-round resident of NC. This definition does not include farm owners and their
    dependents.

    English speaking - Is the patient or the parent/guardian, in the case of a child, able to adequately communicate in
    English with staff and the health care providers. Answer no to this question if a translator is necessary in order to
    communicate with the patient or parent/guardian in the case of a child. Answer no to this question even if a person
    (other than the parent/guardian) who is able to translate accompanies the patient.

    Homeless - An individual having no home or haven.

    Refugee - Any person outside his country of nationality who is unable or unwilling to return to that country because
    of persecution or a well-founded fear of persecution. Refugees apply for and receive this status prior to entry into
    the US indicated by the assignment of an "A" number by INA.

    Mexico - Includes anyone born in Mexico or anyone with parents or ancestors from Mexico who wishes to be
    identified as part of that cultural heritage.

    Haiti - Includes anyone born in Haiti or anyone with parents or ancestors from Haiti and who wishes to be identified
    as part of that cultural heritage.




    ADDRESS 1 (O)                                                   Enter mailing address of patient. Required if using
                                                                    appointment program.




    Revised 03/06/06                                     Page 5 of 13
v1.13 10/22/2008
Page 18 of 208


                                  01. Patient Master                                            S030

    FIELD                                          EXPLANATION

    ADDRESS 2 (O)                                  Enter when additional address line is needed.

     CITY (O)                                      Required if address 1 is entered.
                                                   Required for WIC clients

    STATE (O)                                      Required if address 1 is entered.
                                                   Required for WIC clients

    ZIP     (O)                                    Must be numeric. Required if City/State completed.

    HOME PHONE (O)                                 Enter the patient's home phone number.
                                                   NOTE: If the area code is completed, then the
                                                   phone number must be completed also.

    WORK PHONE (O)                                 Enter the patient's work phone number.

    GUARDIAN LAST NAME (O)                         Enter no more then 20 characters.
                                                   Hyphens and apostrophes are accepted in name
                                                   fields.

    GUARDIAN FIRST NAME (O)                        Enter no more than 15 characters.

    GUARDIAN MI (O)                                Enter the guardian's middle initial. Hyphens and
                                                   apostrophes are accepted as part of the name field.

    FAMILY ID (O)                                  Must be valid ID using social security number or
                                                   temporary ID using normal convention for assigning
                                                   temporary ID numbers.

                                                   Batch users must send 10 position number with 10th
                                                   Position being H.

    RELATIONSHIP TO PATIENT (O)                    1 = Mother
                                                   2 = Father
                                                   3 = Adoptive Parent
                                                   4 = Foster Parent
                                                   5 = Grandparent
                                                   6 = Other Family Member
                                                   7 = Surrogate Member
                                                   8 = Unknown
                                                   Space = Not Specified

    MEDICAID (R)                                   Valid entry codes are Y=Yes or N=No to indicate
                                                   whether patient is Medicaid eligible.

    MEDICAID ID (O)                                Enter the patient's ten character Medicaid ID number
                                                   if the patient is eligible for Medicaid.
                                                   If completed, the first 9 characters must be numeric
                                                   the last character must be alphabetic.




    Revised 03/06/06                     Page 6 of 13
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Page 19 of 208


                            01. Patient Master                                             S030

    FIELD                                    EXPLANATION

    MEDICARE (R)                             Valid entry codes are Y=Yes or N = No.
                                             Note: Not required for WIC or DEC.

    MEDICARE ID (O)                          Enter number if Medicare field is = ‘Y’

    OTHER INSURANCE (R)                      Valid entry codes are Y=Yes or N=No to indicate
                                             whether the patient has other health insurance (i.e.,
                                             Blue Cross/Blue Shield, Champus, Health Choice or
                                             Aetna).

    SELF-PAY (O)                             Valid entry codes are Y=Yes or N=No to indicate
                                             whether patient is self-pay.

    O/P       (NA)                           No entry allowed. Indicates when a Pregnancy
                                             Outcome record needs to be completed.
                                             If the field is = to Y; then a Pregnancy Outcome
                                             record must be entered.

    HEALTH CHOICE (R)                        Valid entry ‘Y’ or ‘N’ to indicate whether patient is
                                              covered by Health Choice.

    SSI (R)                                  Required for all children under 18 years of age.

    RELEASE OF INFO (O)                      An EDI code required for Medicaid billing.
                                             Indicates whether the provider has on file a signed
                                             document by the patient authorizing the release of
                                             medical data to other organizations. Allowable
                                             values are:
                                             A – Appropriate Release of Information on file at
                                             health care service provider or at utilization review
                                             organization
                                             I – Informed consent to release medical information
                                             for conditions or diagnoses regulated by federal
                                             statutes
                                             M – The provider has limited or restricted ability to
                                             release data related to a claim
                                             N – Provider is not allowed to release data
                                             O – On file at Payer or at Plan Sponsor
                                             Y – provider has signed statement permitting release




    SIGNATURE ON FILE (O)                    An EDI code required for Medicaid billing. Code
                                             indicating how the patient or subscriber
                                             authorization signatures were obtained and how the
                                             provider is retaining them.




    Revised 03/06/06               Page 7 of 13
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Page 20 of 208


                                   01. Patient Master                                            S030

    FIELD                                           EXPLANATION
                                                    Allowable Values:
                                                    Blank – If Release of Information value is ‘N’ (no
                                                    release)
                                                    B – Signed signature authorization form or forms for
                                                    both CMS-1500 Claim form blocks 12 and 13 are on
                                                    file
                                                    C – Signed CMS-1500 Claim form on file
                                                    M – Signed signature authorization form for CMS-
                                                    1500 Claim form block 13 on file
                                                    P – Signature generated by provider because the
                                                    patient was not physically present for services
                                                    S – Signed signature authorization form for CMS-
                                                    1500 Claim form block 12 on file.

    RESTRICT PHI (O)                                Indicates that the paper medical file includes a
                                                    patient’s request to restrict their PHI when
                                                    performing treatment, payment and health care
                                                    operations. Allowable Values:
                                                    N – No request on file
                                                    Y – Request on file
                                                    When Y is entered a message as follows displays on
                                                    any screen that displays detail information about that
                                                    patient - RESTRICT PHI REQUEST-SEE
                                                    MEDICAL REC

    OTHER ADDRESS                                   NO ENTRY ALLOWED. Indicates multiple
                                                    addresses are available for the patient (Y or N). Use
                                                    menu option 04 to view or update addresses.
                                                    Patient’s mailing address always displays on Patient
                                                    Master.

    SCREEN VERIFICATION DATE (R)                    NO ENTRY REQUIRED ON 'ADD'.




    Revised 03/06/06                      Page 8 of 13
v1.13 10/22/2008
Page 21 of 208


                                                    01. Patient Master                                              S030


                                                Partial Patient Master Screen


    The partial patient master allows the user to schedule new clients for appointments before a visit has been made to
    the Health Department. Folder Labels can also be printed using the partial master screen. The following fields are
    highlighted for appointment entry only entry:

                       1. Registration Name                 4. County of Residence
                       2. Date of Birth                     5. Address fields
                       3. Sex                               6. Screen verification date

    No entry is required in the APPT ONLY field. The system will require completion of the entire screen, when
    required fields that are not highlighted are entered. A visit record cannot be entered until all required fields have
    been completed on the master screen.




    Revised 03/06/06                                      Page 9 of 13
v1.13 10/22/2008
Page 22 of 208


                                                   01. Patient Master                                              S030


                                                     BASIC MASTERS
                                                     DEC SITES ONLY


    Basic masters are utilized when there is no financial determination and no billable service, but a significant amount
    of time has been expended providing service see examples below:

    1.   Provision of preliminary assessments.
    2.   Those cases when clients do not show up.
    3.   In cases where the DEC wishes to track a client for whom considerable time has been expended but for whom t
         here were no billable services provided

    Clinical services can be entered for clients who have a basic master, but them must be coded as nonbillable.




    Revised 03/06/06                                    Page 10 of 13
v1.13 10/22/2008
Page 23 of 208


                                 01. Patient Master                                           S030


                                   Patient Master
                                     Screen II
                                 (DEC SITES ONLY)

    FIELD                                     EXPLANATION

    HIGHEST GRADE ED LEVEL (R)                Valid codes are 01- 30 or 99 to indicate not
    OF ONE PARENT:                            not known.

    LIVES WITH:        (R )                   Enter one of the following codes to
                                              indicate whom the client lives with:
                                              1 - Both parents
                                              2 - Father
                                              3 - Mother
                                              4 - Foster parents
                                              5 - Other family members
                                              6 - Surrogate family
                                              7 - Unknown

    CASE NBR:          (O)                    Enter DEC assigned number.

    FEE WAIVER: (O)                           Enter one of the following codes
                                              if applicable:
                                              1 - CSC/Intermediate assessment
                                              2 - Willie M
                                              3 - Vaccine related injury
                                              4 - Other
                                              5 - Basic master

    CAUSED BY ACCIDENT (O)                    Enter ‘Y’ if client referred as the result of accident. If
                                              client's medical condition was caused by an accident,
                                              the application must indicate whether a liability
                                              statement is pending, has been awarded, or ruled out.
                                               If settlement has been awarded or is still pending
                                              obtain the name and address of the attorney to
                                              determine when settlement is made and what terms
                                              are covered.
                                              Required when Liability Comp is entered



    LIABILITY COMP (O)                        Enter code from following list if medical condition is
                                              the result of an accident:

                                              1 - Pending
                                              2 - Awarded
                                              3 - Ruled out
                                              Required when caused by accident is Y.



    DETERMINATION DATE (R)                    Enter in MM/DD/YY format, date the




    Revised 03/06/06                Page 11 of 13
v1.13 10/22/2008
Page 24 of 208


                          01. Patient Master                                            S030

    FIELD                              EXPLANATION

                                       financial eligibility was completed and signed by
                                       applicant and interviewer.

                                       Not required with Fee Waiver 1 and 5.

    REFERRAL SOURCE (R)                Enter appropriate code from the following list to
                                       indicate agency or person who referred the child to
                                       the center:

                                       1- Physician
                                       2- Public Health
                                       3- Social Service
                                       4- Mental Health
                                       5 - School
                                       6- Parent/Caregiver
                                       7- Supplemental Security Income
                                       8- Child Service Coordination
                                       9- Children's Special Health Services
                                       10-Sickle Cell Program
                                       11-Genetics Program
                                       12-Community Agency
                                       13-Interagency Council
                                       14-Day Care
                                       15-Head Start
                                       16-Other DEC
                                       17-Neonatal Intensive Care Unit
                                       18-Hospital
                                       19-Early Childhood Intervention Services
                                       20-Developmental Day Care
                                       21-Other
                                       22-DEC re-evaluation

    REFERRAL DATE (R)                  Enter in MM/DD/YY format.

                                       Cannot be greater than current date.
                                       Referral date is date a written request is
                                       received with parent/guardian signature.
                                       NOTE: Not required if Fee Waiver field =
                                       1 or 5.

    TRACKING DATE (O)                  Enter in MM/DD/YY format.
                                       Must be greater than current date.
                                       Must be blank if inactive to tracking is Y.

                                       NOTE: coordinator must track A client at
                                       least once no later than 12 months from the
                                       determination date.

                                       If ‘Tracking Date’ and ‘Inactive to
                                       Tracking’ are blank, program will compute a
                                       tracking date of 1 year from eligibility date.




    Revised 03/06/06         Page 12 of 13
v1.13 10/22/2008
Page 25 of 208


                               01. Patient Master                                               S030

    FIELD                                       EXPLANATION
                                                Upon tracking, the case coordinator must
                                                determine whether to assign a subsequent
                                                tracking date or dispose as inactive to
                                                tracking. If no further tracking services are
                                                indicated, enter zeros in track date and Y
                                                in‘Inactive to Tracking.’

    INACTIVE TO TRACKING (O)                    Must be ‘Y’ or Blank.
                                                If ‘Tracking Date’ is entered ‘Inactive to Tracking ‘
                                                must be blank.

    SERVICE COORDINATOR (R)                     Enter 4-digit coordinator number of staff person
                                                responsible for coordinating the client’s services.
                                                Coordinator number must be valid number from staff
                                                provider table.
                                                Not required with Fee Waiver 1 or 5.

    OTHER DD SERVICES (O)                       Enter all codes that apply using following format to
                                                indicate if client has been or is being served by
                                                program(s) below:

                                                Service 1 - Child Service Coordination must
                                                             be 1 or blank.
                                                Service 2 - Children's Spec. Hlt Srv. must be
                                                            2 or blank.
                                                Service 3 - Genetic program must be 3 or
                                                            Blank.
                                                Service 4 - Sickle Cell Program must be 4
                                                           or blank.

    LOCAL USE CODES (O)                         DEC's may use this field to code information
                                                germane to their individual center not collected on
                                                Supplemental or Services Screens.

    DIAGNOSTIC CODES (O)                        Enter ICD-9 and/or DSMIII-R codes. Enter the
                                                diagnosis known or suspected at time of referral to
                                                the center in the "Referral" field. Record diagnosis
                                                reached after assessment in the "Post" field if
                                                different from Referral Diagnosis. These codes will
                                                be reflected on
                                                DEC reports. Diagnostic codes for billing have to be
                                                entered on the Services & Encounter Screen.

    DATE ARCHIEVED (O)                          Enter in MM/DD/YY format, date sent to archives.

    BOX# (O)                                    Valid codes 01-99.
                                                 NOTE: Entry in Archive fields not allowed on
                                                ‘ADD’ action must be 'C




    Revised 03/06/06                  Page 13 of 13
v1.13 10/22/2008                              02. Patient Financial                               S040
Page 26 of 208


         A Patient Financial master is required for all patients for sites using the HSIS online A/R program.
         Services cannot be entered until the financial record is entered. Applicable action codes are A = Add, C =
         Change I = Inquire and D = Delete.

 HSA020A                                        HSIS – PATIENT FINANCIAL                       ADDED:
                                                                                         CHANGED:
 NEXT RECORD:        COUNTY ___           SCREEN __           ID _________            DATE ______   ACTION _
 MESSAGE:

 NAME: ____________________________________                            HEALTH CHOICE:_

  FAM SIZE     INCOME    SFSCALE PCT                                FAM SIZE           INCOME    SFSCALE          PCT
    CH: __     CH: ______    CH: ___                                CSHS: __         CSHS: ______ CSHS:           ___
 HP/AH: __ HP/AH: ______ HP/AH: ___                                   FP: __           FP: ______    FP:          ___
    DH: __     DH: ______    DH: ___                                  EP: __           EP: ______    EP:          ___
    MH: __     MH: ______    MH: ___                                  GB: __           GB: ______    GB:          ___
    RH: __     RH: ______    RH: ___                                  IM: __           IM: ______    IM:          ___
    OS: __     OS: ______    OS: ___                                  PC: __           PC: ______    PC:          ___
    TB: __     TB: ______    TB: ___                                 STD: __          STD: ______   STD:          ___
 DEC GROSS: ______ DEC TOTAL DED: ______                             DEC: __          DEC: ______   DEC:          ___

                          GUARANTOR INFORMATION IF NO INSURANCE

 LAST NAME:        _________________________ FIRST: _______________ MI: _
  STREET 1:        ________________________________________
  STREET 2:        ________________________________________
      CITY:        _______________    ST: __ ZIP: _____ ____

 ACCT. BALANCE OR WRITE-OFF AMT: __________ W/O: _                                         MAIL: _




         FIELD                                                EXPLANATION

         NAME (R)                                             NO ENTRY REQUIRED – Name automatically
                                                              filled from Patient Master

         HEALTH CHOICE: (O)                                   VALID ENTRY ‘Y’
                                                              (indicates that client is Health Choice client)

         FAMILY SIZE: (O)                                     VALID ENTRIES - 01-20

         INCOME:         (O)                                  VALID ENTRIES - 000000-999999
                                                              (Family size and income should be entered on all
                                                              private pay patients for all programs applicable,
                                                              using guidelines established by each program.)

                                                              DEC sites may, enter gross family income and total
                                                              deductions for computation of net income in the
                                                              DEC income field. (SFSCALE PCT computed
                                                              based on family size and net income).

                                                              NOTE: If income and family size are not entered for
                                                              a specific program, charges will be computed at 0
                                                              percent.



         Issue 4/28/03                                   Page 1 of 2
v1.13 10/22/2008                     02. Patient Financial                                    S040
Page 27 of 208

         FIELD                                  EXPLAINATION

         SFSCALE PCT: (O)                       NO ENTRY REQUIRED.
                                                (computed based on family size and income entered)

         GUARANTOR INFORMATION (O)              Enter the name and address of the person responsible
                                                for patient pay portion of charges if other than
                                                patient.

         ACCOUNT BALANCE:                       No entry required – account balance computed.

                                                *** If patient has a balance that has been written off
                                                this field will be displayed as ‘WRITE OFF
                                                BALANCE.’

         W/O: (O)                               Valid entry space (blank).

                                                W/O flag = ‘Y’ if balance has been written off. To
                                                reinstate write off amount an adjustment must
                                                entered on the payment screen (12). If the
                                                amount written off should not be reinstated W/O
                                                flag must be changed to space (blank).

         MAIL: (O)                              Valid entry ‘N’ or blank. (If N’ entered, indicates
                                                that statement should not be mailed to patient.
                                                When monthly statements are printed if NO MAIL
                                                FIELD = ‘N’ no statement will be printed. However
                                                an individual statement can be printed through
                                                Reports by ID option.




         Issue 4/28/02                     Page 2 of 2
v1.13 10/22/2008                                   03. Patient Insurance                              S050
Page 28 of 208


         A Patient Insurance master is required for:
         •   A/R Sites – Patients with insurance
         •    All Sites– Patients with insurance and Medicaid

         Applicable action codes are A = Add, C = Change, I = Inquire and D = Delete.**

 HSA030A    NORTH CAROLINA HSIS – PATIENT INSURANCE ADDED:
                          CHANGED:
 NEXT RECORD: COUNTY ___ SCREEN __ ID _________ DATE ______ ACTION _
 MESSAGE:

 NAME: ____________________________________ MARITAL STATUS: _ EMPLOY STATUS: _

 INS COMPANY NUM: _____ INS TYPE: _ (M=MEDICAL, D=DENTAL, B=BOTH, C=CONTRACT)

 CLAIM FILING IND: __                PAYER RESP SEQ: _                    INS PROGRAM TYPE: __

 POLICY: ___________________ GROUP: _______________

 POLICY HOLDER DATA: ID ASSIGNED BY INSURANCE COMPANY: ____________________
 LAST NAME: ________________________ FIRST: _______________ MI: _ SSN: _________
 STREET 1: ________________________________________
 STREET 2: ________________________________________
   CITY: _______________ ST: __ ZIP: _____ ____

 RELATIONSHIP TO INSURED: _            GUARANTOR: _         BIRTH DATE: ________ SEX: _

 COND RELATED TO: EMPLOYMENT? _ AUTO ACCIDENT? _ ST: __ OTHER ACCIDENT?: _

 ACCIDENT DATE: ______


         **RE: Deleting a patient insurance record. When screen 03 (patient insurance) is deleted the
         program creates an “effective end date”, rather than physically deleting the insurance record. This
         means the patient insurance record is no longer valid after the effective end date. The end date is
         displayed on the patient insurance list screen which can be accessed by hitting the F3 function key.



         FIELD                                                  EXPLANATION

         NAME (R)                                               NO ENTRY ALLOWED – Name displayed from Patient
                                                                Master

         MARITAL STATUS: (O)                                    Allowable values:
                                                                1= single
                                                                2= married
                                                                3= other

         EMPLOYMENT STATUS: (O)                                 Allowable values:
                                                                1= employed
                                                                2= full-time student
                                                                3= part-time student



         Updated 05/05/03                                Page 1 of 4
v1.13 10/22/2008                 03. Patient Insurance                               S050
Page 29 of 208


         FIELD                              EXPLANATION

         INS COMPANY NUM: (R)               Use menu option 14 INSURANCE/CONTRACTS to
                                            obtain a valid insurance company number. Number must
                                            be valid ID for insurance company.

         INS TYPE: (R)                      Valid entries:
                                            M = medical
                                            D = dental
                                            B = both
                                            C = contract

         CLAIM FILING IND: (O)              A code indicating the type of claim. Required for
                                            Medicaid billing when patient also has insurance.

                                            Allowable values:
                                            09 – Self-pay
                                            10 – Central Certification
                                            11 – Other Non-Federal Programs
                                            12 – Preferred Provider Organization (PPO)
                                            13 – Point of Service (POS)
                                            14 – Exclusive Provider Organization (EPO)
                                            15 – Indemnity Insurance
                                            16 – Health Maintenance Organization (HMO)
                                                 Medicare Risk
                                            AM – Automobile Medical
                                            BL – Blue Cross/Blue Shield
                                            CH – Champus
                                            CI - Commercial Insurance Co
                                            DS - Disability
                                             HM - Health Maintenance Organization
                                            LI - Liability
                                            LM - Liability Medical
                                            MB - Liability Medical
                                            MC - Medicaid
                                            OF - Other Federal Program
                                            TV - Title V
                                            VA - Veteran Administration Plan
                                            WC - Workers’ Compensation Health Claim
                                            ZZ - Mutually Defined




         Revised 11/01/04              Page 2 of 4
         Issued 04/28/03
v1.13 10/22/2008                           03. Patient Insurance                                    S050
Page 30 of 208


         FIELD                                        EXPLANATION

         PAYER RESP SEQ: (R)                          A code indicating the insurance carrier's level of
                                                      responsibility for payment
                                                      Allowable values:
                                                      P – Primary
                                                      S – Secondary
                                                      T – Tertiary

                                                      Client can have multiple tertiary carriers but only one
                                                      primary and/or secondary insurer.


         INS PROGRAM TYPE: (O)                        Code indicating the type of insurance policy. Required for
                                                      Medicaid billing when patient also has insurance.

                                                      Allowable values:
                                                      AP – Auto Insurance Policy
                                                      C1 – Commercial
                                                      CP – Medicare Conditionally Primary
                                                      GP – Group Policy
                                                      HM – Health Maintenance Organization (HMO)
                                                      IP – Individual Policy
                                                      LD – Long Term Policy
                                                      LT – Litigation
                                                      MB – Medicare Part B
                                                      MC – Medicaid
                                                      MI – Medigap Part B
                                                      MP – Medicare Primary
                                                      OT – Other
                                                      PP – Personal Payment (Cash - No Insurance)
                                                      SP – Supplemental Policy

         POLICY: (O)                                  Enter policy number of insured.

         GROUP: (O)                                   Enter insurer’s group number if applicable.

         POLICY HOLDER DATA: (R)                      Enter policy holder’s name, address and social security
                                                      number

         ID ASSIGNED BY INSURANCE COMPANY: (O) Enter insured’s ID if different than policy number
                                                      Required for insurance and Medicaid patients.

         RELATIONSHIP TO INSURED: (O)                 Enter patient’s relationship to the insured
                                                      Required for insurance/Medicaid patients
                                                      01= Spouse
                                                      18 = Self
                                                      19 = Child
                                                      20 = Employee
                                                      21 = Unknown
                                                      22 = Handicapped Dependent


         Revised 11/01/04                        Page 3 of 4
         Issued 04/28/03
v1.13 10/22/2008                      03. Patient Insurance                                    S050
Page 31 of 208


         FIELD                                   EXPLANATION

                                                 29 = Significant Other

         GUARANTOR: (O)                          Enter ‘Y’ if policy holder is the patient’s guarantor

         BIRTH DATE: (O)                         Enter birth date (MM/DD/YYYY) of policy holder
                                                 Required for insurance/medicaid patients

         SEX: (O)                                Enter sex code of policy holder
                                                 Required for insurance/medicaid patients.

                                                 Allowable values:
                                                 1 = Male
                                                 2 = Female
                                                 3 = Unknown

          CONDITION RELATED TO: (O)
             EMPLOYMENT:                         Valid entry ‘Y’ or ‘N’
             AUTO ACCIDENT:                      Valid entry ‘Y’ or ‘N’

             STATE:                              Enter abbreviation of state where auto accident occurred.
                                                 Required if AUTO ACCIDENT = ‘Y’.

             OTHER ACCIDENT:                     Valid entry ‘Y’ or ‘N’

         ACCIDENT DATE: (O)                      Enter date of accident (MM/DD/YYYY). Required if
                                                 EMPLOYMENT, AUTO ACCIDENT or OTHER
                                                 ACCIDENT = ‘Y’.




         Revised 11/01/04                   Page 4 of 4
         Issued 04/28/03
v1.13 10/22/2008
Page 32 of 208


                                                   04. PATIENT ADDRESS                                              S060
    The Patient Address screen (menu option 04) allows the user to maintain a mailing, home and/or work address for
    each patient. The mailing address displays on the Patient Master screen and can also be updated from the Patient
    Master screen. Separate addresses allow the patient to receive mail at a location other than their home address. Each
    address has an effective start and end date. The start/stop dates for multiple addresses of the same type (e.g. mailing)
    are for documentation only – it shows the date range when the address was in effect.

    Menu option 04 allows the user to inquiry, add, change or delete a patient address. There is a detail and list screen.

    List Screen - Inquiry, change and delete action codes go to the list screen where the user selects a specific address
    and is transferred to the detail screen for the selected address. No updates are permitted on the list screen.

    Detail Screen – All changes are made on the detail screen and it is the initial screen for an add.

                                                 Patient Address List Screen

  HSA040C                      HSIS – PATIENT ADDRESS LIST                                      ADDED:__________
                                                                                              CHANGED:__________
  NEXT RECORD:         COUNTY ___            SCREEN __           ID _________             DATE ______   ACTION _
  MESSAGE:

  NAME:                                                                               ID NUMBER:

            EFFECTIVE         EFFECTIVE
  TYPE      START DATE        END DATE          STREET                                              CITY
  ____      __________        __________        ______________________________                      ______________
  ____      __________        __________        ______________________________                      ______________
  ____      __________        __________        ______________________________                      ______________
  ____      __________        __________        ______________________________                      ______________
  ____      __________        __________        ______________________________                      ______________


                                                Patient Address Detail Screen

  HSA040A                     NORTH CAROLINA HSIS – PATIENT ADDRESS                             ADDED:__________
                                                                                              CHANGED:__________
  NEXT RECORD:          COUNTY ___           SCREEN __           ID _________             DATE ______   ACTION _
  MESSAGE:
  NAME:                                                                               ID NUMBER:
                    TYPE: ____                 (HOME, WORK, MAIL)

      EFFECTIVE DATE: ________               THRU __________

               STREET 1: ____________________

               STREET 2: ____________________

                    CITY: ______________

                   STATE: __

                      ZIP: _____ - ____




    Issued 04/28/03                                        Page 1 of 2
v1.13 10/22/2008
Page 33 of 208


                                      04. PATIENT ADDRESS                                           S060
  FIELD                                  EXPLANATION

                                         Patient Address Detail Screen
  NAME:                                  Patient name is automatically displayed from the Patient Master.
                                         No update allowed.

  TYPE (R)                               Identifies the type of address.
                                         Allowable values:
                                         MAIL
                                         HOME
                                         WORK

  EFFECTIVE DATE: ______THRU ______      No entry allowed. For documentation only – shows date range
                                         when address was in effect.

  STREET 1: (R)                          Street address

  STREET 2: (O)                          Supplemental address (e.g. Apt 205B)

  CITY: (R)                              City Address

  STATE: (R)                             Valid state abbreviation

  ZIP: (R)                               Five position zip code is required. Last 4 digits is optional.




  Issued 04/28/03                        Page 2 of 2
v1.13 10/22/2008          Child Service Coordination Identification and Referral                                   S070
Page 34 of 208


    The two Child Service Coordination (CSC) screens are used for identifying and reporting the developmental status
    of children from birth to age five who are at risk or who have developmental disabilities.
    The health department in the county where the child resides is responsible for entering the Identification and Referral
    (I & R) Form information. Required fields are denoted by (R). Optional fields are denoted by (O). A line-by-line
    explanation of each entry follows:




     HSA070B NORTH CAROLINA HSIS-CHILD SERVICE COORDINATION IDENTIFICATION
                           ADDED:       CHANGED:
    NEXT RECORD: COUNTY        SCREEN     ID       DATE       ACTION
    MESSAGE:
    REPORT DATE:                     SERVICE SITE: _____
    CSC DESIGNATED AGENCY: ___ DATE ID & REFERRAL RECEIVED BY H.D.: ______
    RISK CODE(S): ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

     NO REFERRALS AT THIS TIME: _ (ENTER 'Y' IF NONE)

              REFERRAL(S) (ENTER 'Y' WHERE APPLICABLE)
     NURS SERV _        SOC WRK SRV _       PARENT SUP _                              REF TO BFGN _
     PT          _      VIS SRV        _    MED SRV    _                              HRG INT/TRN _
     TRANS        _     INST HOME      _    GEN SRV    _                              HRG CNSLT     _
     PRESCHL(B) _       FIN ASST       _    ALTN RES   _                              VIS CNSLT      _
     FAM CONSL _        SSI            _    BF/AFT SCH _                              NON ENG TRS _
     PSY SRV     _      HLTH SRV       _     IMM       _                              REF CAP/MR/DD _
     OT          _       AUD           _     CSC        _                             REF BEH MGMT _
     SP/LG THRP _       ASST TECH      _     WELL CHLD _                              REF PRT SKL TR _
     HOUSING     _      SPC INST       _     WIC        _                             OTHER          _
     MLTI EVAL _        NUTRITION      _     ON-HM SUP  _
     RESP CARE _        CHLD CARE      _
     PARENT INFORMED: _ (Y/N)


    FIELD                                                 EXPLANATION

    SCREEN (R)                                            Enter '07'

    ID (R)                                                Enter the patient ID number.

    DATE (R)                                              Enter the month, day, and year that the Identification/Referral form,
                                                          DHHS 3748, was completed in the MM/DD/YY format.

                                                          NOTE: If the (I & R) form and the first status report
                                                           interval have the same date, then PRE-DATE
                                                          the identification entry.

    ACTION (R)                                            Enter A, I, C, or D
                                                          A=Add
                                                          I=Inquire
                                                          C=Change
                                                          D=Delete

    LAST NAME (R)                                         No operator intervention required.

    FIRST NAME (R)                                        No operator intervention required.

    MI (O)                                                No operator intervention required.

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    ID NUMBER (R)                                 No operator intervention required.

    REPORT DATE (R)                               No operator intervention required. Report date is
                                                  displayed as entered on the fast-path date field.

    SERVICE SITE (R)                              Service site is displayed as entered on the HSIS screen.

    CSC DESIGNATED AGENCY (R)                     Enter the three-position code assigned to the agency that is
                                                  completing the form DHHS 3748. The first character is alpha,
                                                  denoting the type of program. The second and third characters
                                                  are numeric, denoting the county headquarters of the agency.
                                                  For example, A92 is Wake County Health Department.

    DATE IDENTIFICATION &                         Enter the month, day, & year that the Identification and
    Referral form,
    REFERRAL RECEIVED BY                          DEHNR 3748, was received by the health department.
    HEALTH DEPARTMENT     (R)

    RISK CODE (S) (R)                             Enter as many risk codes as appropriate, but at least one
                                                  code must be entered using codes below.


    PARENTAL/FAMILY CONDITIONSNEONATAL CONDITIONS
          100 Maternal age<15 years                                   200 Birth weight<1500 grams
          101 Maternal PKU                                            201 Gestational age<32 weeks
          102 Mother HIV positive                                     202 Respiratory distress (mechanical
          103 Maternal use of anticonvulsant,                             ventilator>6 hours)
              antineoplastic or anticoagulant drugs                   203 Asphyxia
          104 Parental blindness                                      204 Hypoglycemia (<25 mg/dl)
          105 Parental substance abuse                                205 Hyperbilirubinemia (> 20 mg/dl)
          106 Parental mental retardation                             206 Intracranial hemorrhage
          107 Parental mental illness                                 207 Neonatal seizures
          108 Difficulty in parental/infant bonding
         109 Difficulty in providing basic
             parenting
          110 Lack of stable housing
          111 Lack of familial and social support                     DIAGNOSED CONDITIONS
          112 Family history of childhood                             400 Potential High Risk
             deafness                                                 401 Developmental delay
          113 Maternal hepatitis B                                    402 Atypical Development
          114 Maternal Outreach Worker                                403 Chromosomal anomaly/genetic
          115 Patient History of abuse or neglect                         disorder
                                                                      404 Metabolic disorder
             POSTNEONATAL CONDITIONS                                  405 Infectious Disease
             300 Suspected visual impairment                          406 Neurologic Disease
             301 Suspected hearing impairment                         407 Congenital malformation
             302 No well child care by age                            409 Toxic exposure
                 6 months                                             410 Vision disorder
             303 Failure on standard                                  411 Hearing Disorder
                 developmental or sensory
                 screening test
             304 Significant parental concern
             305 Suspected abuse/neglect
             306 Chronic Lung Disease




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    FIELD                                                                      EXPLANATION

    NO REFERRALS AT THIS TIME (O)                           Enter "Y" if there are NO referrals at this time.

    REFERRAL (S) (O)                                        If No Referrals At This Time is left blank,    then enter Y by
                                                            all known referrals.

    PARENT INFORMED (R)                                     Valid entry codes are Y= Yes or N= No
                                                            Enter "Y" if parent has been informed about Child Service
                                                            Coordination.

    NOTE: Many risk conditions-and particularly post-neonatal conditions-may not be noted until after hospital
    discharge. Identified children remain eligible for enrollment in CSC up to the fifth year of life, (after age 3, the child
    must have a 400 code.) Anyone-parent, provider, etc.-who thinks a child should be enrolled in CSC should contact
    the CSC Program at the health department of the child's county of residence. The Coordinator is then responsible for
    completing the I & R Form, securing parental permission, consulting with the child's primary care provider,
    distributing forms, and giving the data entry operator the relevant information for HSIS input. A child enrolled at
    several months of age will begin receiving support services appropriate to that age. It normally will not be possible
    to "go back" and provide services that might have been provided in earlier months. The CSC coordinator must make
    the critical judgements in this regard.




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                                        Child Service Coordination Status Report
                                                    Screen HSA070A


    The Child Service Coordination Program (CSC) Status Form must be completed at standard intervals for all enrolled
    children: 6-9 months chronological age, 15-18 months, 30-36 months, 60 months, and the time of closure or transfer
    to a new service coordination provider. After the identification record has been entered, then the status screen will
    be displayed.

    The status form must be completed by the Child Service Coordinator at specified intervals and sent to the county
    health department for data entry. The data will give vital information about services needed and received by
    children and families. Required fields are denoted by (R). Optional fields are denoted by (O). A line-by-line
    explanation of each entry follows:

    HSA070B NORTH CAROLINA HSIS-CHILD SERVICE COORDINATION IDENTIFICATION
     08/02/04                    ADDED:                           CHANGED:
    NEXT RECORD: COUNTY         SCREEN 07 ID                DATE  ACTION A
    MESSAGE: 016 ENTER ADD INFORMATION AND THEN PRESS "ENTER"
    NAME:                          ID NUMBER:
    REPORT DATE:                          SERVICE SITE:
    CSC DESIGNATED AGENCY: ___ DATE ID & REFERRAL RECEIVED BY H.D.: ______
    RISK CODE(S): ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

     NO REFERRALS AT THIS TIME: _ (ENTER 'Y' IF NONE)

              REFERRAL(S) (ENTER 'Y' WHERE APPLICABLE)
     NURS SERV _        SOC WRK SRV _       PARENT SUP                     _         REF TO BFGN _
     PT          _       VIS SRV        _   MED SRV                        _         HRG INT/TRN _
     TRANS        _     INST HOME       _   GEN SRV                         _        HRG CNSLT      _
     PRESCHL(B) _        FIN ASST       _   ALTN RES                        _        VIS CNSLT     _
     FAM CONSL _         SSI            _   BF/AFT SCH                     _         NON ENG TRS _
     PSY SRV      _     HLTH SRV        _   IMM                            _         REF CAP/MR/DD _
     OT          _      AUD            _    CSC                            _         REF BEH MGMT _
     SP/LG THRP _       ASST TECH      _    WELL CHLD                      _         REF PRT SKL TR _
     HOUSING    _       SPC INST      _     WIC                            _         OTHER      _
     MLTI EVAL _        NUTRITION _         ON-HM SUP                      _
     RESP CARE _        CHLD CARE _
     PARENT INFORMED: _ (Y/N)

    FIELD                                                 EXPLANATION

    SCREEN (R)                                            Enter '07'

    ID (R)                                                Enter the patient ID number.

    DATE (R)                                              Enter the month, day, and year that the Status Report form,
                                                          DHHS 3750, was completed in the MMDDYY format.

                                                          NOTE: If the I & R form and the first status report
                                                                interval have the same date, then PRE-DATE
                                                                 the identification entry.

    ACTION (R)                                            Enter A, I, C, or D
                                                          A=Add
                                                          I=Inquire
                                                          C=Change
                                                          D=Delete


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    LAST NAME (R)                                No operator intervention required.

    FIRST NAME (R)                               No operator intervention required.

    MI (O)                                       No operator intervention required.

    ID NUMBER (R)                                No operator intervention required.

    REPORT DATE (R)                              No operator intervention required. Report date is displayed
                                                 as entered on the fast-path date field.

    SERVICE SITE (R)                             Service site is displayed as entered on the HSIS screen. Press
                                                 TAB to move the cursor to the next field. Providers with
                                                 more than one service site can change the last two digits in
                                                 the field to indicate the location where the patient received
                                                 services .

    CSC DESIGNATED AGENCY                        Enter the three-position code assigned to the
      COMPLETING FORM   (R)                      agency completing form DHHS 3750 (CSC
                                                 Program Status form).

    REPORT INTERVAL (O)                          Enter one of the following codes:
                                                 A = month of 1st birthday
                                                 B = month of 2nd birthday
                                                 C = month of 3rd birthday
                                                 D = month of 4th birthday
                                                 E = Interval other than A-D.
                                                 F= month of 5th birthday or older

    TRANSFERRED TO                               Valid entry codes are Y= Yes or N= No to indicated if the
    ANOTHER AGENCY (R)                           child was transferred to another agency

    NEW CSC AGENCY        (O)                    Enter the three-position code assigned to the agency where the
    child has                                    been transferred.

    CLOSED TO CSC (R)                            Valid entry codes are Y= Yes or N= No. An entry must be made for
                                                 each report interval.

    REASON CLOSED       (R)                      Enter one of the following codes:

                                                 C = Parent assumes CSC responsibilities
                                                 R = Parent refuses enrollment
                                                 D= Parent discontinues participation
                                                 F= Lost to follow-up
                                                 M= Moved, address unknown or out of state
                                                 T= Transferred to another county of residence
                                                 A= Child aged out of program
                                                 E= Child expired
                                                 U= Unsubstantiated risk factors
                                                 O= Other
                                                  NOTE: Must be an ‘A’ if Report Interval = D. May be an
                                                  ‘A’ if Report Interval = C. A valid code is required if Closed
                                                  to CSC = Y.

    IMMUNIZATIONS ARE CURRENT (O)                 Valid entry codes are Y= Yes, N= No, or leave blank.


    WELL-CHILD CARE           (O)                Valid entry codes are Y= Yes, N= No or leave blank.

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                                                 Enter ‘Y’ if the child is receiving well-child care (routine
                                                 pediatric care).

    CHILD RECEIVING WIC (O)                      Valid entry codes are Y= Yes, N= No or leave blank.
                                                 Enter ‘Y’ if WIC receiving WIC services.

    INTERMEDIATE ASSESSMENT (O)                  Valid entry codes are Y= Yes, N= No or leave blank.
                                                 Enter ‘Y’ if an Intermediate Assessment has been done since
                                                 the last report interval.


    MULTIDISCIPLINARY EVALUATION (O)             Valid entry codes are Y= Yes, N= No or leave blank. Enter
                                                 ‘Y’ if a Multi disciplinary Evaluation has been done since the
                                                 last report interval.

    INDIVIDUAL FAMILY SERVICE PLAN (O)           Valid entry codes are Y= Yes, N= No or leave blank . Enter
                                                 ‘Y’ if an Individual Family Service Plan has been done since
                                                 the last report interval.

    INDIVIDUAL EDUCATION PLAN (O)                Valid entry codes are Y= Yes, N= No or leave blank. Enter
                                                 ‘Y’ if an Individual Education Plan has been done since the
                                                 last report interval.

    DEVELOPMENTAL STATUS (O)                     Valid entry codes are N,F, or D.
                                                 N = Normal
                                                 F = Needs follow-up
                                                 D = Confirmed Diagnosis

    SERVICE STATUS (O)                           Valid entry codes are Y, N, or Blank.
                                                 Y = Need has been met
                                                 N = Need has not been met
                                                 Blank = Not a need

     LOCAL USE CODE (S) (O)                      Local providers may use these fields to collect
                                                 Information not included on the screen.




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                                           Maternity Care Coordination Program                                                 S075


                                                                 Screen I

    The Maternity Care Coordination Program screens are used to report data collected for Division of Public Health, Women’s and
    Children Section.

    Entering this data in HSIS serves the following purposes: (1) tracking the client status during a pregnancy, and (2) providing input
    mechanism for reporting.


    HSA080A         NC HSIS – MATERNITY CARE COORDINATION PROGRAM                              ADDED:
                                    INTAKE SCREENING                                           CHANGED:

    NEXT RECORD: COUNTY 099 SCREEN 08 ID         DATE        ACTION A
    MESSAGE:
    NAME:                                        MEDICAID ID: _____________
    RACE: ________    HISP/LATINO: __
    MEDICAID TYPE: __
    DATE OF INTAKE SCREENING: __________
    VERIFICATION OF PREGNANCY: ______
    DATE OF LAST MENSTRUAL PERIOD: __________
    DELIVERY DUE DATE: __________
    WEEKS GESTATION AT SCREENING: ____
    PREGNANCY INTENDEDNESS: ___
    FAMILY PLANNING: __
    NUMBER PREGNANCIES INCLUDING THIS ONE: ___
    DATE LAST PREGNANCY ENDED: __________
    PRENATAL CARE INDICATOR: ___
    NUMBER OF WEEKS GESTATION AT 1ST PRENATAL VISIT: ___
    WIC STATUS: ___
    PRE-PREGNANCY WEIGHT: ____
    HEIGHT WITHOUT SHOES: FT: ___ IN: ___
    PRE-PREGNANCY BODY MASS INDEX (BMI): ___._
    ENROLLED IN MCCP: ___


    Required fields are denoted by (R). Optional fields are denoted by (O). A line-by-line explanation of each entry follows:

    FIELD                                                   EXPLANATION

    SCREEN (R)                                              Enter '08'

    ID (R)                                                  Enter the patient ID number.

    DATE (R)                                                Enter the date of this report in the MMDDYY format

    ACTION (R)                                              Enter A, I, or C.
                                                            A = Add
                                                            I = Inquire
                                                            C = Change

    LAST NAME (R)                                           No operator intervention required.


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                             Maternity Care Coordination Program                                         S075



    FIELD                               EXPLANATION

    FIRST NAME (R)                      No operator intervention required.

    MI (O)                              No operator intervention required.

    MEDICAID ID (R)                     No operator intervention required.

    RACE (R)                            No operator intervention required.

    HISP/LATINO (R)                     No operator intervention required.

    MEDICAID TYPE (R)                   Enter the code for the type of Medicaid program the client is enrolled in:
                                        1 = Blue; 2 = Pink (MPW); 3 = PE only; 4 = None.

    DATE OF INTAKE SCREENING (R)        Enter this date in MMDDYY format.

    VERIFICATION OF PREGNANCY (R)       Enter the code that indicates the primary document presented by client to
                                        verify pregnancy. Valid entries as follows:

                                        1 = Copy of pregnancy test.

                                        2 = Copy of current month MPW card.

                                        3 = Child’s birth/death certificate.

                                        4 = Provider verification of pregnancy loss.

                                        5 = None available.

    DATE OF LAST MENSTRUAL PERIOD (O)   If known, enter this date in MMDDYY format; else, leave blank.

    DELIVERY DUE DATE (O)               If known, enter date in MMDDYY format; else leave blank.
                                        Note: This field is required if Verification of Pregnancy data value is 1
                                        (Copy of pregnancy test).

    WEEKS GESTATION AT SCREENING (O)    Enter the number of weeks gestation on the date the intake screening takes
                                        place. Valid range is 01 – 43, or blank.
                                        Note: This field is required if Verification of Pregnancy data value is 1
                                        (Copy of pregnancy test); no entry is allowed if Verification of Pregnancy
                                        is 3 (Birth/death certificate).




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                              Maternity Care Coordination Program                                            S075


    FIELD                                EXPLANATION


    PREGNANCY INTENDEDNESS (R)           Enter a code indicating the client’s disposition about the pregnancy.
                                         Valid entries as follows:

                                         1 = Wanted to be pregnant sooner.

                                         2 = Wanted to be pregnant later.

                                         3 = Wants to be pregnant now.

                                         4 = Did not want to be pregnant now or any time in the future.

                                         5 = Doesn’t know.

                                         6 = Declines to answer.


    FAMILY PLANNING (R)                  Data indicates whether client was using any means of birth control when
                                         she became pregnant. Valid codes are as follows: 1 = Yes; 2 = No; 3 =
                                         Doesn’t know; 4 = Declines to answer.

    NUMBER PREGNANCIES
     INCLUDING THIS ONE (R)              The count of pregnancies should include the current one, if pregnant.
                                         Valid range for count is 00 – 99.

    DATE LAST PREGNANCY ENDED (O)        This represents the end date of the last pregnancy prior to the current one.
                                         If applicable, enter in MMDDYY format; else, leave blank.
                                         Note: Field required if ‘Number of Pregnancies Including This One’ > 1.

    PRENATAL CARE INDICATOR (O)          This indicates whether the client is receiving prenatal care. If entered,
                                         valid values are as follows: 1 = In prenatal care; 2 = Not yet in prenatal
                                         care; 3 = Declines to answer.
                                         Note: This field is required if Verification of Pregnancy value is 1 (Copy
                                         of pregnancy test).

    NUMBER OF WEEKS GESTATION AT
     1ST PRENATAL VISIT (O)              This value indicates the length of gestation up to the time of the first
                                         prenatal visit. If applicable, valid week range is 01 – 43; else, leave blank.
                                         Note: This field required if Prenatal Care Indicator is 1 (In prenatal care).

    WIC STATUS (R)                       Enter the code for client’s enrollment status in WIC program at the time of
                                         the intake screening. Valid values are as follows:

                                         1 = Referred, but not yet receiving.

                                         2 = Receiving.

                                         3 = Declined.

                                         4 = Ineligible.

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                               Maternity Care Coordination Program                                         S075


    FIELD                                 EXPLANATION


    PRE-PREGNANCY WEIGHT (R)              Enter the client’s weight, in pounds, prior to this pregnancy. Valid range
                                          is 001-999.
                                          NOTE: If weight unknown, enter 999

    HEIGHT WITHOUT SHOES (R)              The height measurement should be taken with the shoes removed. For the
                                          Feet field, valid range is 1 – 7; for Inches, valid range is 00-11.
                                          NOTE: If height unknown, code 9 in feet field and 99 in inches field

    PRE-PREGNANCY BODY MASS INDEX (R)     Enter the client’s body mass index (BMI) prior to this pregnancy. The
                                          format of the index number is 99.9 (two digits to the left of the decimal,
                                          one digit to the right).
                                          NOTE: IF BMI unknown, enter 99.9

    ENROLLED IN MCCP (R)                  Indicate whether the client is enrolled in the Maternity Care Coordination
                                          Program. Valid values are as follows: 1 = Yes; 2 = Declined; 3 = Not
                                          eligible.




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                                         Maternity Care Coordination Program                                           S075



                                                             Screen II

    On the Psychosocial Risks/Needs screen, MCCP data entry may indicate one need, multiple needs, or no needs at all. Note that
    this screen’s data will populate the corresponding POS screen for verification and/or modification as needed.




    HSA080B        NC HSIS – MATERNITY CARE COORDINATION PROGRAM                            ADDED:
                                   INTAKE SCREENING                                         CHANGED:

    NEXT RECORD: COUNTY 099             SCREEN 08     ID             DATE             ACTION A
    MESSAGE:
    NAME:

             PSYCHOSOCIAL RISKS/NEEDS IDENTIFIED DURING INTAKE SCREENING
                     (ENTER ‘Y’ TO THE LEFT OF ALL THAT APPLY)

    __ MEDICAID PARTICIPATION                         __ NUTRITIONAL COUNSELING
    __ ADEQUATE PRENATAL CARE                         __ FOOD ASSISTANCE
    __ MEDICAL HOME FOR SELF OR FAMILY                __ BREASTFEEDING/INFANT FEEDING
    __ FAMILY PLANNING                                __ PARENTING INFORMATION
    __ INTERPRETER SERVICES                           __ ADEQUATE OR SAFE HOUSING
    __ SUPPORT SYSTEM                                 __ SMOKING CESSATION
    __ TRANSPORTATION                                 __ SUBSTANCE ABUSE
    __ EMPLOYMENT                                     __ MENTAL OR BEHAVIORAL HEALTH
    __ SCHOOL ENROLLMENT OR GED                       __ DOMESTIC VIOLENCE
    __ CHILD CARE                                      __ SEXUAL ABUSE
    __ FINANCIAL RESOURCES                            __ (local use/demonstration)




    Required fields are denoted by (R). Optional fields are denoted by (O). A line-by-line explanation of each entry follows:


    FIELD                                               EXPLANATION

    MEDICAID PARTICIPATION (O)                           Enter ‘Y’ if identified need; else, leave blank.

    NUTRITIONAL COUNSELING (O)                           Enter ‘Y’ if identified need; else, leave blank.

    ADEQUATE PRENATAL CARE (O)                           Enter ‘Y’ if identified risk; else, leave blank.

    FOOD ASSISTANCE (O)                                  Enter ‘Y’ if identified need; else, leave blank.

    MEDICAL HOME FOR SELF OR FAMILY (O) Enter ‘Y’ if identified need; else, leave blank.

    BREASTFEEDING/INFANT FEEDING (O)                     Enter ‘Y’ if identified need; else, leave blank.


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                                    Maternity Care Coordination Program                                          S075


    FIELD                                     EXPLANATION

    FAMILY PLANNING (O)                        Enter ‘Y’ if identified need; else, leave blank.

    PARENTING INFORMATION (O)                  Enter ‘Y’ if identified need; else, leave blank.

    INTERPRETER SERVICES (O)                   Enter ‘Y’ if identified need; else, leave blank.

    ADEQUATE OR SAFE HOUSING (O)               Enter ‘Y’ if identified need; else, leave blank.

    SUPPORT SYSTEM (O)                         Enter ‘Y’ if identified need; else, leave blank.

    SMOKING CESSATION (O)                      Enter ‘Y’ if identified risk; else, leave blank.

    TRANSPORTATION (O)                         Enter ‘Y’ if identified need; else, leave blank.

    SUBSTANCE ABUSE (O)                        Enter ‘Y’ if identified risk; else, leave blank.

    EMPLOYMENT (O)                             Enter ‘Y’ if identified need; else, leave blank.

    MENTAL OR BEHAVIORAL HEALTH (O)            Enter ‘Y’ if identified risk; else, leave blank.

    SCHOOL ENROLLMENT OR GED (O)               Enter ‘Y’ if identified need; else, leave blank.

    DOMESTIC VIOLENCE (O)                      Enter ‘Y’ if identified risk; else, leave blank.

    CHILD CARE (O)                             Enter ‘Y’ if identified need; else, leave blank.

    SEXUAL ABUSE (O)                           Enter ‘Y’ if identified risk; else, leave blank.

    FINANCIAL RESOURCES (O)                    Enter ‘Y’ if identified need; else, leave blank.

    (local use/demonstration) (O)              If need is present for an additional local-use category, enter ‘Y’ for that
                                               category; else, leave blank.




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                                         Maternity Care Coordination Program                                             S075


                                                             Screen III

    On the Medical Risks screen, MCCP data entry may indicate one, multiple, or no risks at all. Note that this screen’s data will
    populate the corresponding POS screen for verification and/or modification as needed



    HSA080C        NC HSIS – MATERNITY CARE COORDINATION PROGRAM                            ADDED:
                                   INTAKE SCREENING                                         CHANGED:

    NEXT RECORD: COUNTY 099             SCREEN 08      ID            DATE             ACTION A
    MESSAGE:
    NAME:

                       MEDICAL RISKS IDENTIFIED DURING INTAKE SCREENING
                             (ENTER ‘Y’ TO THE LEFT ALL THAT APPLY)

    __ PREV PREM/PRET DELIVERY (<37 WK)                  __ DIABETES
    __ PREV BIRTH WEIGHT BABY 5.5 LB/LESS                __ GESTATIONAL DIABETES
    __ PREV ABORTION(S) OR MISCARRIAGE(S)                __ ANEMIA OR SICKLE CELL DISEASE
    __ PREV STILLBIRTH                                   __ ASTHMA
    __ ECTOPIC/MOLAR PREGNANCY (CURR)                    __ HEART, KIDNEY, OR LUNG PROBS
    __ CONGENITAL ANOMALY (CURR PREG)                    __ PRESCRIPTION MEDICATION
    __ OBSTETRICAL PROBLEMS (CURR PREG)                  __ CURRENTLY AGE 35 OR OLDER
    __ MULTIPLE PREGNANCY (CURR PREG)                    __ CURRENTLY AGE 17 OR YOUNGER
    __ HISTORY OF INFERTILITY                            __ INTERCONCEPT. INTERVAL. < 6 MOS
    __ UTERINE OR CERVICAL ABNORM.                       __ ENTERED PRENAT.CARE > 1ST TRIM.
    __ VAGINAL BLEEDING (CURR PREG)                      __ PRE-PREGNANT BMI BELOW 19.8
    __ RECURRING UTIS/STIS/VAGINAL INFEC.                __ PRE-PREGNANT BMI 26.1-29.0
    __ HIGH BLOOD PRESSURE/HYPERTENSION                  __ PRE-PREGNANT BMI 29.0 & ABOVE



    Required fields are denoted by (R). Optional fields are denoted by (O). A line-by-line explanation of each entry follows:


    FIELD                                                EXPLANATION

    PREVIOUS PREMATURE/PRETERM
     DELIVERY (< 37 WKS) (O)                             Enter ‘Y’ if identified risk; else, leave blank.

    DIABETES (O)                                         Enter ‘Y’ if identified risk; else, leave blank.

    PREVIOUS BIRTH WEIGHT BABY
     WAS 5.5 LB OR LESS (O)                              Enter ‘Y’ if identified risk; else, leave blank.

    GESTATIONAL DIABETES (O)                             Enter ‘Y’ if identified risk; else, leave blank.

    PREVIOUS ABORTION(S) OR
     MISCARRIAGE(S) (O)                                  Enter ‘Y’ if identified risk; else, leave blank.

    ANEMIA OR SICKLE CELL DISEASE (O)                    Enter ‘Y’ if identified risk; else, leave blank.

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                                    Maternity Care Coordination Program                             S075


    FIELD                                        EXPLANATION

    PREVIOUS STILLBIRTH (O)                      Enter ‘Y’ if identified risk; else, leave blank.

    ASTHMA (O)                                   Enter ‘Y’ if identified risk; else, leave blank.

    ECTOPIC OR MOLAR PREGNANCY
     (CURRENT PREGNANCY) (O)                     Enter ‘Y’ if identified risk; else, leave blank.

    HEART, KIDNEY, OR LUNG PROBLEMS (O) Enter ‘Y’ if identified risk; else, leave blank.

    CONGENITAL ANOMALY (CURRENT
     PREGNANCY) (O)                              Enter ‘Y’ if identified risk; else, leave blank.

    PRESCRIPTION MEDICATION (O)                  Enter ‘Y’ if identified risk; else, leave blank.

    OBSTETRICAL PROBLEMS (CURRENT
     PREGNANCY) (O)                              Enter ‘Y’ if identified risk; else, leave blank.

    CURRENTLY AGE 35 OR OLDER (O)                Enter ‘Y’ if identified risk; else, leave blank.

    MULTIPLE PREGNANCY (CURRENT
     PREGNANCY) (O)                              Enter ‘Y’ if identified risk; else, leave blank.

    CURRENTLY AGE 17 OR YOUNGER (O)              Enter ‘Y’ if identified risk; else, leave blank.

    HISTORY OF INFERTILITY (O)                   Enter ‘Y’ if identified risk; else, leave blank.

    SHORT INTERCONCEPTIONAL
     INTERVAL (< 6 MOS) (O)                      Enter ‘Y’ if identified risk; else, leave blank.

    UTERINE OR CERVICAL
     ABNORMALITIES (O)                           Enter ‘Y’ if identified risk; else, leave blank.

    LATE ENTRY INTO PRENATAL CARE
     (AFTER 1ST TRIMESTER) (O)                   Enter ‘Y’ if identified risk; else, leave blank.

    VAGINAL BLEEDING (CURRENT
     PREGNANCY) (O)                              Enter ‘Y’ if identified risk; else, leave blank.

    PRE-PREGNANT BMI BELOW 19.8                  Enter ‘Y’ if identified risk; else, leave blank.

    RECURRING UTI’S/ STI’S/ VAGINAL
     INFECTIONS (O)                              Enter ‘Y’ if identified risk; else, leave blank.

    PRE-PREGNANT BMI 26.1-29.0 (O)               Enter ‘Y’ if identified risk; else, leave blank.

    HIGH BLOOD PRESSURE/
    HYPERTENSION (O)                             Enter ‘Y’ if identified risk; else, leave blank.

    PRE-PREGNANT BMI 29.0 AND ABOVE (O)          Enter ‘Y’ if identified risk; else, leave blank.


    Revised 03/09/07                                      Page 8 of 9
v1.13 10/22/2008
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                                           Maternity Care Coordination Program                                                 S075


                                                                Screen IV

    The Intake Screening History screen is presented if the user is in Inquiry mode (Action = ‘I’) and no date is entered on the ‘Next
    Record’ line. This screen will display all previous intake screening dates, one for each prior pregnancy captured under MCCP.
    The user may select one of the displayed dates to pull up the entire screening for that pregnancy. Selection is made by entering the
    date on the ‘Next Record’ line, as normal.



    HSA080D         NC HSIS – MATERNITY CARE COORDINATION PROGRAM                             ADDED:
                               INTAKE SCREENING HISTORY                                       CHANGED:

    NEXT RECORD: COUNTY 099               SCREEN 08       ID            DATE             ACTION I
    MESSAGE:
    NAME:

     PREVIOUS INTAKE SCREENINGS:
        DATE                 DATE                                              DATE
        MM/DD/YYYY           MM/DD/YYYY                                        MM/DD/YYYY
        MM/DD/YYYY           MM/DD/YYYY                                        MM/DD/YYYY
        MM/DD/YYYY           MM/DD/YYYY                                        MM/DD/YYYY
        MM/DD/YYYY           MM/DD/YYYY                                        MM/DD/YYYY
        MM/DD/YYYY           MM/DD/YYYY                                        MM/DD/YYYY
        MM/DD/YYYY           MM/DD/YYYY                                        MM/DD/YYYY
        MM/DD/YYYY           MM/DD/YYYY                                        MM/DD/YYYY
        MM/DD/YYYY           MM/DD/YYYY                                        MM/DD/YYYY
        MM/DD/YYYY           MM/DD/YYYY                                        MM/DD/YYYY
        MM/DD/YYYY           MM/DD/YYYY                                        MM/DD/YYYY




    Required fields are denoted by (R). Optional fields are denoted by (O). A line-by-line explanation of each entry follows:


    FIELD                                                   EXPLANATION

    DATE (on ‘Next Record’ line) (O)                        Enter selected date from screening history list, in normal MMDDYY
                                                            format; if no prior information desired, PF back out of this history screen.




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                                                Pregnancy Outcome Summary                                                   S080


                                                               Screen I

    The Pregnancy Outcome Summary (POS) screens are used to report data collected for Division of Public Health, Women’s and
    Children Section.

    Entering this data in HSIS serves the following purposes: (1) reflecting the completion of prenatal services for the client for a
    pregnancy, and (2) providing input mechanism for reporting. Note that the Maternity Care Coordination Program (MCCP)
    screens, if previously filled in for this pregnancy, will become closed to further update once the POS input is initiated.


    HSA090A              NC HSIS – PREGNANCY OUTCOME SUMMARY                                ADDED:
                                                                                            CHANGED:

    NEXT RECORD: COUNTY 099 SCREEN 09                    ID             DATE           ACTION A
    MESSAGE:
    NAME:                                                          MEDICAID ID: _____________
    RACE: ________  HISP/LATINO: __                        MCCP INTAKE SCREENING SITE # ____

    DATE OF MCCP INTAKE SCREENING: ______                  MEDICAID TYPE: __
    DATE OF FORM COMPLETION: ________                      DATE PREGNANCY ENDED: ________
    DATE OF MCCP CLOSURE: ________                         REASON FOR MAT HLTH CLOSURE: __
    REASON FOR MCCP CLOSURE: __                            MULTIPLE BIRTHS: __
    PRENAT CARE PROVS: __                                  WKS GEST WHEN PRENAT BEGAN: ___
    TOT PRENAT VISITS REGARDLESS PRV: ____                 PRE-PREG WT: ____
    HGT W/O SHOES: FT: ___ IN: ___                         PRE-PREG BMI: ____
    WGT LAST PRENAT VISIT PRE DELIV: ____                  TOTAL PRENATAL WGT GAIN: ____
    REFERRED FOR WIC PRENATALLY: ___                       RECEIVED WIC PRENATALLY: ___
    RECEIVED WIC POSTPARTUM: ___                           RECEIVED POSTPRTM X/FAM PLN X: __
    RECEIVED METHOD OF FAM PLAN: ___                       CLIENT RECEIVED MCCP SERVICES: __
    MCC STAFFING QUALIFICATION: ___                        CLIENT RECEIVED MCW SERVICES: ___

                               WKS GEST WHEN MCCP SERVICES BEGAN: ___
                               NUM MTHS CLIENT RECEIVED MCCP SERVICES: ____
                               TOT UNITS OF MCCP SERVICES RECEIVED: ___


    Required fields are denoted by (R). Optional fields are denoted by (O). A line-by-line explanation of each entry follows:

    FIELD                                                 EXPLANATION

    SCREEN (R)                                             Enter '09'

    ID (R)                                                 Enter the patient ID number.

    DATE (R)                                               Enter the date of POS form completion in the MMDDYY format

    ACTION (R)                                             Enter A, I, C, or D.
                                                           A = Add
                                                           I = Inquire
                                                           C = Change
                                                           D = Delete


    Revised 03/19/07                                                Page 1 of 14
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                                  Pregnancy Outcome Summary                                                S080



    FIELD                                EXPLANATION

    LAST NAME (R)                        No operator intervention required.

    FIRST NAME (R)                       No operator intervention required.

    MI (O)                               No operator intervention required.

    MEDICAID ID (R)                      No operator intervention required.

    RACE (O)                             No operator intervention required.

    HISP/LATINO (O)                      No operator intervention required.

    MCCP INTAKE SCREENING SITE NUM (O)   No operator intervention required.       Displayed from MCCP intake
                                         information, if on file.

    DATE OF MCCP INTAKE SCREENING (O)    No operator intervention required.       Displayed from MCCP intake
                                         information, if on file.

    MEDICAID TYPE (R)                    Enter the type of Medicaid program the client is enrolled in: 1 = Blue; 2 =
                                         Pink (MPW); 3 = PE only; 4 = None.

    DATE OF FORM COMPLETION (R)          Indicates the date the POS form was completed for the client. Enter this
                                         date in MMDDYY format.

    DATE PREGNANCY ENDED (O)             Indicates the date the client’s pregnancy ended. Enter this date in
                                         MMDDYY format if applicable, else leave blank. Required if ‘Reason for
                                         Maternal Health Closure’ or ‘Reason for MCCP Closure’ is 1.

    DATE OF MCCP CLOSURE (O)             Indicates the date the client was closed to the MCCP program. Enter this
                                         date in MMDDYY format if applicable, else leave blank.

    REASON FOR MATERNAL HEALTH
     CLOSURE (O)                         Enter the reason the client’s prenatal care record is closed. Valid entries
                                         as follows:

                                         1 = Pregnancy ended.

                                         2 = Lost to follow-up.

                                         3 = Moved.

                                         4 = Maternal death.

                                         5 = Declined prenatal care.

                                         6 = Not pregnant.

                                         7 = Transferred to other provider.


    Revised 03/19/07                              Page 2 of 14
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                                    Pregnancy Outcome Summary                                              S080


    FIELD                                 EXPLANATION

                                          Note: If ‘Reason for Maternal Health Closure’ = 1, then ‘Date Pregnancy
                                          Ended’ field is required. If it is coded 2-7, then ‘Multiple Births or
                                          Outcomes’ must = 2.

    REASON FOR MCCP CLOSURE (O)           Enter the reason the client’s MCCP services are ended. Valid entries as
                                          follows:

                                          1 = Pregnancy ended.

                                          2 = Lost to follow-up.

                                          3 = Moved.

                                          4 = Maternal death.

                                          5 = Declined prenatal care.

                                          6 = Services no longer needed.

                                          7 = Transferred to other provider.

                                          8 = Incarcerated.

                                          9 = No longer Medicaid eligible.

                                          Note: If ‘Reason for MCCP Closure’ = 1, then ‘Date Pregnancy Ended’
                                          field is required. If it is coded 2-9, then ‘Multiple Births or Outcomes’
                                          must = 2.

    MULTIPLE BIRTHS OR OUTCOMES (R)       Indicates whether client pregnancy ended in multiple births or outcomes.
                                          Enter one of the following codes: 1 = Yes, multiple births/outcomes; 2 =
                                          No; single birth/outcome.

    PRENATAL CARE PROVIDER(S) (O)         Indicates the categories of providers of prenatal care used by the client.
                                          Up to four values may be entered; multiple values must be distinct. Valid
                                          entries are as follows:

                                          1 = Health Department.

                                          2 = Private Provider.

                                          3 = Rural/Community Health Center.

                                          4 = Tertiary High Risk Center.

                                          5 = None.

                                          Note: If code 5 entered, no other categories may accompany it.



    Revised 03/19/07                               Page 3 of 14
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                                          Pregnancy Outcome Summary                                                   S080


    FIELD                                          EXPLANATION

    NUMBER OF WEEKS GESTATION WHEN
     PRENATAL CARE BEGAN (R)                        Enter the number of weeks gestation on the date prenatal care began.
                                                    Valid range is 01 – 43, or 99 (no prenatal care received).

    TOTAL NUMBER OF PRENATAL VISITS
     REGARDLESS OF MEDICAL PROVIDER (R) Indicates number of visits, including all providers. Valid range is 00 – 99.

    PRE-PREGNANCY WEIGHT (R)                        Enter client’s weight prior to pregnancy in pounds. Valid range is 001 –
                                                    999. If pre-pregnancy weight unknown, enter 999
                                                    Note: If a current MCCP record is on file, the pre-pregnancy weight from
                                                    that screening will populate this POS field automatically, and no changes
                                                    will be allowed.

    HEIGHT WITHOUT SHOES (R)                        The client height should be measured with shoes off. Feet and inches are
                                                    entered in the two separate fields. Valid ranges are 1 – 7 feet and 00 – 11
                                                    inches. If height unknown, code 9 in feet field and 99 in inches field
                                                    Note: If a current MCCP record is on file, the height information from
                                                    that screening will populate these POS fields automatically, and no
                                                    changes will be allowed.

    PRE-PREGNANCY BODY MASS INDEX
     (BMI) (R)                                      Enter client’s body mass index prior to pregnancy. Numeric value must
                                                    have 2 positions to the left of the decimal and 1 position to the right.
                                                    Note: If a current MCCP record is on file, the pre-pregnancy BMI from
                                                    that screening will populate this field automatically, and no changes will
                                                    be allowed. If BMI unknown, enter 99.9

    WEIGHT AT LAST PRENATAL VISIT
     PRIOR TO DELIVERY (O)                         Enter weight in pounds. Valid range is 001 – 999, else leave blank.


    TOTAL PRENATAL WEIGHT GAIN (O)                 Enter weight gained during pregnancy, in pounds. Valid range is 00 – 99,
                                                   else leave blank.

    REFERRED FOR WIC PRENATALLY (R)                Indicates if client was referred for WIC services during this pregnancy.
                                                   Valid codes are as follows: 1 = Yes; 2 = No.

    RECEIVED WIC PRENATALLY (R)                    Indicates if client received WIC services during this pregnancy. Valid
                                                   codes are as follows: 1 = Yes; 4 = Declined; 5 = Ineligible.

    RECEIVED WIC POSTPARTUM (R)                    Indicates if client was referred for WIC services postpartum. Valid codes
                                                   are as follows: 1 = Yes; 4 = Declined; 5 = Ineligible.

    RECEIVED POSTPARTUM EXAM/
     FAMILY PLANNING EXAM (R)                      Indicates if client received a postpartum exam or a family planning exam.
                                                   Valid codes are as follows: 1 = Yes; 2 = No; 6 = Lost to Follow-up.

    RECEIVED METHOD OF FAMILY
     PLANNING (R)                                  Indicates if client received a method of family planning. Valid codes are
                                                   as follows: 1 = Yes; 2 = No.

    Revised 03/19/07                                         Page 4 of 14
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                                        Pregnancy Outcome Summary                                                   S080



    FIELD                                        EXPLANATION

    CLIENT RECEIVED MATERNITY CARE
     COORDINATION PROGRAM (MCCP)
     SERVICES (R)                                Indicates if client received MCCP services during this pregnancy. Valid
                                                 codes are as follows: 1 = Yes; 2 = No; 3 = Declined; 4 = Not Eligible; 5 =
                                                 Not Available.
                                                 Note: Remaining entries below required only if this field is coded as 1.

    MCC STAFFING QUALIFICATIONS (O)              Indicates the qualification of the staff member providing the service to the
                                                 client. Valid entries are as follows:

                                                 1 = Registered Nurse.

                                                 2 = Social Worker with Social Work Degree.

                                                 3 = Social Worker with Other Degree.

                                                 Note: This field is required if ‘Client Received MCCP Services’ = 1

    CLIENT RECEIVED MATERNAL OUTREACH
     WORKER (MOW) SERVICES (O)        Indicates if client received MOW services. Valid codes are as follows: 1
                                      = Yes; 2 = No; 3 = Declined; 4 = Not Eligible; 5 = Not Available.
                                      Note: This field is required if ‘Client Received MCCP Services’ = 1

    WEEKS GESTATION WHEN MCCP
     SERVICES BEGAN (O)                          Enter number of weeks of gestation at the time MCCP services began.
                                                 Valid range is 00 – 43, or 99 (services began postpartum), or blank.
                                                 Note: This field is required if ‘Client Received MCCP Services’ = 1

    NUMBER OF MONTHS CLIENT RECEIVED
     MCCP SERVICES (O)                           Enter total number of months client received MCCP services. Valid range
                                                 is 01 – 13.
                                                 Note: This field is required if ‘Client Received MCCP Services’ = 1

    TOTAL NUMBER OF UNITS OF MCCP
     SERVICES CLIENT RECEIVED (O)                Enter the total number of MCCP service units received. Valid range is
                                                 001 – 999.
                                                 Note: This field is required if ‘Client Received MCCP Services’ = 1




    Revised 03/19/07                                      Page 5 of 14
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                                                Pregnancy Outcome Summary                                                    S080


                                                           Screen II

    On the Medical Risks screen, POS data entry may indicate one, multiple, or no risks at all. Note that data in corresponding fields
    from the MCCP will populate these POS fields initially. If a specific POS risk was marked ‘Y’ in MCCP, then it will have the
    same value here and cannot be changed. The field edits detailed below apply only to those fields on this screen that were not
    identified as risks in MCCP.



    HSA090B        NC HSIS – PREGNANCY OUTCOME SUMMARY                                       ADDED:
                                                                                             CHANGED:

    NEXT RECORD: COUNTY 099              SCREEN 09       ID            DATE             ACTION A
    MESSAGE:
    NAME:

    MEDICAL RISKS IDENTIFIED SINCE SCREENING - SELECT ALL THAT APPLY:
    (FIELDS ALREADY MARKED “Y” ARE CARRIED FROM THE MCCP INTAKE SCREENING)

                       __ ECTOPIC OR MOLAR PREGNANCY (CURR PREGNANCY)
                       __ PREGNANCY WITH CONGENITAL ANOMALY (CURR PREGNANCY)
                       __ OBSTETRICAL PROBLEMS (CURR PREGNANCY)
                       __ MULTIPLE PREGNANCY (CURR PREGNANCY)
                       __ UTERINE OR CERVICAL ABNORMALITIES
                       __ VAGINAL BLEEDING (CURR PREGNANCY)
                       __ RECURRING UTIS/STIS/VAGINAL INFECTIONS
                       __ DIABETES
                       __ GESTATIONAL DIABETES
                       __ ANEMIA OR SICKLE CELL DISEASE
                       __ ASTHMA
                       __ HEART, KIDNEY, OR LUNG PROBLEMS
                       __ PRESCRIPTION MEDICATION
                       __ LATE ENTRY TO PRENATAL CARE (AFTER 1ST TRIMESTER)


    Required fields are denoted by (R). Optional fields are denoted by (O). A line-by-line explanation of each entry follows:


    FIELD                                                  EXPLANATION

    ECTOPIC OR MOLAR PREGNANCY
     (CURRENT PREGNANCY) (O)                               Enter ‘X’ if identified risk; else, leave blank.

    PREGNANCY WITH CONGENITAL
     ANOMALY (CURRENT PREGNANCY) (O)                       Enter ‘X’ if identified risk; else, leave blank.

    OBSTETRICAL PROBLEMS (CURRENT
     PREGNANCY) (O)                                        Enter ‘X’ if identified risk; else, leave blank.

    MULTIPLE PREGNANCY (CURRENT
     PREGNANCY) (O)                                        Enter ‘X’ if identified risk; else, leave blank.


    Revised 03/19/07                                                Page 6 of 14
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                                        Pregnancy Outcome Summary                                   S080


    FIELD                                        EXPLANATION

    UTERINE OR CERVICAL
     ABNORMALITIES (O)                           Enter ‘X’ if identified risk; else, leave blank.

    VAGINAL BLEEDING (CURRENT
     PREGNANCY) (O)                              Enter ‘X’ if identified risk; else, leave blank.

    RECURRING UTI’S/ STI’S/ VAGINAL
     INFECTIONS (O)                              Enter ‘X’ if identified risk; else, leave blank.

    DIABETES (O)                                 Enter ‘X’ if identified risk; else, leave blank.

    GESTATIONAL DIABETES (O)                     Enter ‘X’ if identified risk; else, leave blank.

    ANEMIA OR SICKLE CELL DISEASE (O)            Enter ‘X’ if identified risk; else, leave blank.

    ASTHMA (O)                                   Enter ‘X’ if identified risk; else, leave blank.

    HEART, KIDNEY, OR LUNG PROBLEMS (O) Enter ‘X’ if identified risk; else, leave blank.

    PRESCRIPTION MEDICATION (O)                  Enter ‘X’ if identified risk; else, leave blank.

    LATE ENTRY INTO PRENATAL CARE
     (AFTER 1ST TRIMESTER) (O)                   Enter ‘X’ if identified risk; else, leave blank.




    Revised 03/19/07                                      Page 7 of 14
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                                               Pregnancy Outcome Summary                                                  S080


                                                              Screen III

    On the Psychosocial Risks/Needs screen, POS data entry may indicate one need, multiple needs, or no needs at all. The following
    edits apply to each of the risk/need fields on this screen.
    Valid values for risk/need field:
    1 = Need addressed and resolved
    2 = Need addressed and ongoing
    3 = Need not met, insufficient resources
    4 = Need not met, client declined services
    Note: If a given POS risk/need was identified/found on the MCCP Intake Screening record (as pre-marked with a ‘Y’), it must be
    changed to one of the four valid values above. A newly identified risk/need must also be coded with one of these values.



    HSA090C             NC HSIS – PREGNANCY OUTCOME SUMMARY                                ADDED:
                                                                                           CHANGED:

    NEXT RECORD: COUNTY 099             SCREEN 09       ID            DATE            ACTION A
    MESSAGE:
    NAME:

    PSYCHOSOCIAL RISKS/NEEDS OUTCOMES (INDICATE ALL THAT APPLY):
    (FIELDS ALREADY MARKED “Y” ARE CARRIED FROM THE MCCP INTAKE SCREENING)

    __ MEDICAID PARTICIPATION                          __ NUTRITIONAL COUNSELING
    __ ADEQUATE PRENATAL CARE                          __ FOOD ASSISTANCE
    __ MEDICAL HOME FOR SELF OR FAMILY                 __ BREASTFEEDING/INFANT FEEDING
    __ FAMILY PLANNING                                 __ PARENTING INFORMATION
    __ INTERPRETER SERVICES                            __ ADEQUATE OR SAFE HOUSING
    __ SUPPORT SYSTEM                                  __ SMOKING CESSATION
    __ TRANSPORTATION                                  __ SUBSTANCE ABUSE
    __ EMPLOYMENT                                      __ MENTAL OR BEHAVIORAL HEALTH
    __ SCHOOL ENROLLMENT OR GED                        __ DOMESTIC VIOLENCE
    __ CHILD CARE                                       __ SEXUAL ABUSE
    __ FINANCIAL RESOURCES                             __ (local use/demonstration)




    Required fields are denoted by (R). Optional fields are denoted by (O). A line-by-line explanation of each entry follows:


    FIELD                                                 EXPLANATION

    MEDICAID PARTICIPATION (O)                            If identified need, enter value according to the instructions at the
                                                          beginning of this screen section; else, leave blank.

    NUTRITIONAL COUNSELING (O)                            If identified need, enter value according to the instructions at the
                                                          beginning of this screen section; else, leave blank.



    Revised 03/19/07                                               Page 8 of 14
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                                       Pregnancy Outcome Summary                                                    S080



    FIELD                                       EXPLANATION

    ADEQUATE PRENATAL CARE (O)                  If identified risk, enter value according to the instructions at the beginning
                                                of this screen section; else, leave blank.

    FOOD ASSISTANCE (O)                         If identified need, enter value according to the instructions at the
                                                beginning of this screen section; else, leave blank.

    MEDICAL HOME FOR SELF OR FAMILY (O) If identified need, enter value according to the instructions at the
                                        beginning of this screen section; else, leave blank.

    BREASTFEEDING/INFANT FEEDING (O)            If identified need, enter value according to the instructions at the
                                                beginning of this screen section; else, leave blank.

    FAMILY PLANNING (O)                         If identified need, enter value according to the instructions at the
                                                beginning of this screen section; else, leave blank.

    PARENTING INFORMATION (O)                   If identified need, enter value according to the instructions at the
                                                beginning of this screen section; else, leave blank.

    INTERPRETER SERVICES (O)                    If identified need, enter value according to the instructions at the
                                                beginning of this screen section; else, leave blank.

    ADEQUATE OR SAFE HOUSING (O)                If identified need, enter value according to the instructions at the
                                                beginning of this screen section; else, leave blank.

    SUPPORT SYSTEM (O)                          If identified need, enter value according to the instructions at the
                                                beginning of this screen section; else, leave blank.

    SMOKING CESSATION (O)                       If identified risk, enter value according to the instructions at the beginning
                                                of this screen section; else, leave blank.

    TRANSPORTATION (O)                          If identified need, enter value according to the instructions at the
                                                beginning of this screen section; else, leave blank.

    SUBSTANCE ABUSE (O)                         If identified risk, enter value according to the instructions at the beginning
                                                of this screen section; else, leave blank.

    EMPLOYMENT (O)                              If identified need, enter value according to the instructions at the
                                                beginning of this screen section; else, leave blank.

    MENTAL OR BEHAVIORAL HEALTH (O)             If identified risk, enter value according to the instructions at the beginning
                                                of this screen section; else, leave blank.

    SCHOOL ENROLLMENT OR GED (O)                If identified need, enter value according to the instructions at the
                                                beginning of this screen section; else, leave blank.

    DOMESTIC VIOLENCE (O)                       If identified risk, enter value according to the instructions at the beginning
                                                of this screen section; else, leave blank.



    Revised 03/19/07                                     Page 9 of 14
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                                    Pregnancy Outcome Summary                                                 S080


    FIELD                                 EXPLANATION

    CHILD CARE (O)                        If identified need, enter value according to the instructions at the
                                          beginning of this screen section; else, leave blank.

    SEXUAL ABUSE (O)                      If identified risk, enter value according to the instructions at the beginning
                                          of this screen section; else, leave blank.

    FINANCIAL RESOURCES (O)               If identified need, enter value according to the instructions at the
                                          beginning of this screen section; else, leave blank.

    (local use/demonstration) (O)         If identified need, enter value according to the instructions at the
                                          beginning of this screen section; else, leave blank.




    Revised 03/19/07                               Page 10 of 14
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                                               Pregnancy Outcome Summary                                                     S080


                                                              Screen IV

    The Infant Data screen, HSA090D, records live birth data. It is activated only if the “Reason for Maternal Health Closure” data
    field on HSA090A has a value of 1 (Pregnancy Ended).



    HSA090D             NC HSIS – PREGNANCY OUTCOME SUMMARY                                 ADDED:
                                                                                            CHANGED:

    NEXT RECORD: COUNTY 099             SCREEN 09       ID            DATE             ACTION A
    MESSAGE:
    NAME:

                                        *** INFANT DATA


    PREGNANCY OUTCOME: ___
    GESTATIONAL AGE AT PREGNANCY OUTCOME: ___ WEEKS
    WEIGHT: ___ LBS, ___ OZ OR ____ GRAMS
    SEX: __
    MOTHER BREASTFEEDING: ___
    BABY RECEIVING WIC: ___
    HEALTH CHECK EXAM OR WELL CHILD CARE: ___
    REFERRED TO CSC: ___




    Required fields are denoted by (R). Optional fields are denoted by (O). A line-by-line explanation of each entry follows:


    FIELD                                                 EXPLANATION

    PREGNANCY OUTCOME (R)                                 Indicates the outcome of pregnancy. Valid entries are as follows:

                                                          1 = Live Birth.

                                                          2 = Spontaneous Abortion.

                                                          3 = Therapeutic Abortion.

                                                          4 = Fetal Death (>20 weeks).

    GESTATIONAL AGE AT PREGNANCY
     OUTCOME (O)                                          Enter the age of the fetus, in weeks, at time of delivery. Valid range is 01
                                                          – 43, if entered.
                                                          Note: This field is required if ‘Pregnancy Outcome’ = 1.

    Revised 03/19/07                                               Page 11 of 14
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                                Pregnancy Outcome Summary                                               S080


    FIELD                             EXPLANATION

    WEIGHT (O)                        Enter the weight of the baby at time of delivery. Values may be expressed
                                      in English-system weight (pounds/ounces) or metric-system weight
                                      (grams), but not both. Value ranges for entered fields are as follows: (a)
                                      pounds, 00 – 99; (b) ounces, 00 – 15; (c) grams, 0000 – 9999.
                                      Note: Entry of weight is required if ‘Pregnancy Outcome’ = 1.

    SEX (O)                           Indicate the gender of the baby. Valid codes, if entered, are as follows: 1
                                      = Male; 2 = Female.
                                      Note: This field is required if ‘Pregnancy Outcome’ = 1.

    MOTHER BREASTFEEDING? (O)         Indicate whether the mother is breastfeeding the baby. Valid values, if
                                      entered, are as follows: 1 = Yes; 2 = No.
                                      Note: This field is required if ‘Pregnancy Outcome’ = 1.

    BABY RECEIVING WIC? (O)           Indicate whether the baby is receiving WIC services. Valid values, if
                                      entered, are as follows: 1 = Yes; 2 = No.
                                      Note: This field is required if ‘Pregnancy Outcome’ = 1.

    HEALTH CHECK EXAM OR
     WELL CHILD CARE? (O)             Indicate whether the baby has had a Health Check Exam or is receiving
                                      well-child care. Valid values, if entered, are as follows: 1 = Yes; 2 = No.
                                      Note: This field is required if ‘Pregnancy Outcome’ = 1.

    REFERRED TO CSC? (O)              Indicate whether the baby has been referred for Child Service
                                      Coordination. Valid values, if entered, are as follows: 1 = Yes; 2 = No.
                                      Note: This field is required if ‘Pregnancy Outcome’ = 1.




    Revised 03/19/07                           Page 12 of 14
v1.13 10/22/2008
Page 61 of 208


                                               Pregnancy Outcome Summary                                                  S080


                                                              Screen V

    The Infant Data screen, HSA090E, records live birth data. It is activated only if the “Reason for Maternal Health Closure” data
    field on HSA090A has a value of 1 (Pregnancy Ended) and the “Multiple Births or Outcomes” has a value of 1 (Yes). Refer to
    Screen IV information, infant data for first baby, for explanation of field entries for each additional baby.



    HSA090E            NC HSIS – PREGNANCY OUTCOME SUMMARY                                 ADDED:
                                                                                           CHANGED:

    NEXT RECORD: COUNTY 099             SCREEN 09       ID            DATE            ACTION A
    MESSAGE:
    NAME:

    ENTER 2ND AND 3RD INFANT DATA AS APPLICABLE:

                               2ND INFANT DATA
    PREGNANCY OUTCOME: ___
    GESTATIONAL AGE AT PREGNANCY OUTCOME: ___ WEEKS
    WEIGHT: ___ LBS, ___ OZ OR ____ GRAMS                SEX: ___
    MOTHER BREASTFEEDING: ___             BABY RECEIVING WIC: ___
    HEALTH CHECK EXAM OR WELL CHILD CARE: ___
    REFERRED TO CSC: ___

                               3RD INFANT DATA
    PREGNANCY OUTCOME: ___
    GESTATIONAL AGE AT PREGNANCY OUTCOME: ___ WEEKS
    WEIGHT: ___ LBS, ___ OZ OR ____ GRAMS                 SEX: ___
    MOTHER BREASTFEEDING: ___              BABY RECEIVING WIC: ___
    HEALTH CHECK EXAM OR WELL CHILD CARE: ___
    REFERRED TO CSC: ___




    Revised 03/19/07                                               Page 13 of 14
v1.13 10/22/2008
Page 62 of 208


                                                 Pregnancy Outcome Summary                                                     S080


                                                                Screen VI

    The Intake Screening History screen is presented if the user is in Inquiry mode (Action = ‘I’) and no date is entered on the ‘Next
    Record’ line. This screen will display all previous intake screening dates, one for each prior pregnancy captured under MCCP.
    The user may select one of the displayed dates to pull up the entire screening for that pregnancy. Selection is made by entering the
    date on the ‘Next Record’ line, as normal.



    HSA090F             NC HSIS – PREGNANCY OUTCOME SUMMARY                                    ADDED:
                                       POS HISTORY                                             CHANGED:

    NEXT RECORD: COUNTY 099               SCREEN 09       ID            DATE             ACTION I
    MESSAGE:
    NAME:

     PREVIOUS PREGNANCY OUTCOME SUMMARIES:
        DATE                DATE                                               DATE
        MM/DD/YYYY          MM/DD/YYYY                                         MM/DD/YYYY
        MM/DD/YYYY          MM/DD/YYYY                                         MM/DD/YYYY
        MM/DD/YYYY          MM/DD/YYYY                                         MM/DD/YYYY
        MM/DD/YYYY          MM/DD/YYYY                                         MM/DD/YYYY
        MM/DD/YYYY          MM/DD/YYYY                                         MM/DD/YYYY
        MM/DD/YYYY          MM/DD/YYYY                                         MM/DD/YYYY
        MM/DD/YYYY          MM/DD/YYYY                                         MM/DD/YYYY
        MM/DD/YYYY          MM/DD/YYYY                                         MM/DD/YYYY
        MM/DD/YYYY          MM/DD/YYYY                                         MM/DD/YYYY
        MM/DD/YYYY          MM/DD/YYYY                                         MM/DD/YYYY




    Required fields are denoted by (R). Optional fields are denoted by (O). A line-by-line explanation of each entry follows:


    FIELD                                                   EXPLANATION

    DATE (on ‘Next Record’ line) (O)                        Enter selected date from POS history list, in normal MMDDYY format; if
                                                            no prior information desired, PF back out of this history screen.




    Revised 03/19/07                                                 Page 14 of 14
v1.13 10/22/2008
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                                     PAYMENT/ADJUSTMENTS                                                     S090



    The Payment/Adjustment screen (12) is used to record payments and/or adjustments made to individual patient
    accounts. Required fields are denoted by (R). Optional fields are denoted by (O). Insurance payments for clients
    who are covered by insurance and Medicaid should be entered on 68B screen.


    HSA120A   NORTH CAROLINA HSIS - PAYMENTS AND ADJUSTMENTS
                               ADDED:
     09901                       CHANGED:
    NEXT RECORD: COUNTY    SCREEN 12 ID       DATE    ACTION
    MESSAGE:

    NAME:                                                        ID NUMBER:           H

    DATE OF PAYMENT:
                              WRITE-OFF: _                      WRITE-OFF AMT:

    PAYMENT/CR TYPE: _ (I,C,P,M) CASH RECEIPT: ____               RECEIVED BY: __________

    BILLED AMOUNT:               PAYMENT/CR AMOUNT:                  PROGRAM TYPE: __

    OTHER ADJ AMT:              OTHER ADJ DESCRIPTION: _______________

    BILL REMAINDER TO: _  REMAINDER AMOUNT:
     (C,P)
    SFSCALE PCT:  SFSCALE AMOUNT:     SFSCALE ADJ AMOUNT:

    MEDICAID:    INSURANCE:                   CURRENT ACCT BALANCE:
    ACCT PERIOD:                              AR-SKIP-IND



    FIELD                                                       EXPLANATION

    NAME (R)                                                    No entry required.

    ID NUMBER (R)                                                No entry required.

                                                                 NOTE: (Field is populated from fast path line)

    DATE OF PAYMENT (R)                                         No entry required.
                                                                Date entered from date on fast path line. Payment
                                                                date can be changed if necessary within the current
                                                                accounting period – enter date of payment on Fast
                                                                Path Line, action ‘C’ – tab to Date if Payment field
                                                                and change to correct date.




    Revised 05/20/04                           Page 1 of 4
v1.13 10/22/2008
Page 64 of 208


                                    PAYMENT/ADJUSTMENTS                                                   S090
                                                             Payments can be predated up to 3 days to allow
                                                             reconciling   with cash deposits. (This is only
                                                             applicable on payments, predating refunds or
                                                             adjustments is not allowed.)

    ACCOUNT BALANCE BEFORE (R)                               No entry required.

    WRITE-OFF (O)                                            Enter ‘Y’ to indicate that the amount in ‘Other
                                                             Adjustment’ field is a write off.

                                                             Enter ‘R’ to indicate amount written off should be
                                                             reinstated. To reinstate a write off balance enter
                                                             following: Pay Type = ‘P’ - Program Type - and
                                                             other adjustment negative for amount of write off
                                                             balance - Other adjustment description – ‘reinstate
                                                             write off bal.’


    PAYMENT/CR TYPE (R)                                      Enter appropriate payment type as follows:
                                                                I=Insurance
                                                                C=Contract
                                                                P=Private Pay
                                                                M=Medicaid

    NOTE: Medicaid payments and adjustments are created by the program. Enter only Medicaid adjustments/refunds
    when necessary because of overpayment or recoupments from Medicaid.

    NOTE: Insurance payments for Ins/Med patients must be entered on screen 68B (Billing/Billing Inquiry
    Payment/Adjustment Screen). Medicaid services are created for INS/MED patients when a payment has been
    posted against an insurance service.

    DO NOT ENTER INSURANCE PAYMENTS ON SCREEN 12 IF THE PATIENT ALSO IS A MEDICAID
    RECIPIENT.

    NOTE FOR CDSA SITES ONLY: Insurance payments for CDSA clients must also be entered on screen 68B
    (Billing/Billing Inquiry Payment/Adjustment Screen). This is to facilitate billing private patients after
    insurance has been adjudicated (please see instruction in section S280 for these entries). DO NOT ENTER
    INSURANCE PAYMENTS ON SCREEN 12.




    Revised 05/20/04                         Page 2 of 4
v1.13 10/22/2008
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                           PAYMENT/ADJUSTMENTS                                              S090
    FIELD                               EXPLANATION

    CASH RECEIPT (O)                          Enter receipt number for payments received if
                                              applicable.                                 .

                                              NOTE: Method of payment can also be entered in
                                              this field (ex: cc for credit card, etc).

    RECEIVED BY: ( O)                         Enter person receiving payment.

    BILLED AMOUNT (O)                         Enter amount billed for visit date(s) being
                                              paid/adjusted.

                                              NOTE: If ‘Billed Amount’ is completed
                                                 ‘Bill Remainder To’ will be required.


    PAYMENT/CR AMT (O)                        Enter amount of payment or refund.

                                              NOTE: This is the only field that affects cash.
                                                    Enter amount as positive to increase cash .
                                                    Enter amount as negative to decrease cash
                                                    Refunds and bad checks should be entered
                                                    as negative amount.
                                                    Ex: - $10.00 for $10.00 refund

    PROGRAM TYPE (R)                          Enter code for the program the payment should be
                                              applied to using following codes:

                                              AH - ADULT HEALTH
                                              CC - CHILDREN SPECIAL HEALTH SERVICES
                                              CH - CHILD HEALTH
                                              CL - DEC
                                              FP - FAMILY PLANNING
                                              EP - EPIDEMIOLOGY
                                              MH - MATERNAL HEALTH
                                              GB - GENERIC BILLING
                                              CS - Child Service Coordination
                                              RH – Rural Health

    OTHER ADJUSTMENT (O)                      Enter amount of adjustment.


                                               NOTE: This field changes the account balance
                                              but will not affect cash flow. To decrease the
                                              account balance enter amount as positive. To
                                              increase the account balance enter amount as
                                              negative (ex: -10.00).




    Revised 05/20/04            Page 3 of 4
v1.13 10/22/2008
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                             PAYMENT/ADJUSTMENTS                                                S090
    FIELD                                       EXPLANATION

    OTHER ADJ DESCRIPTION (O)                   Enter reason for adjustment.
                                                Required if other adjustment amount is completed.




    BILL REMAINDER TO (O)                       Enter pay source to bill balance to as follows:

                                                C = Contract
                                                P = Patient

                                                If P is entered, the sliding fee scale percentage will
                                                 be calculated and a financial statement can be
                                                  printed.

                                                NOTE: Bill Remainder To required if Billed
                                                      Amount is completed.

                                                NOTE: Payment type and bill remainder to cannot
                                                      be the same.

    REMAINDER AMOUNT (O)                        No entry required.

    SFSCALE PCT (O)                             No entry required.

                                                NOTE: APPROPRIATE SLIDING FEE SCALE
                                                PERCENTAGE WILL BE DISPLAYED ON THE
                                                SCREEN, BY PROGRAM TYPE, WHEN ‘ENTER’
                                                KEY IS DEPRESSED.


    SFSCALE AMOUNT (O)                          No entry required.

    SFSCALE ADJ AMOUNT (O)                      No entry required.

    ACCT BALANCE AFTER (O)                      No entry required.




    Revised 05/20/04              Page 4 of 4
v1.13 10/22/2008                                Payment Examples                        S090a
Page 67 of 208


         EXAMPLE 1 - PATIENT PAYMENT


         FIELDS TO BE COMPLETED:

         CLIENT ID
         PAYMENT DATE
         PAYMENT/CR AMOUNT
         PROGRAM TYPE


         HSA120A    NORTH CAROLINA HSIS - PAYMENTS AND ADJUSTMENTS
         11/07/01                      ADDED: 11/07/01
         01201                        CHANGED: 11/07/01
         NEXT RECORD: COUNTY 012 SCREEN 12 ID 111111111 DATE 110101 ACTION C
         MESSAGE: 022 RECORD HAS BEEN CHANGED - ENTER NEXT KEY

         NAME: PARKER, JULI                 ID NUMBER: 111111111H

         DATE OF PAYMENT: 110101             ACCT BALANCE BEFORE:          55.00
                     WRITE-OFF: _      WRITE-OFF AMT:  .00

         PAYMENT/CR TYPE: P (I,C,P,M) CASH RECEIPT:        RECEIVED BY:

         BILLED AMOUNT:     .00   PAYMENT/CR AMOUNT:       10.00   PROGRAM TYPE: GB

         OTHER ADJ AMT:     .00   OTHER ADJ DESCRIPTION:

         BILL REMAINDER TO:    REMAINDER AMOUNT:     .00
          (C,P)
         SFSCALE PCT: 0 SFSCALE AMOUNT:   .00 SFSCALE ADJ AMOUNT:                 .00

         MEDICAID: Y      INSURANCE:         ACCT BALANCE AFTER:          45.00




                                                      Page 1 of 17
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         EXAMPLE 2 - INSURANCE PAYMENT ACCOUNT PAID IN FULL


         FIELDS TO BE COMPLETED:

         CLIENT ID
         PAYMENT DATE
         PAYMENT/CR TYPE
         PAYMENT/CR AMOUNT
         PROG TYPE

         HSA120A    NORTH CAROLINA HSIS - PAYMENTS AND ADJUSTMENTS
         11/07/01                      ADDED: 11/07/01
         01201                        CHANGED: 11/07/01
         NEXT RECORD: COUNTY 012 SCREEN 12 ID 111111111 DATE 110101 ACTION C
         MESSAGE: 022 RECORD HAS BEEN CHANGED - ENTER NEXT KEY

         NAME: PARKER, JULI                 ID NUMBER: 111111111H

         DATE OF PAYMENT: 110101             ACCT BALANCE BEFORE:         55.00
                     WRITE-OFF: _      WRITE-OFF AMT:  .00

         PAYMENT/CR TYPE: I (I,C,P,M) CASH RECEIPT:        RECEIVED BY:

         BILLED AMOUNT:     .00   PAYMENT/CR AMOUNT:        55.00   PROGRAM TYPE: GB

         OTHER ADJ AMT:     .00   OTHER ADJ DESCRIPTION:

         BILL REMAINDER TO:    REMAINDER AMOUNT:     .00
          (C,P)
         SFSCALE PCT: 0 SFSCALE AMOUNT:   .00 SFSCALE ADJ AMOUNT:                 .00

         MEDICAID: Y      INSURANCE:         ACCT BALANCE AFTER:          .00




         (CDSA’S USE SCREEN 68 FOR THIS TYPE ENTRY)




                                                      Page 2 of 17
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         EXAMPLE 3 - INSURANCE PAYS PARTIAL PAYMENT – BILL REMAINDER TO PATIENT


         FIELDS TO BE COMPLETED

         CLIENT ID
         PAYMENT DATE
         BILLED AMOUNT
         PAYMENT/CR TYPE
         PAYMENT/CR AMOUNT
         PROGRAM TYPE
         BILL REMAINDER TO



         HSA120A    NORTH CAROLINA HSIS - PAYMENTS AND ADJUSTMENTS
         11/07/01                      ADDED: 11/07/01
         01201                        CHANGED: 11/07/01
         NEXT RECORD: COUNTY 012 SCREEN 12 ID 111111111 DATE 110101 ACTION C
         MESSAGE: 022 RECORD HAS BEEN CHANGED - ENTER NEXT KEY

         NAME: PARKER, JULI                   ID NUMBER: 111111111H

         DATE OF PAYMENT: 110101              ACCT BALANCE BEFORE:          55.00
                     WRITE-OFF: _       WRITE-OFF AMT:  .00

         PAYMENT/CR TYPE: I (I,C,P,M) CASH RECEIPT:          RECEIVED BY:

         BILLED AMOUNT:     55.00     PAYMENT/CR AMOUNT:       15.00   PROGRAM TYPE: GB

         OTHER ADJ AMT:     .00     OTHER ADJ DESCRIPTION:

         BILL REMAINDER TO: P    REMAINDER AMOUNT:   40.00
          (C P)
         SFSCALE PCT: 80 SFSCALE AMOUNT: 32.00 SFSCALE ADJ AMOUNT:                  8.00

         MEDICAID: Y      INSURANCE:           ACCT BALANCE AFTER:       32.00




         (CDSA’S USE SCREEN 68 FOR THIS TYPE ENTRY)




                                                        Page 3 of 17
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         EXAMPLE 4 - INSURANCE BILLED DENIED ALL BILL REMAINDER TO PATIENT


         FIELDS TO BE COMPLETED:




         CLIENT ID
         PAYMENT TYPE
         BILLED AMOUNT
         BILL REMAINDER TO


         HSA120A    NORTH CAROLINA HSIS - PAYMENTS AND ADJUSTMENTS
         11/07/01                      ADDED: 11/07/01
         01201                        CHANGED: 11/07/01
         NEXT RECORD: COUNTY 012 SCREEN 12 ID 111111111 DATE 110101 ACTION C
         MESSAGE: 022 RECORD HAS BEEN CHANGED - ENTER NEXT KEY

         NAME: PARKER, JULI                   ID NUMBER: 111111111H

         DATE OF PAYMENT: 110101              ACCT BALANCE BEFORE:          55.00
                     WRITE-OFF: _       WRITE-OFF AMT:  .00

         PAYMENT/CR TYPE: I (I,C,P,M) CASH RECEIPT:          RECEIVED BY:

         BILLED AMOUNT:     55.00     PAYMENT/CR AMOUNT:        .00   PROGRAM TYPE: GB

         OTHER ADJ AMT:    .00      OTHER ADJ DESCRIPTION:

         BILL REMAINDER TO: P    REMAINDER AMOUNT:   55.00
          (A,C,P,R)
         SFSCALE PCT: 80 SFSCALE AMOUNT: 44.00 SFSCALE ADJ AMOUNT: 11.00




                                                        Page 4 of 17
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         EXAMPLE 5 – REFUND TO PATIENT

         FIELDS TO BE COMPLETED

         CLIENT ID
         DATE
         PAYMENT/CR TYPE
         PAYMENT/CR AMOUNT
         PROGRAM TYPE

         HSA120A    NORTH CAROLINA HSIS - PAYMENTS AND ADJUSTMENTS
         11/07/01                      ADDED: 11/07/01
         01201                        CHANGED: 11/07/01
         NEXT RECORD: COUNTY 012 SCREEN 12 ID 111111111 DATE 110101 ACTION C
         MESSAGE: 022 RECORD HAS BEEN CHANGED - ENTER NEXT KEY

         NAME: PARKER, JULI                 ID NUMBER: 111111111H

         DATE OF PAYMENT: 110101             ACCT BALANCE BEFORE:          55.00
                     WRITE-OFF: _      WRITE-OFF AMT:  .00

         PAYMENT/CR TYPE: P (I,C,P,M) CASH RECEIPT:        RECEIVED BY:

         BILLED AMOUNT:     .00   PAYMENT/CR AMOUNT:       10.00-   PROGRAM TYPE: GB

         OTHER ADJ AMT:     .00   OTHER ADJ DESCRIPTION:

         BILL REMAINDER TO:     REMAINDER AMOUNT:     .00
          (A,C,P,R)
         SFSCALE PCT: 80 SFSCALE AMOUNT:   .00 SFSCALE ADJ AMOUNT:                 .00

         MEDICAID: Y      INSURANCE:         ACCT BALANCE AFTER:          65.00



         NOTE: ENTRY WOULD BE THE SAME FOR ALL PAY SOURCES
         (MEDICAID/INSURANCE REFUNDS)




                                                      Page 5 of 17
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         EXAMPLE 6 – BEGINNING BALANCE


         FIELDS TO BE COMPLETED

         CLIENT ID
         PAYMENT DATE
         PAYMENT/CR TYPE
         OTHER ADJUSTMENT
         OTHER ADJ. DESCRIPTION


         HSA120A     NORTH CAROLINA HSIS - PAYMENTS AND ADJUSTMENTS
         11/07/01                       ADDED: 11/07/01
         01201                        CHANGED: 11/07/01
         EXT RECORD: COUNTY 012 SCREEN 12 ID 111111111 DATE 110201 ACTION A
         ESSAGE: 021 RECORD HAS BEEN ADDED - ENTER NEXT KEY

         AME: PARKER, JULI                  ID NUMBER: 111111111H

         ATE OF PAYMENT: 110201             ACCT BALANCE BEFORE:        65.00
                     WRITE-OFF: _      WRITE-OFF AMT:  .00

         AYMENT/CR TYPE: P (I,C,P,M) CASH RECEIPT:       RECEIVED BY:

         ILLED AMOUNT:       .00   PAYMENT/CR AMOUNT:    .00   PROGRAM TYPE: GB

         OTHER ADJ AMT: 200.00-      OTHER ADJ DESCRIPTION: BEGINNING BAL

         ILL REMAINDER TO:     REMAINDER AMOUNT:    .00
          (C P)
         FSCALE PCT: 80 SFSCALE AMOUNT:   .00 SFSCALE ADJ AMOUNT:               .00

         EDICAID: Y    INSURANCE:           ACCT BALANCE AFTER:        265.00




                                                        Page 6 of 17
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         EXAMPLE 7 – PATIENT HAS BALANCE WRITTEN OF COMES TO PAY OR
         WALK-IN PROCEDURE




         FIELDS TO BE COMPLETED

         CLIENT ID
         PAYMENT DATE
         PAYMENT/CR TYPE
         PAYMENT/CR AMT
         PROGRAM TYPE
         OTHER ADJ AMT
         OTHER ADJ DESCRIPTION


         HSA120A    NORTH CAROLINA HSIS - PAYMENTS AND ADJUSTMENTS
         11/07/01                      ADDED: 11/07/01
         01201                        CHANGED: 11/07/01
         NEXT RECORD: COUNTY 012 SCREEN 12 ID 111111111 DATE 110201 ACTION C
         MESSAGE: 022 RECORD HAS BEEN CHANGED - ENTER NEXT KEY

         NAME: PARKER, JULI                 ID NUMBER: 111111111H

         DATE OF PAYMENT: 110201           ACCT BALANCE BEFORE:        65.00
                     WRITE-OFF: _    WRITE-OFF AMT:  .00

         PAYMENT/CR TYPE: P (I,C,P,M) CASH RECEIPT:     RECEIVED BY:

         BILLED AMOUNT:     .00   PAYMENT/CR AMOUNT: 100.00    PROGRAM TYPE: GB

         OTHER ADJ AMT: 100.00-     OTHER ADJ DESCRIPTION: WALK IN SERV

         BILL REMAINDER TO:     REMAINDER AMOUNT:     .00
          (C,P)
         SFSCALE PCT: 80 SFSCALE AMOUNT:   .00 SFSCALE ADJ AMOUNT:             .00




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         EXAMPLE 8 – DISCOVER AFTER ACCOUNTING PERIOD ENDS THAT PAYMENT
         WAS APPLIED TO INCORRECT PROGRAM

         (REMEMBER PAYMENTS CAN BE CHANGED UNTIL ACCOUNTING PERIOD HAS
         CLOSED)


         ENTRY 1 –
         HSA120A     NORTH CAROLINA HSIS - PAYMENTS AND ADJUSTMENTS
         11/07/01                       ADDED: 11/07/01
         01201                        CHANGED: 11/07/01
         EXT RECORD: COUNTY 012 SCREEN 12 ID 111111111 DATE 110301 ACTION A
         ESSAGE: 021 RECORD HAS BEEN ADDED - ENTER NEXT KEY

         NAME: PARKER, JULI                  ID NUMBER: 111111111H

         DATE OF PAYMENT: 110301              ACCT BALANCE BEFORE:        65.00
                     WRITE-OFF: _      WRITE-OFF AMT:   .00

         PAYMENT/CR TYPE: P (I,C,P,M) CASH RECEIPT:        RECEIVED BY:

         BILLED AMOUNT:     .00   PAYMENT/CR AMOUNT:       10.00-    PROGRAM TYPE: GB

         OTHER ADJ AMT:     .00   OTHER ADJ DESCRIPTION:

         BILL REMAINDER TO:     REMAINDER AMOUNT:     .00
          (,C,P)
         FSCALE PCT: 80 SFSCALE AMOUNT:   .00 SFSCALE ADJ AMOUNT:                 .00

         EDICAID: Y     INSURANCE:          ACCT BALANCE AFTER:        75.00




         ENTRY 2 –
         HSA120A    NORTH CAROLINA HSIS - PAYMENTS AND ADJUSTMENTS
         11/07/01                      ADDED: 11/07/01
         01201                        CHANGED: 11/07/01
         NEXT RECORD: COUNTY 012 SCREEN 12 ID 111111111 DATE 110301 ACTION A
         MESSAGE: 021 RECORD HAS BEEN ADDED - ENTER NEXT KEY

         NAME: PARKER, JULI                  ID NUMBER: 111111111H

         DATE OF PAYMENT: 110301             ACCT BALANCE BEFORE:         75.00
                     WRITE-OFF: _      WRITE-OFF AMT:  .00

         PAYMENT/CR TYPE: P (I,C,P,M) CASH RECEIPT:        RECEIVED BY:

         BILLED AMOUNT:     .00   PAYMENT/CR AMOUNT: 10.00          PROGRAM TYPE: AH

         OTHER ADJ AMT:     .00   OTHER ADJ DESCRIPTION:

         BILL REMAINDER TO:    REMAINDER AMOUNT:     .00
          (C,P)
         SFSCALE PCT: 0 SFSCALE AMOUNT:   .00 SFSCALE ADJ AMOUNT:                 .00

         MEDICAID: Y      INSURANCE:          ACCT BALANCE AFTER:       65.00
         ACCT PERIOD:                   AR-SKIP-IND

         IF AN ADJUSTMENT WAS ENTERED IN INCORRECT PROGRAM THE SAME TWO ENTRIES WOULD HAVE TO
         BE MADE ON OTHER ADJUSTMENT FIELD .

         NOTE – REMEMBER ALL MONEY TRANSACTIONS HAVE TO BE ENTERED ON THE PAYMENT/CREDIT FIELD.



                                                      Page 8 of 17
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         EXAMPLE 8 – BAD DEBT WRITE OFF
         FIELDS TO BE COMPLETED

         CLIENT ID
         DATE
         W/O
         PROGRAM TYPE
         OTHER ADJUSTMENT
         OTHER ADJUSTMENT DESC



         HSA120A    NORTH CAROLINA HSIS - PAYMENTS AND ADJUSTMENTS
         11/07/01                      ADDED: 11/07/01
         01201                        CHANGED: 11/07/01
         NEXT RECORD: COUNTY 012 SCREEN 12 ID 111111111 DATE 110101 ACTION A
         MESSAGE: 021 RECORD HAS BEEN ADDED - ENTER NEXT KEY

         NAME: PARKER, JULI                 ID NUMBER: 111111111H

         DATE OF PAYMENT: 110101           ACCT BALANCE BEFORE:        65.00
                     WRITE-OFF: Y     WRITE-OFF AMT:  .00

         PAYMENT/CR TYPE: P (I,C,P,M) CASH RECEIPT:     RECEIVED BY:

         BILLED AMOUNT:     .00   PAYMENT/CR AMOUNT:     .00   PROGRAM TYPE: GB

         OTHER ADJ AMT: 65.00      OTHER ADJ DESCRIPTION: WRITE OFF

         BILL REMAINDER TO:     REMAINDER AMOUNT:     .00
          (C,P)
         SFSCALE PCT: 80 SFSCALE AMOUNT:   .00 SFSCALE ADJ AMOUNT:             .00

         MEDICAID: Y    INSURANCE:          ACCT BALANCE AFTER:        .00




                                                      Page 9 of 17
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         EXAMPLE 9 – REINSTATE BAD DEBT BALANCE



         FIELDS TO BE COMPLETED


         CLIENT ID
         DATE
         W/O
         PROGRAM TYPE
         OTHER ADJ
         OTHER ADJ DESC


         HSA120A    NORTH CAROLINA HSIS - PAYMENTS AND ADJUSTMENTS
         11/07/01                      ADDED: 11/07/01
         01201                        CHANGED: 11/07/01
         NEXT RECORD: COUNTY 012 SCREEN 12 ID 111111111 DATE 110601 ACTION A
         MESSAGE: 021 RECORD HAS BEEN ADDED - ENTER NEXT KEY

         NAME: PARKER, JULI                 ID NUMBER: 111111111H

         DATE OF PAYMENT: 110601          ACCT BALANCE BEFORE:          .00
                     WRITE-OFF: R     WRITE-OFF AMT: 65.00

         PAYMENT/CR TYPE: P (I,C,P,M) CASH RECEIPT:     RECEIVED BY:

         BILLED AMOUNT:     .00   PAYMENT/CR AMOUNT:     .00   PROGRAM TYPE: GB

         OTHER ADJ AMT: 65.00-     OTHER ADJ DESCRIPTION: REINSTATE BAL

         BILL REMAINDER TO:     REMAINDER AMOUNT:     .00
          (C,P)
         SFSCALE PCT: 80 SFSCALE AMOUNT:   .00 SFSCALE ADJ AMOUNT:            .00

         MEDICAID: Y    INSURANCE:          ACCT BALANCE AFTER:       65.00




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         EXAMPLE 10 – PATIENT PAYS ACCOUNT IN FULL , LATER INSURANCE
         SUBMITTED AND INSURANCE PAYS


         2 ENTRIES ARE NEEDED TO COMPLETE THIS EXAMPLE

         ENTRY 1 (REFUND TO PATIENT)

         HSA120A    NORTH CAROLINA HSIS - PAYMENTS AND ADJUSTMENTS
         11/07/01                      ADDED: 11/07/0
         01201                        CHANGED: 11/07/0
         NEXT RECORD: COUNTY 012 SCREEN 12 ID 111111111 DATE 110601 ACTION C
         MESSAGE: 022 RECORD HAS BEEN CHANGED - ENTER NEXT KEY

         NAME: PARKER, JULI                  ID NUMBER: 111111111H

         DATE OF PAYMENT: 110601             ACCT BALANCE BEFORE:          .00
                     WRITE-OFF: _      WRITE-OFF AMT:  .00

         PAYMENT/CR TYPE: P (I,C,P,M) CASH RECEIPT:        RECEIVED BY:

         BILLED AMOUNT:     .00   PAYMENT/CR AMOUNT:        55.00-   PROGRAM TYPE: GB

         OTHER ADJ AMT:     .00   OTHER ADJ DESCRIPTION:

         BILL REMAINDER TO:     REMAINDER AMOUNT:     .00
          (C,P)
         SFSCALE PCT: 80 SFSCALE AMOUNT:   .00 SFSCALE ADJ AMOUNT:                .00

         MEDICAID: Y      INSURANCE:         ACCT BALANCE AFTER:         55.00

         ENTRY 2 ( INSURANCE PAYMENT)


         HSA120A    NORTH CAROLINA HSIS - PAYMENTS AND ADJUSTMENTS
         11/07/01                      ADDED: 11/07/01
         01201                        CHANGED: 11/07/01
         NEXT RECORD: COUNTY 012 SCREEN 12 ID 111111111 DATE 110601 ACTION A
         MESSAGE: 021 RECORD HAS BEEN ADDED - ENTER NEXT KEY

         NAME: PARKER, JULI                  ID NUMBER: 111111111H

         DATE OF PAYMENT: 110601             ACCT BALANCE BEFORE:         45.00
                     WRITE-OFF: _      WRITE-OFF AMT:  .00

         PAYMENT/CR TYPE: I (I,C,P,M) CASH RECEIPT:        RECEIVED BY:

         BILLED AMOUNT:     .00   PAYMENT/CR AMOUNT:        55.00    PROGRAM TYPE: GB

         OTHER ADJ AMT:     .00   OTHER ADJ DESCRIPTION:

         BILL REMAINDER TO:     REMAINDER AMOUNT:     .00
          (,C,P
         SFSCALE PCT: 80 SFSCALE AMOUNT:   .00 SFSCALE ADJ AMOUNT:                .00

         MEDICAID: Y      INSURANCE:          ACCT BALANCE AFTER:         .00
         ACCT PERIOD:                   AR-SKIP-IND

         IT MAY BE SAFER TO WAIT UNTIL INSURANCE PAYS OR DENIES BECAUSE THE
         REFUND AMOUNT TO THE PATIENT COULD BE LESS THATN THE AMOUNT THEY
         ACTUALLY PAID. IN THAT CASE YOU WOULD JUST REVERSE THE SEQUENCE OF THE
         ENTRIES.



                                                      Page 11 of 17
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         EXAMPLE 11 – PATIENT 0% PAY BILLED SERVICES TO PATIENT LATER SUBMITTED
         TO INSURANCE – INSURANCE PAYS OR DENIES.


         IN THIS EXAMPLE THE PATIENT’S ACCOUNT BALANCE WOULD BE 0. WHEN THE INSURANCE
         INFORMATION IS ENTERED ON THE BILLING SCREEN AN INSURANCE BALANCE WOULD BE 0
         CREATED. WHEN INSURANCE PAYS YOU ENTER THE INSURANCE PAYMENT OR DENIAL AS
         YOU NORMALLY WOULD.




         EXAMPLE 12 – MEDICAID UNDERPAYMENT – LATER PAYS THE REMAINDER AMOUNT

         WHEN THE MEDICAID PAYMENT IS RECEIVED THE PROGRAM WILL CREATE THE PAYMENT
         WITH AN ADJUSTMENT FOR THE AMOUNT THAT IS NOT PAID. IF MEDICAID PAYS THE
         BALANCE OR AN ADDITIONAL AMOUNT LATER AND THESE TRANSACTIONS DO NOT
         COME THROUGH HSIS THE FOLLOWING ENTRY SHOULD BE MADE.

         HSA120A    NORTH CAROLINA HSIS - PAYMENTS AND ADJUSTMENTS
         11/07/01                      ADDED: 11/07/01
         01201                        CHANGED: 11/07/01
         NEXT RECORD: COUNTY 012 SCREEN 12 ID 111111111 DATE 110501 ACTION A
         MESSAGE: 021 RECORD HAS BEEN ADDED - ENTER NEXT KEY

         NAME: PARKER, JULI                ID NUMBER: 111111111H

         DATE OF PAYMENT: 110501           ACCT BALANCE BEFORE:         .00
                     WRITE-OFF: _    WRITE-OFF AMT:  .00

         PAYMENT/CR TYPE: M (I,C,P,M) CASH RECEIPT:      RECEIVED BY:

         BILLED AMOUNT:    .00    PAYMENT/CR AMOUNT: 100.00     PROGRAM TYPE: GB

         OTHER ADJ AMT: 100.00-     OTHER ADJ DESCRIPTION: MED ADJUSTMENT

         BILL REMAINDER TO:     REMAINDER AMOUNT:     .00
          (C,P)
         SFSCALE PCT: 80 SFSCALE AMOUNT:   .00 SFSCALE ADJ AMOUNT:            .00

         MEDICAID: Y    INSURANCE:          ACCT BALANCE AFTER:       .00




                                                      Page 12 of 17
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         EXAMPLE 13 - MEDICAID RECOUPMENT


         WHEN MEDICAID RECOUPS MONIES AN ADJUSTMENT HAS TO BE MADE TO OFFSET
         THAT RECOUPMENT TO SHOW THE DECREASE IN THE CASH/CREDIT TOTALS AND
         BALANCE WITH YOUR DEPOSITS.


         HSA120A    NORTH CAROLINA HSIS - PAYMENTS AND ADJUSTMENTS
         11/07/01                      ADDED: 11/07/01
         01201                        CHANGED: 11/07/01
         NEXT RECORD: COUNTY 012 SCREEN 12 ID 111111111 DATE 110501 ACTION A
         MESSAGE: 021 RECORD HAS BEEN ADDED - ENTER NEXT KEY

         NAME: PARKER, JULI                ID NUMBER: 111111111H

         DATE OF PAYMENT: 110501           ACCT BALANCE BEFORE:         .00
                     WRITE-OFF: _    WRITE-OFF AMT:  .00

         PAYMENT/CR TYPE: M (I,C,P,M) CASH RECEIPT:      RECEIVED BY:

         BILLED AMOUNT:    .00    PAYMENT/CR AMOUNT:      5.00-   PROGRAM TYPE: GB

         OTHER ADJ AMT:    5.00   OTHER ADJ DESCRIPTION: MED RECOUPMENT

         BILL REMAINDER TO:     REMAINDER AMOUNT:     .00
          (C,P)
         SFSCALE PCT: 80 SFSCALE AMOUNT:   .00 SFSCALE ADJ AMOUNT:            .00

         MEDICAID: Y    INSURANCE:          ACCT BALANCE AFTER:        .00




                                                      Page 13 of 17
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         EXAMPLE 14 – CLIENT RECEIVES SERVICES HAS MEDICAID AND
         INSURANCE


         If client has both insurance and medicaid the program will not bill medicaid until an insurance payment has
         been posted. When insurance pays post the payment using the example below:



          HSA680C           BILLING INQUIRY / BILLING ONLY
          04/28/05
         NEXT RECORD: COUNTY 012 SCREEN 68 ID 111111111 DATE         ACTION I
         MESSAGE: 350 PF8 TO DISPLAY MORE RECORDS -OR- TAB TO VISIT AND PRESS ENTER
              ENTER 'B' FOR BILLING ONLY OR 'P' FOR POSTING PAYMENT
          LAST NAME: MORRIS           FIRST NAME: KATHI        MI:
                                  ACCOUNT BALANCE: 2,211.90
            SERVICE PROC PAY PROG BILLED BILLED PAYMENT PAYMENT EOB
         B/O/P DATE CODE SRCE TYPE DATE AMOUNT DATE AMOUNT CODE
           03/05/05 99201 M FP / /       78.00           .00
           03/02/05 99201 M FP / /       78.00           .00
           02/01/05 90658 I AH / /      11.00           .00
           02/01/05 PYMNT I GB              .00 02/01/05 10.00
          p 02/01/05 99201 I AH / /      78.00           .00
           01/01/05 92587 I AH / /      25.00           .00



         HSA680B   NORTH CAROLINA HSIS - PAYMENTS AND ADJUSTMENTS      01201
          04/28/05                            04/28/05
         NEXT RECORD: COUNTY 012 SCREEN 68 ID 111111111H DATE      ACTION A
         MESSAGE: HP93 SELECT INS CO ('X') THEN ENTER PAYMENT INFO

         NAME: MORRIS        KATHI          ID NUMBER: 111111111H
          X INS CO A: 001 BLUE CROSS BLUE SHIELD OF SC CPT CODE: 99201 02/01/05
           INS CO B:

         DATE OF PAYMENT: 042805      WRITE-OFF:    WRITE-OFF AMT:    .00
         PAYMENT/CR TYPE: I (I,C,P,M) CASH RECEIPT: ____ RECEIVED BY: __________
         BILLED AMOUNT: 78.00 PAYMENT/CR AMOUNT: 10 .00 PROGRAM TYPE: AH
         OTHER ADJ AMT:    .00 OTHER ADJ DESCRIPTION: INS ADJUSTMENT
         BILL REMAINDER TO: (P) REMAINDER AMOUNT:          .00
         SFSCALE PCT: 00 SFSCALE AMOUNT:       .00 SFSCALE ADJ AMOUNT:      .00
         MEDICAID:     INSURANCE:          CURRENT ACCT BALANCE: 2,211.90

                          HIPAA DATA FIELDS

                                         ADJUSTED UNITS: 00




                                                       Page 14 of 17
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         EXAMPLE 15 – SERVICES PROVIDED TO COMPANY EMPLOYEES


         FIELDS

         CLIENT ID - (have to create pseudo patient master– for the company to bill against that)
         PAYMENT DATE
         PAYMENT/CR TYPE
         PAYMENT/CR AMOUNT
         PROGRAM TYPE
         OTHER ADJ
         OTHER ADJUST DESC


         HSA120A    NORTH CAROLINA HSIS - PAYMENTS AND ADJUSTMENTS
         11/07/01                      ADDED: 10/15/01
         01201                        CHANGED: 11/07/01
         NEXT RECORD: COUNTY 012 SCREEN 12 ID 111111111 DATE 100801 ACTION: A
         MESSAGE: 022 RECORD HAS BEEN CHANGED - ENTER NEXT KEY

         NAME: PARKER, JULI                  ID NUMBER: 111111111H

         DATE OF PAYMENT: 100801             ACCT BALANCE BEFORE:       65.00
                     WRITE-OFF: _      WRITE-OFF AMT:  .00

         PAYMENT/CR TYPE: P (I,C,P,M) CASH RECEIPT:        RECEIVED BY:

         BILLED AMOUNT:     .00     PAYMENT/CR AMOUNT:        PROGRAM TYPE: AH

         OTHER ADJ AMT:    10.00-   OTHER ADJ DESCRIPTION: J JONES ABC CO

         BILL REMAINDER TO:    REMAINDER AMOUNT:     .00
          (C, P)
         SFSCALE PCT: 0 SFSCALE AMOUNT:   .00 SFSCALE ADJ AMOUNT:               .00

         MEDICAID: Y      INSURANCE:          ACCT BALANCE AFTER:      65.00



         This eliminates the need to enter a patient master for every client that is seen under this agreement. A
         financial statement can be generated and sent to the company if needed.

         As patients come in add the charge by entering it as a negative other adjustment. You can put the
         patient’s name or company name, service type, etc. on the other description line.

         When the company sends a payment it should be entered as usual against the charges that have been
         created for their employees as they come in. The program type should be the program the money should
         be allocated against.




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         Example 16 – check returned – client charged returned check fee


         Fields to be completed:

         Payment Credit type
         Payment/CR amount
         Program type
         Other adjustment amt.
         Other adjustment description



         HSA120A    NORTH CAROLINA HSIS - PAYMENTS AND ADJUSTMENTS
         11/20/01                      ADDED: 11/20/01
         71291                        CHANGED: 11/20/01
         NEXT RECORD: COUNTY 712 SCREEN 12 ID 111111111 DATE 112001 ACTION A
         MESSAGE: 021 RECORD HAS BEEN ADDED - ENTER NEXT KEY

         NAME: PARKER, JULIE                  ID NUMBER: 111111111H

         DATE OF PAYMENT: 112001              ACCT BALANCE BEFORE:           .00
                     WRITE-OFF: _       WRITE-OFF AMT:  .00

         PAYMENT/CR TYPE: P (I,C,P,M) CASH RECEIPT:           RECEIVED BY:

         BILLED AMOUNT:      .00   PAYMENT/CR AMOUNT:         25.00- PROGRAM TYPE: GB

         OTHER ADJ AMT: 25.00-      OTHER ADJ DESCRIPTION: RETURN CK FEE

         BILL REMAINDER TO:    REMAINDER AMOUNT:    .00
          (C,P)
         SFSCALE PCT: 0 SFSCALE AMOUNT:  .00 SFSCALE ADJ AMOUNT:                   .00

         MEDICAID: Y     INSURANCE:           ACCT BALANCE AFTER:        50.00




                                              Page 16 of 17
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         Example 17 - Insurance billed patient responsible for copay and SFP


         Fields to be completed:

         Payment Credit type
         Payment/CR amount
         Program type
         Billed Amount
         Other adjustment amt.
         Other adjustment description
         Bill Remainder to




         HSA120A   NORTH CAROLINA HSIS - PAYMENTS AND ADJUSTMENTS
         10/20/05                     ADDED:
          01001                      CHANGED:
         NEXT RECORD: COUNTY 010 SCREEN 12 ID 111111111 DATE 101404
         ACTION A
         MESSAGE: 016 ENTER ADD INFORMATION AND THEN PRESS "ENTER"

         NAME: IIII, JJJ                      ID NUMBER: 111111111H

         DATE OF PAYMENT: 101404
                     WRITE-OFF: _          WRITE-OFF AMT:           .00

         PAYMENT/CR TYPE: i (I,C,P,M) CASH RECEIPT: ____              RECEIVED BY:
         __________

         BILLED AMOUNT: 500 .00         PAYMENT/CR AMOUNT: 253 .00             PROGRAM
         TYPE: gb

         OTHER ADJ AMT: 20 .00          OTHER ADJ DESCRIPTION: co pay_________

         BILL REMAINDER TO: p   REMAINDER AMOUNT:
           (C,P)
         SFSCALE PCT: 0 SFSCALE AMOUNT:   .00 SFSCALE ADJ AMOUNT:
         .00

         MEDICAID:    INSURANCE:                 CURRENT ACCT BALANCE:            500.00
         ACCT PERIOD:                        AR-SKIP-IND




                                            Page 17 of 17
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                                     SUPPLEMENTAL ACTIVITY                                                   S100
    The Supplemental Activity screen is used to record dates & numbers of encounters and individuals for whom
    Developmental Evaluation Center staff have provided screening technical assistance, case management, community
    development contacts, workshops, and training during a designated reporting period.

    Refer to instructions: "Supplemental Activity Worksheet" (found on the back of the supplemental form).

    HSA130A 77091  NORTH CAROLINA HSIS - DEC SUPPLEMENTAL ADDED:
                                CHANGED:
    NEXT RECORD: COUNTY 770 SCREEN 13 ID        DATE    ACTION
    MESSAGE:

      STAFF PROVIDER NAME: ______________________________ REPORT DATE: ______


      SCREENING ENCOUNTERS                       TECH ASSISTANCE ENCOUNTERS

      STAFFING ENCOUNTERS                               99-457 INTERAGENCY ACTV

      COMMUNITY DEVELOPMENT                       CASE MANAGEMENT

        99-457 INTERAG ACTV                              99-457 INTERAGENCY ACTV

      HOURS OF STAFF                              NUMBER OF HOURS TRAINING
      DEVELOPMENT RECEIVED                        NON-DEC PERSONS

      NUMBER OF ATTENDEES                       NUMBER OF
      AT WORKSHOP                               WORKSHOPS PROVIDED

      HOURS OF PRESENTATION                      INTERMEDIATE ASSESSMENT
      AT WORKSHOP                                CONSULTATION

    FIELD                                                        EXPLANATION

    STAFF PROVIDER NAME (R)                                      No entry required.

    REPORT DATE (R)                                              No entry required

    SCREENING ENCOUNTERS (O)                                     Must be numeric.

    TECHNICAL ASSISTANCE
    ENCOUNTERS (O)                                                Must be numeric.

    STAFFING ENCOUNTERS (O)                                       Must be numeric.

      99-457 INTERAGENCY (O)                                      Must be numeric.
             Interagency Activity                                 Enter 99-457 Interagency Encounters.

    COMMUNITY DEVELOPMENT (O)                                     Must be numeric.

    CASE MANAGEMENT (O)                                           Must be numeric.

       99-457 INTERAGENCY (O)                                     Must be numeric.
              Community Develop.



                                                   Page 1 of 2
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                                SUPPLEMENTAL ACTIVITY                   S100
       99-457 INTERAGENCY (O)                        Must be numeric.
              Case Management

    HOURS OF STAFF
    DEVELOPMENT RECEIVED (O)                         Must be numeric.


    NUMBER OF HOURS TRAINING (O)                     Must be numeric.
    NON-DEC PERSONS

    NUMBER OF ATTENDEES
    AT WORKSHOP (O)                                  Must be numeric

    NUMBER OF WORKSHOPS
    PROVIDED (O)                                     Must be numeric.

    HOURS OF PRESENTATION
    AT WORKSHOP (O)                                  Must be numeric.

    INTERMEDIATE ASSES.
    CONSULTATION        (O)                          Must be numeric.




                                       Page 2 of 2
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                             INSURANCE AND OTHER CONTRACTS                                                     S110

    Screen 14 allows user to assign an identification number to all insurance companies, contract agencies and private
    companies, if applicable for billing. Enter locally assigned ID number for insurance company or contract agency.
    The insurance ID number field is a four position alpha/numeric (letters, numbers or combination of both) code. For
    billing purposes each agency or insurance company must have a record on the Insurance & Other Contracts Table.


    HSA140A                           NORTH CAROLINA HSIS
     08-29-2005               INSURANCE COMPANY AND OTHER CONTRACTS        ADDED: 08-11-2005
     09201                                                               CHANGED: 08-29-2005
    NEXT RECORD:       COUNTY 092        SCREEN 14    ID ____         DATE          ACTION I
    MESSAGE: P41                               "F3" TO RETURN TO LIST SCREEN OR ENTER NEXT K


        NUMBER: ____      NAME: ___________________________________

                   STREET/BOX: ________________________________________

          ADDITIONAL STREET: ________________________________________

                          CITY: ______________

                         STATE: __

                            ZIP: ______ ____

                          TYPE: _     (I,C)

              CONTRACT LIMIT: ___

       CMS1500 LINE 24 IND: _



    FIELD                                       EXPLANATION
    NUMBER (R)                                  No operator intervention necessary.
                                                Number entered from fast- path line.

    NAME (R)                                    Enter name of insurance company or contract agency.

    ADDRESS (R)                                 Enter address of company or contract agency.
                                                City, state and zip must be completed.

    TYPE (R)                                    Enter I if insurance. Enter C if contract.

    CONTRACT LIMIT (O)                          Must be numeric. Required if Type is C.

    CMS1500 LINE 24 IND (O)                     Enter ‘Y’ to indicate that this is BCBS insurance
                                                company. Provider’s individual BCBS number will
                                                print on line 24K on the CMS1500 form when printed.
                                                BSBC assigned provider number must be entered on
                                                staff provider screen. **CDSA’s & HSIS online AR sites only.




    Revised 04/28/03                               Page 1 of 1
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                           All reports can be selected through option 19 on the Main Menu.



    HSA190A        NORTH CAROLINA HEALTH SERVICES INFORMATION SYSTEM                          NC25 05401
    09/22/05          REPORT REQUEST PROCESSING       BILLCODE: xxx

    NEXT ENTRY=> COUNTY              SCREEN: 19        ID        DATE:               ACTION:


     SELECTION SELECTION DATE(S) REPORT              JOB NBR OF FORM
      TYPE      FROM THRU PROFILE          PRINTER CLASS COPIES TYPE
     (R,V,E,B) _ ______ ______ (M,Q,F,C) _ NRAP5801 G   1  *

     REPORTS BY GROUP- ENTER 'X' FOR SELECTION(S)
     _ CHILD HEALTH   _ CHILDREN SPECIAL HEALTH   _ ADULT HEALTH
     _ FAMILY PLANNING _ CHILD SERVICE COORDINATION _ MATERNAL HEALTH
     _ PAN REPORTING   _ DEVELOP EVAL CENTER REPORTS _ BILLING REPORTS

     INDIVIDUAL REPORTS- ENTER 'X' FOR SELECTION(S)
     _ CSC LOG ALL      _ CSC LOG ACTIVE CLIENTS ONLY _ INPUT RECORD COUNT
     _ PRINT LABELS      _ ALPHA LIST - FROM: _ TO: _ _ REPORT(S) BY ID
     _ SERVICE COUNT BY SERVICE SITE          _ MEDICAL NUTRITION THERAPY
     _ CPT RATE REPORT          _ SERVICE COUNT BY PROGRAM TYPE
     _ INS CO. LIST -ALPHA      _ INS CO. LIST -NUM
     _ SERVICE COUNT BY PROVIDER DISCIPLINE          _SERVICE COUNT BY STAFF PROV CODE




    FIELD                                             EXPLANATION

    SELECTION TYPE (R)                                Entry required
                                                      Enter the appropriate code.
                                                      R = Receipt date (when Raleigh received the data)
                                                      V = Visit date
                                                      E = Entry date
                                                      B = Billing (use only for Billing reports)

    SELECTION FROM DATE (R)                           Entry required
                                                      Enter the beginning date range for the report
                                                      period in MMDDYY format.

    SELECTION THRU DATE (R)                           Entry required
                                                      Enter the ending date range for the report
                                                      period in MMDDYY format.

    REPORT PROFILE (R)                                Entry required
                                                      Enter the appropriate code.
                                                      M = Monthly
                                                      Q = Quarterly
                                                      F = Fiscal
                                                      C = Calendar

    NOTE: None of the above is required for CSC Log(s), Label Print, or Insurance listings.

    PRINTER (R)                                       No operator intervention required.
    Revised: 03/06/06                             Page 1 of 16
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    JOB CLASS (R)                                     No operator intervention required.

    NUMBER OF COPIES (R)                              No operator intervention required.
                                                      Default is ‘1’. Can change to more than one copy.

    FORM TYPE (R)                                     No operator intervention required.
                                                      Default is ‘A’, which is standard .
    GROUP OR INDIVIDUAL
    REPORTS (O)                                       Place an ‘X’ to the left of the desired
                                                      report (s) and enter.

    NOTE: The Family Planning, Adult Health, Billing and Pan reports require individual selection.
          PF8 will page forward to the next selection page.
          PF3 will page back to the Report Processing screen
         The printer must be in condensed print to run reports on 8 ½" x 11" paper.




    Revised: 03/06/06                             Page 2 of 16
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                                                       LABEL SIZE SELECTION



    The label selection screen allows you to choose the size and number of labels to be printed. There are three label
    selections to choose from. Label #2 was developed to use on all lab forms being submitted to the state lab.



      HSA198A   NORTH CAROLINA HEALTH SERVICES INFORMATION SYSTEM
      09/07/05     L A B E L SIZE SELECTION
      NEXT RECORD: COUNTY      SCREEN 19 ID   DATE           ACTION
      MESSAGE:

      LABEL #: _                     SIZE: _ ENTER (2) FOR 2-UP (3 1/2 X 15/16)
       QTY #: __                             ENTER (3) FOR 3-UP (2 1/2 X 15/16)

                   MAILING                                                      LAB (3 1/2 X 15/16)
          --------------------------------------                    -------------------------------------------------------
       #1 DOE, JOHN P                                      #2        DOE, ETHNICITY/RACE
            1400 W. MAIN STREET                                      JOHN, P,         DOB:MM/DD/CCYY
            LUMBERTON                  NC                            MID:123456789M,LOC:123456789H
            078        28358-2324                                    051,561234567-AB,SS:123456789
         -----------------------------------                         092,NC 27601,DOV:MM/DD/CCYY,M
                                                                    --------------------------------------------------------

                 FOLDER                                             ADDITIONAL FIELDS FOR LAB LABELS:
          ---------------------------------------                   DATE OF VISIT: ________
       #3    DOE, JOHN P                                            HEALTH DEPT EIN - 566000280
              ID# XXXXX000H                                          ENTER EIN SUFFIX IF NECESSARY __
              DOB MM/DD/CCYY
              R 1 S 1 C# 0000000000
              098 MEDID:XXXX0000M
          ------------------------------------------




    FIELD                                                       EXPLANATION

    LABEL (R)                                                   Enter 1, 2, or 3

                                                                1 = Mailing labels

                                                                2 = Lab labels
                                                                Refer to information from the State Health lab for lab label
                                                                requirements.

                                                                3 = Lab labels     (Social Security & Medicaid ID will only
                                                                                    display the last 4 digits of the number)




    Revised: 03/06/06                                    Page 3 of 16
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    FIELD                                         EXPLANATION

    SIZE (R)                                      Enter 2 or 3

                                                  2 = 2-up labels
                                                  3 = 3-up labels
    QUANTITY (R)                                  Enter 01-99

    Enter ID numbers for all patients needed - <ENTER>
    (Labels can be selected for up to 40 patients)

    ** 3-UP FOLDER LABELS CAN ALSO BE PRINTED FROM PATIENT MASTER SCREEN


    NOTE: FOR STATE LAB LABELS ENTER DATE OF VISIT AND IF APPLICABLE THE EIN SUFFIX




    Revised: 03/06/06                        Page 4 of 16
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                                                Account Receivable Reports

    120a - Accounts Receivable By Patient - report list billable services entered for accounting period for each client.
    Gives total fee, any adjustments, total charge, payment credit amount. Report is cumulative for fiscal year and will
    give total amounts billed, adjustments, and charges for fiscal year. This report is cumulative for the fiscal year and is
    zeroed out at the end of the fiscal year.

    120b - Accounts Receivables By Payment Source - report list billable services by payment source (insurance,
    medicaid, contract, patient) with overall current outstanding balance. The current outstanding balance is not
    unduplicated, if you have a client that was billed to both medicaid and insurance, both totals are included in the
    'current outstanding balance' on the 120b report. The individual pay source balances are unduplicated and these
    totals should be compared to the pay source balances on the 122 and 124 b, c, and d reports to reconcile your
    accounts receivables each month. The medicaid, insurance, contract, patient balance on the 120b report should equal
    the medicaid insurance, contract, patient balances on the 122 and 124 reports.

    120c - Accounts Receivable - Escrow/Cash Deposit - report list all payments entered for clients by pay sources.
    Totals will reflect all monies received for client services by pay source.

    121 - Financial Statement - list all billable services for client with account balance, amount billed to other pay
    sources, and remaining due from client. This can be mailed and/or printed and given to client for statement. Report
    also ages the clients outstanding balance.

    122 - reports list clients by id number with cumulative fees and adjustments and calculated charges after
    adjustments; account balance; and balance for the clients for each pay source that was billed.

    122a - Client Bal With Adjust (Activity This Month) -report lists totals for current accounting period -only clients
    who had billable services entered during accounting period will be on the 122a

    122b - Client Bal With Adjust (All Activity) - list all client who have billable services entered - (this report could
    be quite lengthy because it will include clients with 0 balances and may exceed the maximum line limit allowed by
    sips.)

     122c - Client Bal With Adjust (Errors And Pay Source Totals) -prints totals only for clients with outstanding
    balances -this report should be used in reconciling your pay source balances each month. The pay source totals on
    this report should match the pay sources balances on the 120b report for the accounting period. The account balance
    is an unduplicated total of all outstanding accounts.

     122d - Client Bal With Adjust (Non Zero Activity) -prints for all clients that have an outstanding balance. This
    report will give you an account balance for all clients who have an outstanding balance and list balance for each pay
    source billed for each client. Report will also flag accounts that are out of balance and print message to that affect.
    The balances on this report will be the same as the 122c and should also equal the 120b report.

    123 - HCFA Insurance Form - that is sent to insurance companies - this report should be run separately from other
    reorts because it should be printed on the forms that are supplied by eds.

    124 a, b, c, and d reports list the patients name along with the id and have the same information as the 122 report
    with the exception of the fees, adjustments and charges information. The totatls for these reports will be the same as
    the 122 reports.
    126 - Financial History -replaces client ledge card - the financial history is a complete history of all 'billable'
    services and payments entered for client. The report gives the account balance and outstanding balances by pay
    source -

    135 - Aged Balance Due From Client Report - lists all clients who have an outstanding patient balance. Balances
    are aged from 0-30 to over 120 days.


    Revised: 03/06/06                                Page 5 of 16
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                                                      Billing Reports

    The selection type entered on the Report processing screen will determine how the billing reports are processed.

    Valid options are:
    R= Receipt Period
    B = Accounting Period

    *Enter the selection dates and report profile.
     Selection from & thru dates should be beginning of month thru end of month or current date. Profile should be M.

    *Enter X in Billing Reports Option

    HSA194A        NORTH CAROLINA HEALTH SERVICES INFORMATION SYSTEM                             71291
    09/21/01        BILLING AND A/R REPORT SELECTION

    MESSAGE: 144 PF8 TO BROWSE FORWARD, PF7 TO BROWSE BACKWARD, PF6 FOR FIRST PAGE
              'ENTER' TO PRINT REPORTS, PF3 TO RETURN WITHOUT PROCESSING
              ‘X' TO ENTER 'X' TO PRINT HBP120 REPORT TOTALS ONLY: _

    SELECT            REPORT ID         REPORT DESCRIPTION

    _                 HSAE118           ATTORNEY GENERALS REPORT
    _                 HBP120A           ACCOUNTS RECEIVABLE - BY PATIENT
    _                 HBP120B           ACCOUNTS RECEIVABLE - BY PAYMENT SOURCE
    _                 HBP120C           ACCOUNTS RECEIVABLE - ESCROW/CASH DEPOSIT
    _                 HBP121            FINANCIAL STATEMENT
    _                 HBP122A           CLIENT BAL WITH ADJUST (ACTIVITY THIS MONTH)
    _                 HBP122B           CLIENT BAL WITH ADJUST (ALL ACTIVITY)
    _                 HBP122C           CLIENT BAL WITH ADJUST (ERRORS AND PAY SOURCE TOTALS)
    _                 HBP122D           CLIENT BAL WITH ADJUST (NON ZERO ACTIVITY)
    _                 HNAE123           HCFA INSURANCE FORM
    _                 HBP124A           CLIENT BAL WITH NAME (ACTIVITY THIS MONTH)
    _                 HBP124B           CLIENT BAL WITH NAME (ALL ACTIVITY)
    _                 HBP124C           CLIENT BAL WITH NAME (ERRORS AND PAY SOURCE TOTALS)
    _                 HBP124D           CLIENT BAL WITH NAME (NON ZERO ACTIVITY)
    _                 HBP126            FINANCIAL HISTORY
    _                 HBP135            AGED BALANCE DUE FROM CLIENT REPORT

   HSAE118 ATTORNEY GENERAL'S REPORT
   NOT AVAILABLE FOR HEALTH DEPARTMENTS.

    HSAE120A ACCOUNTS RECEIVABLE BY PATIENT
    REPORT POST FINANCIAL ENTRIES. CAN BE USED TO TRACK DAILY PAY SOURCE
    ENTRIES ON PATIENTS.

    HSAE120B ACCOUNTS RECEIVABLE - BY PAY SOURCE
     REPORT POSTS FINANCIAL ENTRIES BY THIRD PARTY PAYORS, (I.e. MEDICAID,
    INSURANCE, AND PATIENT PAY).

    HSAE120C ACCOUNTS RECEIVABLE - ESCROW/CASH DEPOSIT
    POST ALL MONIES RECEIVED OR REFUNDED BY PAY SOURCE BY PROGRAM.
    HSA194A   NORTH CAROLINA HEALTH SERVICES INFORMATION SYSTEM
              BILLING AND A/R REPORT SELECTION




    Revised: 03/06/06                              Page 6 of 16
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    MESSAGE: 119 119 LAST PAGE DISPLAYED, PRESS PF7 TO PAGE BACKWARD
          'ENTER' TO PRINT REPORTS, PF3 TO RETURN WITHOUT PROCESSING
    X' TO ENTER 'X' TO PRINT HBP120 REPORT TOTALS ONLY: _

    SELECT REPORT ID REPORT DESCRIPTION

    _    HSAE150A     MEDICAID CLAIMS BY COUNTY AND SERVICE PROVIDED
    _    HSAE150B    MEDICAID CLAIMS BY SERVICE PROVIDED
    _    HSAE150C    MEDICAID CLAIMS SUBMITTED (DETAIL)
    _    HSAE150D     MEDICAID CLAIMS BY PROGRAM TYPE AND SERVICE PROVIDED
    _    HSAE150E    MEDICAID CLAIMS BY BILLING TYPE AND SERVICE PROVIDED
    _    HSAE154D     MEDICAID CLAIMS PROCESSED (DETAIL)
    _    HSAE154E    MEDICAID CLAIMS PROCESSED FOR PAYMENT BY CTY & EDS EOB CODE
    _    HSAE154F    MEDICAID CLAIMS PROCESSED FOR PAYMENT BY EDS EOB CODE
    _    HSAE154G     MEDICAID CLAIMS PENDING
    _    HSAE154H     MEDICAID CLAIMS DENIED
    _    HSAE156     MEDICAID CLAIMS NOT RESPONDED TO BY EDS
    _    HSAE157     MEDICAID CLAIMS PAID BY PROGRAM TYPE AND CPT CODE
    _    HBP129      DENTAL CLAIM FORM

    The following is a description of the billing reports Health Departments may use:

     1. HSAE150A MEDICAID CLAIMS BY COUNTY & SERVICE PROVIDED

     REPORT LISTS BILLED AMOUNT AND NUMBER OF SERVICES SUMMARIZED BY PROCEDURE
    CODE WITHIN YEAR AND MONTH WITHIN COUNTY WITHIN BILLING TYPE.

     2. HSAE150B MEDICAID CLAIMS BY SERVICE PROVIDED

        REPORT LISTS BILLED AMOUNT AND NUMBER OF SERVICES SUMMARIZED BY PROCEDURE
        CODE WITHIN YEAR AND MONTH WITHIN BILLING TYPE. TOTALS ARE BY MONTH, BILLING
        TYPE, AND STATE.

     3. HSAE150C MEDICAID CLAIMS SUBMITTED

        REPORT LISTS BILLED AMOUNT FOR EACH RECORD SELECTED AND PROVIDES TOTALS FOR
        BILLED AMOUNT AND NUMBER OF SERVICES BY MONTH, COUNTY, BILLING TYPE, COUNTY,
        AND OVERALL.

     4. HSAE154D MEDICAID CLAIMS PROCESSED

        REPORT LISTS PAID AMOUNT FOR EACH PROCESSED RECORD AND PROVIDES TOTALS FOR
        PAID AMOUNT AND NUMBER OF SERVICES BY EDS INDICATOR (PAID, PENDING, OR DENIED),
        PROCEDURE CODE, BILLING TYPE, AND COUNTY,

     5. HSAE154E MEDICAID CLAIMS PROCESSED FOR PAYMENT BY COUNTY AND EDS EOB CODE

        REPORT LISTS NUMBER OF SERVICES SUMMARIZED BY EDS EOB CODE WITHIN COUNTY.
        OVERALL TOTALS ARE PROVIDED BY COUNTY.

     6. HSAE154F MEDICAID CLAIMS PROCESSED FOR PAYMENT BY EDS EOB CODE

        REPORT LISTS NUMBER OF SERVICES SUMMARIZED BY EDS EOB CODE.OVERALL
        TOTAL IS PROVIDED.




    Revised: 03/06/06                              Page 7 of 16
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    7. HSAE154G MEDICAID CLAIMS PENDING
       REPORT LISTS EACH RECORD PENDING BY EDS. TOTALS BY BILLED AMOUNT AND
       NUMBER OF SERVICES ARE PROVIDED BY PROCEDURE CODE, BILLING TYPE,
       COUNTY, AND OVERALL.

     8. HSAE156A MEDICAID CLAIMS NOT RESPONDED TO BY EDS

     9. HSAE157 MEDICAID CLAIMS PAID- POST BY PROGAM BY CPT CODE CLAIMS
        PAID BY EDS




    Revised: 03/06/06                 Page 8 of 16
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v1.13 10/22/2008
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      Program Name            Report Name                         Report Purpose                 Report     Report           Report Profile
                                                                                                 Number     Period       R = Receipt(Received
                                                                                                          M = Monthly        By Raleigh -All
                                                                                                                             Visits entered
                                                                                                          Q = Quarter
                                                                                                                              Within selected
                                                                                                          F = Fiscal          Report period)
                                                                                                          C = Calendar   V = Visit(within
                                                                                                                             Selected report
                                                                                                                             Period)
    Family Planning   Activity Summary               •     Provides an unduplicated patient    HBS081     M,Q,F,C
                                                           count by Patient Type                                             Request by Visit
                                                     •     Totals the activity within the                                    Date to compare
                                                           selected reporting period                                         with Nurse’s Tic
                                                                                                                             sheets.

                      Evaluation Report              •     Provides the following:             HBS084     F,C                Can select on
                                                     •     Percent of need met for teens                                     individual bases for
                                                     •     Percent of Total caseload from                                     site, county, district,
                                                           Target Population
                                                     •     High-risk case load                                               or region
                                                     •     Frequency of reported staff
                                                           encounters
                                                                                                                             Run separate from
                                                                                                                             other reports.
                      Patient Characteristic         Provides a summary of patient             HBS085     M,Q,F,C
                                                     demographic information by age
                                                     Groups and percentage of the
                                                     Whole for the parameters requested.
                      Norplant Insertion                                                       HBS088I    M,Q,F,C
                      Norplant Removal                                                         HBS088R
                      Norplant removal/Reinsertion   Provides an unduplicated count of         HBS088RR
                                                     insertions, removals, and reinsertion’s
                                                     by race, education level and income.
    Child Service     Identification & Tracking      Provides unduplicated counts of           CNAE131    M,Q,F,C            Can’t print if FP
    Coordination                                     children Identified & Tracked by risk                                   /AH are also
                                                     codes, race, sex, pay source, & service                                 selected at the same
                                                     needs.                                                                  time.
                                                                                                                             Canned reports
                      Children Active in CSC         Provides the number of active children    CNAE 132   M,Q,F,C
                                                     in the program within the reporting
                                                     period.




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    Program Name              Report Name                     Report Purpose                    Report     Report        Report Profile
                                                                                               Number      Period
    Child Health      Activity Summary           •     Provides an unduplicated patient      HBS 141     M,Q,F,C        Can’t print if FP/AH
                                                       count by patient type                                            are also selected at
                                                 •     Totals the activity within the                                   same time.
                                                       selected reporting period.                                       Canned reports

                      Patient Characteristics    Provides a summary of patient               HBS142      F,C
                                                 demographic information.
    Breast and        Cervical Follow-up         Provides a list of patients by:             HCA116A     M,Q,F,C        Run separate from
    Cervical Cancer   Rescreening for Patients        Name                                                              the other reports
                      over 50                         Age
                                                      Address
                                                      Phone Number                                                      Run by individual
                                                      Disposition date                                                  selection for
                                                      Note: Rescreening are usually done                                site, county, district
                                                 One year after the previous screening.
                                                 Hence the selection dates should be in                                  or region.
                                                 the previous year.

                                                                                                                    * If run by site, then
                      Breast Follow-up           Provides a list of patients by:             HCA116B     M,Q,F,C    report will be for the
                      Rescreening for Patients       Name                                                           service site the user is
                      over 50                        Age                                                            logged on to.
                                                     Address
                                                     Phone Number
                                                     Disposition date


                      Breast and Cervical        Provides a list of patients whose           HCA117      M,Q,F,C
                      Pending Record Follow-up   records have been pending 90 or more
                                                 days.

                      Duplicate Record Report    Provides a list of patients who appear to   HCA118      M,Q,F,C
                                                 have been seen at least twice for Breast
                                                 and Cervical screening within the
                                                 selected report period.

                      Breast and Cervical        Not Available
                      Screening Performance                                                  HCA119
                                                 Provides a list of patients whose
                      Cancer Indicated Report    Diagnostic disposition indicates the        HCA120      M,Q,F,C
                                                 present of cancer.

                                                               Page 10 of 16
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      Program Name         Report Name                         Report Purpose                 Report     Report   Report Profile
                                                                                             Number      Period
    Maternal Health   Patient Characteristics   Provides a summary of patient              HBS 101     M,Q,F,C
                                                demographic information.

                      Program Indicators            Provides the percentage of women       HBS102      F,C        Canned Reports
                                                    who had live births by Trimester
                                                    when prenatal care began
                                                    Number of prenatal visits
                                                    Teen Service indicators
                                                    Received Care Coordination

                                                                                                                  Can’t print if FP/AH
                      Activity Summary              Provides an unduplicated patient       HBS103      M,Q,F,C    Are also selected at
                                                    count by Patient Type                                                the same
                                                    Totals the activity within the                                time
                                                    selected reporting period

                      Closure Summary           Provides an unduplicated count of          HBS104
                                                closures by :                                          F,C
                                                    Reason closed
                                                    Outcome of pregnancy
                                                    Receiving Care Coordination


                      Risk Summary              Produces a list of risk codes and totals   HBS 105     F,C
                                                the Number of persons having those
                                                risk status.

                      Provider Service Report       Provides number of New and             HBS 106-1   F,C
                      (Women - All ages )           Continuation patients/Complete                     F,C
                      (Women - 00 to 19 )           and Limited services                   HBS106-2
                                                    Percent of women having live
                                                    births by Trimester when prenatal
                                                    care began


                      Astho Report                  Provides by race and age the           HBS107-1    F,C
                      (Women under 18)              number of women who initiated          HBS107-2    F,C
                      (Women 18 and over)           prenatal care at 0-14-weeks            HBS107-3    F,C
                      (Women all ages)              gestation, 15-27 weeks gestation
                                                    and 28+ weeks gestation.


                                                             Page 11 of 16
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      Program Name            Report Name                       Report Purpose                       Report   Report          Report Profile
                                                                                                    Number    Period
    Adult Health    *    Adult Patients - Number and   Provides patient statistics for the        HCA101      M,Q,F,C       Run separate from
                         Percent by Age/Race/Sex       number and percent of Race and Sex                                   other reports
    * Indicates not                                    information by age group within the
    available for data                                 selected report period.
    entered after July
    10th 2000
                         Adult Patients - Number and   Provides patient statistics for the        HCA102      M,Q,F,C       Run by individual
    *                    Percent by Age/Sex            number and percent of Sex information                                selection for site,
                                                       by age group within the selected report                              county, district, or
                                                       period.                                                              region


                         Adult Patients - Number and   Provides patient statistics for the        HCA103      M,Q,F,C   * If run by site, then
    *                    Percent by Age/Race           number and percent of Race                                       report will be for the
                                                       information by age group within the                              service site the user is
                                                       selected report period.                                          logged on to.


    *                    Adult Visits - Number and     Provides visit statistics for the number   HCA104      M,Q,F,C
                         Percent by Age/Race/Sex       and percent of Race and Sex
                                                       information by age group within the
                                                       selected report period.


    *                    Adult Visits - Number and     Provides visit statistics for the number   HCA105      M,Q,F,C
                         Percent by Age/Sex            and percent of Sex information by age
                                                       group within the selected report period.


                         Adult Visits – Number and     Provides visit statistics for the number   HCA106      M,Q,F,C
    *                    Percent by Age/Race           and percent of Race information by age
                                                       group within the selected report period.

                         Unduplicated Patient          Provides number and percent statistics     HCA107      M,Q,F,C
    *                    Services – Number and         of Adult Health types of services for
                         Percent by Service/ Age       various age categories within the
                                                       selected report period.




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    Program Name                Report Name                      Report Purpose                    Report     Report         Report Profile
                                                                                                  Number      Period
    Adult Health *       Total Adult Services         Provides number and percent of total      HCA108      M,Q,F,C        Run by individual
                         Number and percent by        Adult Health type services for various                               selection for site,
    * Indicates not      Service /Age                 age categories within the selected                                   county, district, or
    available for data                                report period.                                                       region
    entered after July
    10th 2000
                         Blood Pressure Readings by   Provides the Systolic and Diastolic       HCA109      M,Q,F,C    * If run by site, then
    *                    Age 18-64                    Pressure readings for ages 18-64 within                          report will be for the
                                                      the selected report period.                                      service site the user is
                                                                                                                       logged on to.

                         Blood Pressure Readings by   Provides the Systolic and Diastolic       HCA110      M,Q,F,C
    *                    Age 65 and Older             Pressure readings for ages 65 & over
                                                      within the selected report period.


                         Blood Pressure Readings by   Provides the Systolic and Diastolic       HCA111      M,Q,F,C
    *                    Sex – Female                 Pressure readings for Female patients
                                                      within the selected report period.


    *                    Blood Pressure Readings by   Provides the Systolic and Diastolic       HCA112      M,Q,F,C
                         Sex – Male                   Pressure readings for Male patients
                                                      within the selected report period.



    *                    Blood Pressure Readings by   Provides the Systolic and Diastolic       HCA113      M,Q,F,C
                         Race – White                 Pressure readings for White patients
                                                      within the selected report period.



    *                    Blood Pressure Readings by   Provides the Systolic and Diastolic       HCA114      M,Q,F,C
                         Race – Non-White             Pressure readings for Non-White
                                                      patients within the selected report
                                                      period.




                                                                   Page 13 of 16
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      Program Name            Report Name                     Report Purpose                    Report     Report    Report Profile
                                                                                                Number     Period

    Adult Health --- *   Blood Pressure Readings   Provides the Systolic and Diastolic        HCA115     M,Q,F,C
     * Indicates not     For All Patients          Pressure readings for All patients
    available for data                             within the selected report period.
    entered after July
    10th 2000        *   Blood Pressure Readings   Provides statistics for the number and     HCA121     M,Q,F,C
                         Number and percent by     percent of Adult Health Blood Pressure
                         Sex/Race                  readings by Sex/Race for various Blood
                                                   Pressure categories within a selected
                                                   report period

    *                    Cholesterol readings      Provides statistics for the number and     HCA122     M,Q,F,C
                                                   percent of Adult Health Cholesterol
                                                   Readings by Sex/Race for various
                                                   Cholesterol categories within a selected
                                                   report period.


    *                    Glucose Readings          Provides statistics for the number and     HCA123     M,Q,F,C
                                                   percent of Adult Health Glucose
                                                   Readings by Sex/Race for various
                                                   Glucose categories within a selected
                                                   report period
    Children’s
    Special Health       Patient Characteristics   Provides a summary of patient              HBS122     M,Q,F,C    Canned Reports
                                                   demographic information

                         Clinic Services Summary   Provides a summary of the number of        HBS123     M,Q,F,C    Can’t run if FP/AH
                                                   services by clinic type within the                               are also selected at
                                                   reporting period                                                 the same time.


                         Activity Report               Provides an unduplicated patient       HBS124     M,Q,F,C
                                                       count by patient type
                                                       Totals the activity within the
                                                       selected reporting period




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      Program Name        Report Name                      Report Purpose                       Report     Report     Report Profile
                                                                                               Number      Period
    Alpha List       From A to Z                Provides a list by:                          HSAE005     Not
                                                     Client Name                                         Applicable
                                                     Client ID Number
                                                     Date of Birth
                                                     Race & Sex
                                                     Medicaid Id Number
    All Programs     Service Count by Program   Provides a list within the selected report   HSAE010A    M,Q,F,C
                     Type                       period by:
                                                     Program Type
                                                     Service provided
                                                     Medicaid services entered
                                                     Non-Medicaid services entered &
                                                     Total Number of services
    All Programs     Service Count by Medical   Provides a list within the selected report   HSAE010B    M,Q,F,C
                     Discipline                 period by:
                                                     Medical Discipline
                                                     Service provided
                                                     Medicaid services entered
                                                Non-Medicaid services entered & Total
                                                Number of services
    All Programs     Service Count by           Provides a list if services for Medicaid     HSAE015A    M,Q,F,C
                     Service Site               and Non-Medicaid clients for each site
                                                where the service was provided.

    PAN Reporting    PAN BEHAVIORS BY AGE       Provides a break down by age of the 13       HSAE360     Not used
                     GROUP                      different PAN categories.

                     PAN BEHAVIORS BY AGE       Provides a break down by age and race        HSAE362     Not used
                     GROUP BY RACE              of the 13 different PAN categories.          HSAE364
                     (W,B,AI,O)                 W=white                                      HSAE366
                                                B=black                                      HSAE368
                                                AI=American Indian
                                                O=other

                     PAN BEHAVIORS BY AGE       Provides a break down by age and             HSAE370     Not used
                     GROUP BY ETHNICITY         ethnicity of the 13 different PAN            HSAE372
                     (H,NH)                     categories.
                                                H=Hispanic
                                                NH=non Hispanic



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                   PAN BEHAVIORS BY AGE    Provides a break down by age and   HSAE374   Not used
                   GROUP BY GENDER (M,F)   gender of the 13 different PAN     HSAE376
                                           categories.
                                           M=male
                                           F=female




                                                       Page 16 of 16
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Page 103 of 208




         Screen 28 (Forms Alignment) allows the user to align labels and insurance form (HCFA and Dental)


         HSA280A       NORTH CAROLINA HEALTH SERVICES INFORMATION SYSTEM                             09901
                                    F O R M S ALIGNMENT

         NEXT RECORD- COUNTY:     SCREEN: 28 ID:      DATE:    ACTION:
         MESSAGE:
            ENTER LABEL NBR, PRINTER ID AND 'ENTER' FOR ALIGNMENT OR REPEAT

          SELECT: 01 PRINTER: BDA0048E

         #01 3-UP LABELS 1 X 2 1/2
            -----------------------
            ] XXXXXXXXXXXXXXXXXXXX]
            -----------------------
          #02 2-UP LABELS 1 X 3 1/2
            --------------------------------
            ] XXXXXXXXXXXXXXXXXXXXXXXXXXXXX]
            --------------------------------

          #03 HCFA HEALTH INSURANCE CLAIM FORM

          #04 DENTAL CLAIM FORM




         FIELD                                     EXPLANATION

         SELECT      (R)                           Valid Entries are 01 – 04 to test alignment for following
                                                   Forms:

                                                   Enter 01 to align 3-up labels
                                                   Enter 02 to align 2-up labels
                                                   Enter 03 to align HCFA forms
                                                   Enter 04 to align Dental Claim Forms

         PRINTER (R)                               Program will display user’s default printer ID.
                                                   To print to different printer, enter printer
                                                   ID.




                                                       Page 1 of 1
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                                                 Breast Cancer Screen - HSA300A

All patients who are provided services through the Breast and Cervical Cancer Control Program (BCCCP) MUST have all breast
cancer screening and diagnostic follow-up services they receive reported on the breast cancer screen. These patients should also
have a Patient Master Screen HSA010A updated annually.

For a clinician, a breast cancer screening cycle consists of the patient screening and follow-up. For BCCCP, a breast cancer
screening cycle is generally similar to the clinical definition and has three components: a) patient screening, b) diagnostic work-up,
and c) breast cancer treatment. Most breast cancer screenings end with normal screening results and thus require no further
diagnostic tests or procedures. For an abnormal screening result, a screening cycle of a patient continues with immediate diagnostic
tests or procedures and ends if no cancer diagnosed. If a cancer is diagnosed, a screening cycle can only be complete when the
cancer treatment is initiated. The BCCCP screening cycle definition may differ from clinical practice in the case of short-term
follow-up. For purposes of reporting BCCCP data, the screening cycle is complete and the diagnostic disposition should be coded as
1(case closed, no cancer), if no immediate follow-up diagnostic test or procedure is recommended. The "repeat" or "short-term
follow-up" mammogram becomes the initial mammogram of a new screening cycle and must be reported on a new breast cancer
screen.

The initial mammogram and clinical breast exam are the two breast cancer procedures that begin a patient’s screening cycle. The
initial mammogram is usually a “screening” mammogram but may be a “diagnostic” mammogram depending on the clinical
recommendation (i.g., a diagnostic mammogram is often recommended as the initial mammogram if the clinical breast exam is
abnormal). If any diagnostic tests or procedures are required as a result of an initial mammogram, clinical breast exam, or for other
reasons, then all information pertaining to subsequent diagnostic tests and procedures should be updated on the breast cancer screen
created for the initial service date. To complete, this screen must be closed when all diagnostic test results and the diagnostic
disposition, as well as the treatment information if appropriate are entered. Enter only one breast cancer screening record per
patient, per screening cycle. Data fields that are required are denoted by (R). Data fields that are optional are denoted by (O).

HSA300A                 NORTH CAROLINA HSIS - ADULT HEALTH SERVICES                          ADDED:
09/14/04                          BREAST CANCER FOLLOW-UP                                  CHANGED:

NEXT RECORD: COUNTY        SCREEN 30    ID              DATE          ACTION
MESSAGE:
  NAME:                                                ID NUMBER:
 DOB:          BCCP CLIENT: _ BREAST SYMP: _ LAST MAM.: ____ BSE: _ B.C.HIST _
 REFERRAL/REFERENCE DATE : ______      CHARGED
                           PROC DATE   TO BCCCP RESULT DATE RESULT TYPE
 BREAST EXAM              : ______        _         ______      __
 INITIAL MAMMOGRAM        : ______        _         ______      __      _
 REPEAT INITIAL MAM       : ______        _         ______      __      _
 WORKUP PLANNED: _        SHORT-TERM FU: _      NEXT SCREENING MAMMOGRAM: __
                           PROC DT   CHGD/BCCCP RESULT DATE RESULT
 REPEAT BREAST EXAM       : ______        _         ______      __
 ADDITIONAL MAMMOGRAM     : ______        _         ______      __
 REPEAT ADDITIONAL MAM    : ______        _         ______      __
 PHYSICIAN CONSULTATION   : ______        _         ______
 ULTRASOUND               : ______        _         ______
 BIOPSY                   : ______        _         ______
 FINE NEEDLE ASPIRATION   : ______        _         ______
 DIAGNOSIS: DX DISP. _ FINAL DIAG: _ STAGE: _ SIZE: _ DX DATE: ______
 TREATMENT: TX DISP. _ TX DATE: ______ CMN ASSESS: _      CMC PLAN: _
 COMMENTS: ______________________________




Revision date: 9/14/2004                           Page 1 of 11
Revised for coding changes effective on 1-November-2002
  v1.13 10/22/2008                                                                                                              S170
  Page 105 of 208
A line by line explanation of each field follows. Please notice that the new or revised codes are bold

 Fields                        Explanations
 Screen (R)                    Enter “30"
 ID (R)                        Enter the patient ID number (This is usually the client’s SS#)
 Date (R)                      Enter the date of first screening service. This should be clinical breast exam procedure date. For
                               short term follow-up cases, use the date of the short term follow-up initial mammogram or CBE
                               date

                               NOTE: If any further reporting from the initial mammogram or the clinical breast exam is
                               necessary, then the initial screening date MUST be entered and a “C” entered in the action field to
                               update the record.
 Action (R)                    A = Add
                               I = Inquire
                               C = Change
                               D = Delete
 BCCCP Client (R)              Enter the appropriate code as follows:
                               1 = Yes, 2 = No
                               BCCCP CLIENT field should be coded as 1 (Yes), if a woman is at or below 200 percent federal
                               poverty level, between 18-64 years of age, not Medicaid eligible and enrolled in BCCCP.
                               Medicare Part B patients CAN NOT be BCCCP clients
                               Exception: Women over age 64 who do not have Medicare Part B can be enrolled in BCCCP.




Revision date: 9/14/2004                           Page 2 of 11
Revised for coding changes effective on 1-November-2002
  v1.13 10/22/2008                                                                                                            S170
  Page 106 of 208

 Breast Symptoms (O)          Enter the appropriate code as follows:
                              1 = Yes 2 = No
                              Note: Required for BCCCP patients.
 Date of Last                 Enter the month and year of last mammogram, if known, in MM/YY format.
 Mammogram(O)                 Enter 88/88 if unknown, or 00/00 if the patient never received one. Enter the client’s best
                              estimate of the month, if the year is known, and the month is unknown or 01/YY.
                              Note: Required for BCCCP patients.
 Breast Self Exam (O)         Enter the appropriate code as follows:
                              1 = No follow required
                              2 = Follow-up required
                              8 = Not indicated
                              9 = Indicated but not provided,(e.g. the patient refused instruction)
                              Note: Required for BCCCP patients.
 Breast Cancer History (O)    Enter the appropriate code as follows:
                              1 = No personal or family history
                              2 = Patient has had breast cancer
                              3 = Mother, daughter, &/or sisters have had breast cancer
                              4 = Patient and mother, daughter &/or sisters have had breast cancer
                              8 = Unable to answer
                              9 = Refused to answer
                              Note: Required for BCCCP patients.
 SCREENING
 BREAST EXAM
 Date of Procedure (O)        Enter date (MM/DD/YY) the breast exam was performed.
 Charged to BCCCP (O)         1 = Paid by Federal BCCCP funds
                              2 = Not paid by any BCCCP funds
                              3 = Partially paid by Federal BCCCP funds
                              4 = Paid by State BCCCP funds
                              5 = Partially paid by State BCCCP funds
                              6 = Partially paid by State and Federal BCCCP funds
 Date Results Received (O)    Enter (MM/DD/YY) the breast exam report was received by the BCCCP Provider.
 Breast Exam Results (O)      Enter the appropriate code using the Model Clinical Breast Exam result categories (01-06) below
                              if performed. If not performed for this visit, choose a code between 07-09 that describes the reason
                              for not performing the CBE:
                              01 = Normal exam
                              02 = Benign finding
                              03 = Discrete palpable mass
                              04 = Bloody or serous nipple discharge
                              05 = Nipple or areolar scaliness
                              06 = Skin dimpling or retraction
                              07 = Previous normal CBE in last 12 months
                              08 = CBE not done today-other reason
                              09 = CBE refused
                              NOTE: If a breast mass is palpable but not suspicious of cancer and no follow-up required, please
                              report as a benign finding. Codes 03,04,05 and 06 are suspicious for cancer and require a
                              diagnostic work-up plan (follow-up). If there are multiple findings (03,04,05, or 06), enter the
                              most clinically important (severe) finding.




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 INITIAL MAMMOGRAM
 Date of Procedure (O)        Enter date (MM/DD/YY) the initial mammogram was performed.
 Charged to BCCCP (O)         1 = Paid by Federal BCCCP funds
                              2 = Not paid by any BCCCP funds
                              3 = Partially paid by Federal BCCCP funds
                              4 = Paid by State BCCCP funds
                              5 = Partially paid by State BCCCP funds
                              6 = Partially paid by State and Federal BCCCP funds
 Date Results Rec’d (O)       Enter the date (MM/DD/YY) the initial mammogram report was received by the BCCCP
                              PROVIDER.
 Results (O)                  Enter the appropriate code using the American College of Radiology’s Lexicon of Breast Imaging
                              Reporting (codes 01-07) if performed. if not performed, choose a code among 08, 09, 11, and 12
                              that describes the reason for not performing the initial mammogram ):
                              01 = Negative
                              02 = Benign findings
                              03 = Probably benign - short term follow-up suggested
                              04 = Suspicious Abnormality-Biopsy should be considered
                              05 = Highly suggestive of Malignancy
                              06 = Assessment Incomplete (i.e., additional imaging required)
                              07 = Technically unsatisfactory (i.e., mammogram could not be interpreted by radiologist)
                              08 = Not indicated/needed
                              09 = Indicated but not performed (i.e., Patient refused exam)
                              10 = Result Pending
                              11 = Recent abnormal mammogram result from non-program funded source, receiving follow-up
                              services (i.g. an eligible patient enrolled in BCCCP after having an abnormal mammogram to
                              receive diagnostic services).
                              12 = Done recently elsewhere, breast screening and follow-up services not paid with BCCCP
                              funds.

                              NOTE: If initial mammogram results are 04,05,06, or 11 then diagnostic work-up must be
                              planned. If there are multiple findings, enter the most clinically important (severe) finding.
 Type                         Enter the appropriate code as follows:
                              1 = Screening mammogram.
                              2 = Diagnostic mammogram.
                              NOTE: Required if initial mammogram results are 01-07.
 REPEAT INITIAL               Repeat initial mammogram can only be entered if the initial mammogram is technically
 MAMMOGRAM                    unsatisfactory (Code = 07)
 Date of Procedure (O)        Enter date (MM/DD/YY) the repeat initial mammogram was performed.
 Charged to BCCCP (O)         1 = Paid by Federal BCCCP funds
                              2 = Not paid by any BCCCP funds
                              3 = Partially paid by Federal BCCCP funds
                              4 = Paid by State BCCCP funds
                              5 = Partially paid by State BCCCP funds
                              6 = Partially paid by State and Federal BCCCP funds
 Date Results Rec’d (O)       Enter date (MM/DD/YY) the repeat initial mammogram report was received by the BCCCP
                              PROVIDER.




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 Repeat Initial               Enter the appropriate code using the Lexicon of Breast Imaging Reporting below
 Mammogram Results (O)        01 = Negative.
                              02 = Benign findings.
                              03 = Probably benign - short-term follow-up suggested.
                              04 = Suspicious Abnormality-Biopsy should be considered.
                              05 = Highly suggestive of Malignancy.
                              06 = Assessment Incomplete (additional imaging required).
                              07 = Technically unsatisfactory; (i.e., mammogram could not be interpreted by radiologist).

                              NOTE: If the repeat initial mammogram results are 04,05 or 06 then diagnostic work-up must be
                              planned. Again, if there are multiple findings, enter the most clinically important (severe) finding.

 Type                         Enter the appropriate code as follows:
                              1 = Screening mammogram
                              2 = Diagnostic mammogram
                              NOTE: Required if the repeat initial mammogram was performed.
 Diagnostic work-up           Enter the appropriate code as follows:
 planned (R)
                              1 = Yes, 2 = No

                              NOTE: A diagnostic work-up should be planned for:
                              Initial or repeated initial mammogram results of :
                              --Suspicious Abnormality (Mammogram result code = 04)
                              --Highly suggestive of Malignancy (Mammogram result code =05)
                              --Assessment Incomplete (Mammogram result code = 06)
                              --the patient is enrolled in BCCCP after having a recent abnormal mammogram to receive
                              diagnostic services (Mam. code = 11)
                              --clinical breast exam results of discrete palpable mass, bloody or serous nipple discharge, nipple
                              or areolar scaliness, skin dimpling or retraction (CBE codes = 03,04,05,06)
                              --any other result that the physician specifies immediate follow-up required due to suspicion of
                              cancer.

 Short Term Follow-up (R)     Enter the appropriate code as follows:

                              1 = Yes 2 = No

                              NOTE: Short Term Follow-up is decided based mostly on the initial mammogram result by the
                              radiologist. Short Term Follow-up implies a need for repeating the mammogram after 2-6 months
                              (NOT an immediate follow-up). In most cases, an initial mammogram result coded as 3 needs to
                              be repeated after 2-6 months. If Short Term Follow-up Required is coded as 1 (YES), than Next
                              Screening Mammogram field must be completed. In this case, the cycle is complete, thus the DX
                              Disposition must be coded as 1 (No Cancer, Case Closed).

                              After the specified (2-6 months) time, the mammogram should be repeated and entered as an
                              initial mammogram starting a new screening cycle on a new Breast Cancer Screen HSA300A




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 Next Screening               Enter the appropriate code as follows:
 Mammogram (O)                 0= no screening mammogram is indicated in the next +24 month (i.g., the client is <38 y.o.)
                               2 = After two months from this screening date.
                               3 = After three months from this screening date.
                               4 = After four months from this screening date.
                               6 = After six months from this screening date.
                              12 = After twelve months from this screening date.
                              24 = After twenty-four months from this screening date.

                              NOTE: After the completion of each screening cycle, an approximate time in months for the next
                              recommended screening mammogram must be indicated here. If the DX Disposition is coded as 1
                              or 7, this field is required. Please enter time (in approximate months) to the scheduled or
                              recommended rescreening




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 DIAGNOSTIC WORK-UP
 REPEAT BREAST EXAM:          As a part of diagnostic work-up, a repeat breast exam may be performed by a NP or a physician
                              and entered. This field should only be used when diagnostic work-up is planned.
 Date of Procedure (O)        Enter date (MM/DD/YY) the repeat breast exam was performed.
 Charged to BCCCP (O)         1 = Paid by Federal BCCCP funds
                              2 = Not paid by any BCCCP funds
                              3 = Partially paid by Federal BCCCP funds
                              4 = Paid by State BCCCP funds
                              5 = Partially paid by State BCCCP funds
                              6 = Partially paid by State and Federal BCCCP funds
 Date Results Received (O)    Enter (MM/DD/YY) the repeat breast exam report was received by the BCCCP Provider.
 Repeat Breast Exam           Enter the appropriate code using the Model Clinical Breast Exam result categories below.
 Results (O)                  01 = Normal exam
                              02 = Benign finding
                              03 = Discrete palpable mass
                              04 = Bloody or serous nipple discharge
                              05 = Nipple or areolar scaliness
                              06 = Skin dimpling or retraction

                              NOTE: If a breast mass is palpable but not suspicious of cancer and no follow-up is required,
                              please report as a benign finding. Codes 03,04,05 and 06 are suspicious for cancer and require a
                              further diagnostic work-up plan (follow-up). If there are multiple findings (03,04,05, or 06), enter
                              the most clinically important (severe) finding.
 ADDITIONAL MAMMOGRAM
 Date of Procedure (O)     Enter date (MM/DD/YY) the additional mammogram was performed.
 Charged to BCCCP (O)      1 = Paid by Federal BCCCP funds
                           2 = Not paid by any BCCCP funds
                           3 = Partially paid by Federal BCCCP funds
                           4 = Paid by State BCCCP funds
                           5 = Partially paid by State BCCCP funds
                           6 = Partially paid by State and Federal BCCCP funds
 Date Results Rec’d (O)    Enter the date (MM/DD/YY) the additional mammogram report was received by the BCCCP
                           Provider.
 Results (O)               Enter the appropriate code using the Lexicon of Breast Imaging Reporting below
                           01 = Negative
                           02 = Benign findings
                           03 = Probably benign - short term follow-up suggested
                           04 = Suspicious Abnormality-Biopsy should be considered
                           05 = Highly suggestive of Malignancy
                           06 = Assessment Incomplete, ( additional imaging required)
                           07 = Mammogram technically unsatisfactory (i.e. mammogram could not be interpreted by
                           radiologist)
                           NOTE: If the additional mammogram results are 04,05 or 06 then a further diagnostic work-up is
                           required. If there are multiple findings, enter the most clinically important (severe) finding.
 REPEAT ADDITIONAL         A repeat additional mammogram can only be entered if the additional mammogram result is 06 or
 MAMMOGRAM                 07 (technically unsatisfactory or assessment incomplete)
 Date of Procedure (O)     Enter date (MM/DD/YY) the repeat additional mammogram was performed.
 Charged to BCCCP (O)      1 = Paid by Federal BCCCP funds
                           2 = Not paid by any BCCCP funds
                           3 = Partially paid by Federal BCCCP funds
                           4 = Paid by State BCCCP funds
                           5 = Partially paid by State BCCCP funds
                           6 = Partially paid by State and Federal BCCCP funds
 Date Results Received (O) Enter the date (MM/DD/YY) the repeat additional mammogram report was received by the
                           BCCCP Provider.
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 Results (O)                  Same as the additional mammogram result codes.
                              NOTE: If the repeat additional mammogram results are 04,05 or 06 then a further diagnostic
                              work-up is required. Again, if there are multiple findings, enter the most clinically important
                              (severe) finding.




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 PHYSICIAN/SURGICAL CONSULTATION
 Date of Procedure (O)    Enter date (MM/DD/YY) the physician consultation exam was performed

 Charged to BCCCP (O)         1 = Paid by Federal BCCCP funds
                              2 = Not paid by any BCCCP funds
                              3 = Partially paid by Federal BCCCP funds
                              4 = Paid by State BCCCP funds
                              5 = Partially paid by State BCCCP funds
                              6 = Partially paid by State and Federal BCCCP funds
 Date Results Rec’d (O)       Enter date (MM/DD/YY) the consultation report was received by the BCCCP Provider.
 ULTRASOUND
 Date of Procedure (O)        Enter date (MM/DD/YY) the ultrasound was performed.
 Charged to BCCCP (O)         1 = Paid by Federal BCCCP funds
                              2 = Not paid by any BCCCP funds
                              3 = Partially paid by Federal BCCCP funds
                              4 = Paid by State BCCCP funds
                              5 = Partially paid by State BCCCP funds
                              6 = Partially paid by State and Federal BCCCP funds
 Date Results Rec’d (O)       Enter date (MM/DD/YY) the ultrasound report was received by the BCCCP Provider.
 BIOPSY
 Date of Procedure (O)        Enter date (MM/DD/YY) the biopsy was performed.
 Charged to BCCCP (O)         1 = Paid by Federal BCCCP funds
                              2 = Not paid by any BCCCP funds
                              3 = Partially paid by Federal BCCCP funds
                              4 = Paid by State BCCCP funds
                              5 = Partially paid by State BCCCP funds
                              6 = Partially paid by State and Federal BCCCP funds
 Date Results Rec’d (O)       Enter date (MM/DD/YY) the tissue biopsy report was received by the BCCCP Provider.
 FINE NEEDLE ASPIRATION
 Date of Procedure (O)        Enter date (MM/DD/YY) the fine needle aspiration was performed.
 Charged to BCCCP (O)         1 = Paid by Federal BCCCP funds
                              2 = Not paid by any BCCCP funds
                              3 = Partially paid by Federal BCCCP funds
                              4 = Paid by State BCCCP funds
                              5 = Partially paid by State BCCCP funds
                              6 = Partially paid by State and Federal BCCCP funds
 Date Results Rec’d (O)       Enter the date (MM/DD/YY) the fine needle aspiration report was received by the BCCCP
                              Provider.
 DIAGNOSIS
 DX Disposition (R)           Enter the appropriate code as follows:
                              1 = No breast cancer present; case closed
                              2 = Workup and/or test results pending
                              3 = Patient died
                              4 = Patient moved out of county/state
                              5 = Unable to obtain results from the provider
                              6 = Patient refused or non-responsive to workup/ further services
                              7 = Breast cancer diagnosed; treatment required

                              NOTE: Only if a 7 is entered are Final Diagnosis, Stage, Tumor Size, TX Disposition and Date
                              required. If breast cancer is diagnosed (i.e., 7 is entered), then the Biopsy and/or the Fine Needle
                              Aspiration row must have been completed.




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 DX Disposition Date (O)      Enter the date of DX Disposition (MM/DD/YY). This should be the date of the last procedure
                              used to determine the absence of breast cancer (DX disposition = 1) or presence of breast cancer
                              (DX disposition = 7). If the case is closed for administrative reasons (dx disposition = 3,4,5,6)
                              then use the date of administrative closure.

                              NOTE: If the DX Disposition is equal to 1,3,4,5,6, or 7, this field is required. Leave blank if DX
                              Disposition is 2.


 Final Diagnosis (O)          If cancer has been diagnosed, enter the appropriate code as follows:
                              0 = Breast Cancer, ductal carcinoma in-situ (DCIS)
                              1 = Breast Cancer, lobular carcinoma in-situ (LCIS)
                              2 = Breast Cancer, invasive
                              3 = Other cancer (not Breast Cancer)
                              4 = Atypical epithelial hyperplasia

                              NOTE: If DX Disposition is 7 then this field is required. If DX Disposition is 1 and biopsy is
                              performed, this field may be completed to report other cancer or atypical epithelial hyperplasia.
 Stage (O)                    If a breast cancer has been diagnosed, enter the clinical stage at diagnosis (code 1-4) according to
                              the American Joint Committee on Cancer (AJCC). If the clinical stage is not available, summary
                              stage codes (6-8) can be used. AJCC stage is preferred for reporting, when available.
                              0 = Stage 0 (Cancer in-situ)
                              1 = Stage I
                              2 = Stage II
                              3 = Stage III
                              4 = Stage IV
                              5 = Unknown/Unstaged
                              6 = Summary Local
                              7 = Summary Regional
                              8 = Summary Distant

                              NOTE: If DX Disposition is 7, then this field is required. This information is provided on the
                              pathology report. If DX Disposition is anything other than 7, no data should be entered in this
                              field. If Final Diagnosis = 0 or 1 then stage must = 0.
 Tumor Size (O)               If the cancer has been diagnosed as Stage I through Stage IV (1,2,3, or 4), enter the appropriate
                              code for the size of the lesion:
                              1 = 0 - < 1 cm.
                              2 = 1 - < 2 cm.
                              3 = 2 - < 5 cm.
                              4 = > than or = 5 cm.
                              5 = Unknown
                              NOTE: If DX Disposition is 7 then this field is required. This information is provided on the
                              pathology report. If the DX Disposition is anything other than 7, no data should be entered in this
                              field.
 TREATMENT
 TX Disposition (O)           Enter the appropriate code as follows:
                              0 = Treatment not needed
                              1 = Treatment initiated
                              2 = Treatment pending
                              3 = Patient died
                              4 = Patient moved out of county/ state
                              5 = Unable to obtain results from provider
                              6 = Patient refused or not responsive to treatment
                              NOTE: If DX Disposition is equal to 7 (breast cancer diagnosed), then this field is required.
 TX Date (O)                  Enter date (MM/DD/YY) of. the TX Disposition
                              NOTE: If the TX Disposition is 1,3,4,5, or 6, then this field is required. Leave blank if TX
                              Disposition = 2 (pending) or 0=not needed
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 CASE MANAGEMENT
 ( Case Management is required only for Abnormal CBE or mammogram results)

 Case Management Needs         Enter the appropriate code as follows:
 Assessment (O)                1 = Yes, 2 = No

                               NOTE: This field is required
                               If the CBE results are:

                               03 = Discrete palpable mass
                               04 = Bloody or serous nipple discharge
                               05 = Nipple or areola scariness
                               06 = Skin dimpling or retraction

                               or (and) mammogram results are:

                               04 = Suspicious Abnormality-Biopsy should be considered
                               05 = Highly suggestive of Malignancy
                               11 = Recent abnormal mammogram result from non-program funded source




 Case Management Care          Enter the appropriate code as follows:
 Plan (O)                      1 = Yes, 2 = No
                               NOTE: This field is required only if CMN Assessment is “Yes”



 Comments                      Memo field, up to 25 characters (any special situation with the client’s screening or follow
                               up that you want to communicate with the case manager, e.g., a breast cancer recurrence).




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BCCCP BREAST CANCER SCREENING AND FOLLOW-UP DATA ENTRY FORM (screen 30)                                                                                               Revised 1-Nov. 2002

NAME                                                                   ID (usually SS#)                                        VISIT DATE
BCCCP               BREAST                 LAST MAM                    BSE                            BREAST CANCER HISTORY
CLIENT              SYMPTOMS                                           1=No FU needed                 1=No personal or family history of breast cancer
1=Yes               1=Yes                                              2=FU required                  2=Patient has had breast cancer
2=No                2=No                   _____/_________             8=Not indicated                3=Mother, daughter and/or sister has had breast cancer
                                             MM        YYYY
                                                                       9=Indicated, but               4=Patient and mother/daughter/sister have had breast cancer
                                                                         not provided                 8=Unable to answer
                                                                                                      9=Refused to answer
SCREENING               PROCEDURE                 PROC DATE                 CHARGED TO                     RESULT DATE                                   RESULT
                    CLINICAL BREAST                                                                                            1=Normal exam
                    EXAM                                               1= Paid in full                                         2=Benign finding
                                                                       by BCCCP funds                                          3=Discrete palpable mass
                                                                       2= Paid by Non                                          4=Bloody or serous nipple discharge
                                                                       BCCCP funds                                             5=Nipple or areolar scaliness
                                                                                                                               6=Skin dimpling or retraction
                                                                       3= Partially paid by                                    7=Normal CBE in last 12 months
                                           ____/____/_______           BCCCP                          ____/____/_______        8=CBE not done for other reason
                                           MM     DD      YYYY                                        MM   DD     YYYY         9=Patient Refused CBE
                    INITIAL                                                                                                    01=Negative
                    MAMMOGRAM                                                                                                  02=Benign findings
                                                                                                                               03=Probably benign; Short-term follow up suggested
                                                                                                                               04=Suspicious abnormality; Consider biopsy
                                                                                                                               05=Highly suggestive of malignancy
                                                                                                                               06=Assessment incomplete; additional imaging reqd
                                                                                                                               07=Technically unsatisfactory
                                                                        1       2       3                                      08=Not indicated/needed
                                                                                                                               09=Indicated, but not performed (refused)
                    TYPE:    1    2                                    (see codes above)                                       10=Result is pending
                                           ____/____/_______                                          ____/____/_______
                             S    D        MM     DD      YYYY                                        MM   DD     YYYY         11=Recent, NonBCCCP, abnormal Mam requires FU
                                                                                                                               12=Recent, NonBCCCP, Mam w/ no followup required
                    RPT INITIAL MAM                                     1       2       3                                                    01 02 03 04 05 06 07
                                                                                                                                    (same as initial mammogram codes 1-7 above)
                    TYPE:    1     2       ____/____/_______           (see codes above)              ____/____/_______
                                           MM     DD      YYYY                                        MM   DD     YYYY
PLAN                DX WORK-UP                                         SHORT-TERM                                                     NEXT SCREENING MAMOGRAM DUE IN
                    PLANNED?   1=Yes         2=No                      FU REQUIRED?           1=Yes    2=No                                2 3 4 5 6 12 24 MONTHS
DX WORKUP               PROCEDURE                 PROC DATE                 CHARGED TO                     RESULT DATE                                   RESULT

                    REPEAT BREAST                                       1       2       3                                                             1 2 3 4 5 6
                    EXAM
                                           ____/____/_______           (see codes above)              ____/____/_______                   (same as CBE result codes 1-6 above)
                                           MM     DD      YYYY                                        MM   DD     YYYY
                    ADDITIONAL                                          1       2       3                                                      01 02 03 04 05 06 07
                    MAMMOGRAM
                                           ____/____/_______           (see codes above)              ____/____/_______             (same as initial mammogram codes 1-7 above)
                                           MM     DD      YYYY                                        MM   DD     YYYY
                    REPEAT                                              1       2       3                                                      01 02 03 04 05 06 07
                    ADDITIONAL
                    MAMMOGRAM              ____/____/_______           (see codes above)              ____/____/_______             (same as initial mammogram codes 1-7 above)
                                           MM     DD      YYYY                                        MM   DD     YYYY
                    PHYSICIAN                                           1       2       3                                      Comments:

                    CONSULT                ____/____/_______           (see codes above)              ____/____/_______
                                           MM     DD      YYYY                                        MM   DD     YYYY
                    ULTRASOUND                                          1       2       3
                                           ____/____/_______           (see codes above)              ____/____/_______
                                           MM     DD      YYYY                                        MM   DD     YYYY
                    BIOPSY                                              1       2       3
                                           ____/____/_______           (see codes above)              ____/____/_______
                                           MM     DD      YYYY                                        MM   DD     YYYY
                    FINE NEEDLE                                         1       2       3

                    ASPIRATION             ____/____/_______           (see codes above)              ____/____/_______
                                           MM     DD      YYYY                                        MM   DD     YYYY
DIAGNOSIS           DX DISP                                            DX DISP DATE
                    1=No Breast Cancer; case closed
                    2=Diagnostic workup or results are pending
                    3=Patient Died
                    4=Moved out of county/state
                    5=Unable to obtain results from provider           ____/____/________
                    6=Patient non-responsive/refuses follow up         MM      DD    YYYY
                    7=Breast cancer diagnosed
ADDITIONAL          FINAL DX                                           STAGE                                                   SIZE
DX INFO             0=Breast ductal carcinoma in-situ (DCIS)           0=Stage 0 (in-situ)  6=Summary local                    1= 0 - <1 cm.
                    1=Breast lobular carcinoma in-situ (LCIS)          1=Stage I            7=Summary regional                 2= 1 - <2 cm.
                    2=Invasive breast cancer                           2=Stage II           8=Summary distant                  3= 2 - <3 cm.
                    3=Other cancer (non breast)                        3=Stage III                                             4= >= 5 cm.
                    4=Atypical epithelial hyperplasia                  4=Stage IV                                              5= Unknown
                                                                       5=Stage unknown or unstaged
TREATMENT           TX DISP                            3=Patient died                                                          TX DATE
INFO                0=Treatment not needed             4=Moved out of the county or state
                    1=Treatment initiated              5=Unable to obtain results from provider
                    2=Treatment pending                6=Non-responsive or refused treatment                                   ____/____/________
                                                                                                                               MM    DD        YYYY
CASE MGMT.          CMGMT ASSESS: 1=Yes ; 2= No                                                                                CMGT PLAN: 1=YES; 2=NO




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                                                 Cervical Cancer Screen –HSA310A

All patients who are provided services through the Breast and Cervical Cancer Control Program (BCCCP) MUST have all cervical
cancer screening and diagnostic services they receive reported on the cervical cancer screen. These patients should also have a
Patient Master Screen HSA010A updated annually.

For a clinician, a cervical cancer screening cycle consists of the patient screening and follow-up. For BCCCP, a cervical cancer
screening cycle is generally similar to the clinical definition and has three components: a) patient screening, b) diagnostic work-up,
and c) cervical dysplasia or cancer treatment. Most screenings end with normal screening results and thus require no further
diagnostic tests or procedures. For an abnormal screening result, a screening cycle of a patient continues with immediate diagnostic
tests or procedures and ends if no cancer is diagnosed. If a biopsy result reveals a moderate to severe dysplasia or an invasive
cervical cancer, a screening cycle can only be complete when the cancer treatment is initiated. The BCCCP screening cycle
definition may differ from clinical practice in the case of short-term follow-up (based on the screening result such as AS-CUS ). For
purposes of reporting BCCCP data, the screening cycle is complete and the diagnostic disposition should be coded as 1 (case closed,
no cancer), if no immediate follow-up diagnostic test or procedure is recommended. For BCCCP, the repeat Pap test starts a new
screening cycle and must be reported on a new cervical cancer screen.

The screening Pap test and the pelvic exam are the two cervical cancer-screening procedures that begin a woman’s screening cycle.
If any follow-up procedures are required as a result of a screening Pap test/pelvic exam, then all information pertaining to
subsequent tests and procedures should be updated on the screen created for initial screening date. To complete, this screen must be
closed when all diagnostic test results and the diagnostic disposition, as well as the treatment information if appropriate are entered.
Enter only one follow-up record per patient, per screening cycle. Required fields denoted by (R). Optional fields denoted by (O).

 HSA310A                   NORTH CAROLINA HSIS - ADULT HEALTH SERVICES                          ADDED:
 09/14/04                           CERVICAL CANCER SCREENING                                 CHANGED:

NEXT RECORD:         COUNTY 092          SCREEN 31           ID                      DATE                   ACTION I
MESSAGE:

 NAME:                                                                           ID NUMBER:
 DOB :                                    BCCCP CLIENT: _                        LAST PAP : ____
                                           CHARGED   SPEC                   SPEC   RESULT
 SCREENING                       PROC DATE TO BCCCP   AD                    TYPE    DATE     RESULT

 PELVIC/RECTAL EXAM:  ______                           _                             ______             _
 SYSTEM USED: _ (1=1991,2=2001)
 PAP SMEAR         :  ______                           _            _        _       ______             __
 REPEAT PAP SMEAR :   ______                           _            _        _       ______             __

 WORKUP PLANNED: _   SHORT TERM FOLLOW-UP: _    NEXT SCREENING PAPSMEAR: __
                                CHARGED
 DIAGNOSTIC WORKUP   PROC DATE TO BCCCP    RESULT DATE RESULT
 COLPOSCOPY:          ______       _          ______      _
 BIOPSY:              ______       _          ______      _
 DIAGNOSIS: DX DISP: _     DX DATE: ______     STAGE: _
 TREATMENT: TX DISP: _     TX DATE: ______     CMN ASSESS: _     CMC PLAN: _
 COMMENTS: ______________________________




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A line by line explanation of each field follows. Please notice that the new or revised codes are bold

 Fields                         Explanations
 Screen (R)                     Enter “31"
 ID (R)                         Enter the patient ID number ( This is usually the patient’s SS#)
 Date (R)                       Enter the date of the first screening service. This should be the date of pelvic exam and Pap test
                                specimen collection (Pap test procedure date). For short term follow-up cases, use the date of
                                the Pap test procedure that is repeated.

                                NOTE: If any further reporting from the initial screening Pap test is necessary, then the initial
                                screening date MUST be entered and a “C” entered in the action field to update the record.
 Action (R)                     A = Add
                                I = Inquire
                                C = Change
                                D = Delete
 BCCCP Client (R)               Enter the appropriate code as follows:
                                1 = Yes, 2 = No.
                                BCCCP CLIENT field should be coded as 1 (Yes), if a woman is at or below 200 percent
                                federal poverty level, between 18-64 years of age, not Medicaid eligible and enrolled in
                                BCCCP. Medicare Part B patients CAN NOT be BCCCP clients.
                                Exception: Women over age 64 who do not have Medicare Part B can be enrolled in BCCCP.
 Date of Last Pap test(O)       Enter the month and year of the last Pap test, if known, in MM/YY format.
                                Enter 88/88 if unknown, or 00/00 if the patient never received one. Enter the client’s best
                                estimate of the month, if the year is known, and the month is unknown or 01/YY.
                                NOTE: Required for BCCCP patients.




 SCREENING
 PELVIC/RECTAL EXAM
 Date of Procedure (O)          Enter date (MM/DD/YY) the pelvic exam was performed.
 Charged to BCCCP (O)           1 = Paid by Federal BCCCP funds
                                2 = Not paid by any BCCCP funds
                                3 = Partially paid by Federal BCCCP funds
                                4 = Paid by State BCCCP funds
                                5 = Partially paid by State BCCCP funds
                                6 = Partially paid by State and Federal BCCCP funds
 Date Results Received (O)      Enter (MM/DD/YY) the pelvic exam report was received by the BCCCP Provider.
 Pelvic/Rectal Exam             Enter the appropriate code as follows:
 Result(O)                      1 = Normal exam; no follow-up required
                                2 = Abnormal; follow-up required
                                8 = Not indicated
                                9 = Indicated but not provided,(E.g., patient refused exam)




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 SCREENING PAP TEST          Enter the appropriate code as follows:
 SYSTEM USED                 1 = Bethesda 1991 System
                             2 = Bethesda 2001 System


 SCREENING PAP TEST
 Charged to BCCCP (O)        1 = Paid by Federal BCCCP funds
                             2 = Not paid by any BCCCP funds
                             3 = Partially paid by Federal BCCCP funds
                             4 = Paid by State BCCCP funds
                             5 = Partially paid by State BCCCP funds
                             6 = Partially paid by State and Federal BCCCP funds
                             Enter the appropriate code if SYSTEM USED is 1 (Bethesda 1991) or SYSTEM USED is 2 (Bethesda
 Specimen Adequacy           2001)
                             1-Satisfactory
                             2-Satisfactory for evaluation but limited by…(Bethesda 1991 results only)
                             3-Unsatisfactory
                             4-Unknown
                             If Bethesda System is ‘1’ and Specimen Adequacy is 1,2 or 4 then results of Pap test must be
                             completed. If specimen adequacy is ‘3’,then result of Pap test must be Unsatisfactory.
                             If Bethesda system is ‘2’ and specimen Adequacy is 1 or 4, then results of Pap test must be
                             completed. If Specimen Adequacy is ‘3’, than result of Pap test must be left blank. A specimen
                             adequacy result of ‘2’ is NOT VALID for Bethesda 2001.




 Specimen Type               Required if SYSTEM USED is 2 (Bethesda 2001),
                             1= Conventional test
                             2= Liquid Based
                             3=Other
                             4= Unknown
 Date Result Rec’d (O)       Enter the date (MM/DD/YY) on which the result of the Pap test was received in the BCCCP
                             Provider.




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 Results (O)                 Enter the appropriate code as follows. If SYSTEM USED is 1, use Bethesda 1991 codes. If SYSTEM
                             USED is 2, use Bethesda 2001 codes If a Pap test is not performed for this visit, choose a code
                             among 09, 10, 12, and 13 that describes the reason for not performing the Pap test.

                             Bethesda 1991
                             00 = Abnormal glandular cells (includes AGUS and adenocarcinoma)
                             01 = Negative (Within normal limits).
                             02 = Infection (Infection/Reactive Changes).
                             03 = Atypical Squamous Cells, of undetermined significance.
                             04 = Low Grade SIL (Including HPV changes).
                             05 = High Grade SIL.
                             06 = Squamous Cell Cancer.
                             07 = Other malignant neoplasms with normal glandular cells.
                             08 = Unsatisfactory.
                             09 = Not Indicated.
                             10 = Needed but not performed at this visit --includes refusal.
                             11 = Result Pending.
                             12 = Recent abnormal Pap test result from non-program funded source, receiving follow-up
                             services (i.e. an eligible patient enrolled in BCCCP after having an abnormal pap test to receive
                             diagnostic services).
                             13 = Done Recently elsewhere, cervical screening and follow-up services not paid with BCCCP
                             funds.

                             If Pap test result is coded as 05 or 06 or 12 or 00, a diagnostic work-up planned must be coded
                             as 1(Yes).

                              Bethesda 2001
                             01=Negative for Intraepithelial lesion or malignancy
                             02= Atypical squamous cells of undetermined significance (ASC-US)
                             03=Low grade squamous intraepithelial lesion (LSIL) (including HPV changes)
                             04= Atypical squamous cells (ASC-US) cannot exclude HSIL (ASC-H)
                             05= High grade SIL (HSIL) encompassing: moderate and severe dysplasia, CIS/CIN 2 and CIN
                             3
                             06= Squamous cell carcinoma
                             07= Abnormal glandular cells (including Atypical, Endocervical adenocarcinoma in situ and
                             Adenocarcinoma.
                             08 =Other malignant neoplasms
                             09 = Not Indicated.
                             10 = Needed but not performed at this visit --includes refusal.
                             11 = Result Pending.
                             12 = Recent abnormal Pap test result from non-program funded source, receiving follow-up
                             services (i.e. an eligible patient enrolled in BCCCP after having an abnormal pap test to receive
                             diagnostic services).
                             13 = Done Recently elsewhere, cervical screening and follow-up services not paid with BCCCP
                             funds.

                             If Pap test result is coded as 04, or 05,or 06 ,or 07, or 12, a diagnostic work-up planned must be
                             coded as 1(Yes).

                             NOTE: If the date result received was entered, this field is required.
 REPEAT SCREENING PAP                 Should be entered only if the initial Pap test adequacy was unsatisfactory
 TEST

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 Date Result Rec’d (O)                 Enter the date (MM/DD/YY) on which the result of the Pap test was received in the
                                       BCCCP Provider.

 Charged to BCCCP (O)        1 = Paid by Federal BCCCP funds
                             2 = Not paid by any BCCCP funds
                             3 = Partially paid by Federal BCCCP funds
                             4 = Paid by State BCCCP funds
                             5 = Partially paid by State BCCCP funds
                             6 = Partially paid by State and Federal BCCCP funds
                             Enter the appropriate code if SYSTEM USED is 1 (Bethesda 1991) or SYSTEM USED is 2 (Bethesda
 Specimen Adequacy (O)       2001)
                             1-Satisfactory
                             2-Satisfactory for evaluation but limited by…(Bethesda 1991 results only)
                             3-Unsatisfactory
                             4-Unknown
                             If Bethesda System is ‘1’ and Specimen Adequacy is 1,2 or 4 then results of Pap test must be
                             completed. If specimen adequacy is ‘3’,then result of Pap test must be Unsatisfactory.
                             If Bethesda system is ‘2’ and specimen Adequacy is 1 or 4, then results of Pap test must be
                             completed. If Specimen Adequacy is ‘3’, than result of Pap test must be left blank. A specimen
                             adequacy result of ‘2’ is NOT VALID for Bethesda 2001.



 Specimen Type (O)           1= Conventional test
                             2= Liquid Based
                             3=Other
                             4= Unknown




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 Results (O)                 Enter the appropriate code as follows:

                             Bethesda 1991
                             00 = Abnormal glandular cells (includes AGUS and adenocarcinoma)
                             01 = Negative (Within normal limits).
                             02 = Infection (Infection/Reactive Changes).
                             03 = Atypical Squamous Cells, of undetermined significance.
                             04 = Low Grade SIL (Including HPV changes).
                             05 = High Grade SIL.
                             06 = Squamous Cell Cancer.
                             07 = Other (Endocervical carcinoma).
                             08 = Unsatisfactory.
                             NOTE: If the date result received was entered, this field is required. If Pap test result is 00, 05
                             or 06, diagnostic work-up planned must be coded as 1(Yes).

                             Bethesda 2001
                             01=Negative for Intraepithelial lesion or malignancy
                             02= Atypical squamous cells of undetermined significance (ASC-US)
                             03=Low grade squamous intraepithelial lesion (LSIL) (including HPV changes)
                             04= Atypical squamous cells (ASC-US) cannot exclude HSIL (ASC-H)
                             05= High grade SIL encompassing: moderate and severe dysplasia, CIS/CIN 2 and CIN 3
                             06= Squamous cell carcinoma
                             07= Abnormal glandular cells (including Atypical, Endocervical adenocarcinoma in situ and
                             Adenocarcinoma.
                             08 =Other malignant neoplasms
                             09 =Not Indicated.
                             10 = Needed but not performed at this visit --includes refusal.
                             11 = Result Pending.
                             12 = Recent abnormal Pap test result from non-program funded source, receiving follow-up
                             services (i.e. an eligible patient enrolled in BCCCP after having an abnormal pap test to receive
                             diagnostic services).
                             13 = Done Recently elsewhere, cervical screening and follow-up services not paid with BCCCP
                             funds.

                             If Pap test result is coded as 04, or 05,or 06, or 07, or 12, a diagnostic work-up planned must be
                             coded as 1(Yes).




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 Diagnostic work-up planned    Enter the appropriate code as follows:
 (R)                           1 = Yes, 2 = No

                               NOTE: Diagnostic work-up should be planned:
                               If Bethesda 1992 test results:
                               -Pap test results of High Grade SIL (Pap test result code = 05 )
                               -Pap test results of Abnormal glandular cells (Pap test result code = 00)
                               -Squamous Cell Cancer (Pap test result code = 06 ).

                               or

                               Bethesda 2002 test results are:
                               04= Atypical squamous cells (Pap test result code = 04 )
                               05= High grade SIL (Pap test result code = 05 )
                               06= Squamous cell carcinoma (Pap test result code = 06 )
                               07= Abnormal glandular cells (Pap test result code = 07 )

                               and

                               - Recent abnormal Pap test result from non-program funded source, receiving follow-up
                               services
                               -Any other result that the physician specifies immediate follow-up required due to suspicion of
                               cancer.

 Short Term Follow-up (R)      Enter the appropriate code as follows:
                               1 = Yes, 2 = No
                               NOTE: Short Term Follow-up should be decided based on Pap test results. Short Term Follow-
                               up implies a need for repeating Pap test after 2-6 months (not an immediate follow-up). In most
                               cases, if Short Term Follow-up Required is 1 (YES), the next screening Pap test field must be
                               completed, and the DX Disposition must be coded as 1 (No Cancer, Case Closed). After the
                               specified (2-6 months) time, Pap test should be repeated and entered as a screening Pap test
                               starting a new cycle on a new Cervical Cancer Screen HSA310A
 Next Screening Pap test (O)   Enter the appropriate code as follows:
                               2 = After two months from this screening date.
                               3 = After three months from this screening date.
                               4 = After four months from this screening date.
                               6 = After six months from this screening date.
                               12 = After twelve months from this screening date.
                               24 = After twenty-four or more months from this screening date.

                               NOTE: If Short Term Follow-up Required be coded as 1 (YES), this field is required. Please
                               enter time (in approximate months) to the scheduled follow-up.




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 DIAGNOSTIC WORK-UP
 COLPOSCOPY
 Date of Procedure (O)       Enter date (MM/DD/YY) the colposcopy was performed.
 Charged to BCCCP (O)        1 = Paid by Federal BCCCP funds
                             2 = Not paid by any BCCCP funds
                             3 = Partially paid by Federal BCCCP funds
                             4 = Paid by State BCCCP funds
                             5 = Partially paid by State BCCCP funds
                             6 = Partially paid by State and Federal BCCCP funds
 Date Results Received (O)   Enter date (MM/DD/YY) the colposcopy results were available to the BCCCP Provider.
 Results (O)                 Enter the appropriate code as follows:
                             1 = Normal and/or no biopsy performed (Colposcopy without biopsy)
                             2 = Biopsy performed (Colposcopy with Biopsy)

                             NOTE: If the date the result received was entered, then this field is required. If colposcopy result
                             is coded as 2, then a biopsy field must be completed.
 BIOPSY
 Date of Procedure (O)       Enter date (MM/DD/YY) the biopsy was performed.
 Charged to BCCCP (O)        1 = Paid by Federal BCCCP funds
                             2 = Not paid by any BCCCP funds
                             3 = Partially paid by Federal BCCCP funds
                             4 = Paid by State BCCCP funds
                             5 = Partially paid by State BCCCP funds
                             6 = Partially paid by State and Federal BCCCP funds




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 Date Results Received (O)   Enter the date (MM/DD/YY) the biopsy result was available to the BCCCP PROVIDER.
 Results (O)                 Enter the appropriate code as follows:
                             1 = Normal exam/Benign reaction
                             2 = HPV/Condylomata/Atypia
                             3 = CIN I
                             4 = CIN II
                             5 = CIN III/Carcinoma in situ (= Stage 0)
                             6 = Invasive Cervical Carcinoma
                             7 = Invasive Adenocarcinoma
                             8 = Other Cancer (not cervical cancer)

                             NOTE: If the date the result received was entered, then this field is required.
 DIAGNOSIS
 DX Disposition (R)          Enter the appropriate code as follows:
                             1 = No cervical cancer present; case closed
                             2 = Work up and/or test results pending
                             3 = Patient died
                             4 = Patient moved out of county/state
                             5 = Unable to obtain results from provider
                             6 = Patient refused or not responsive to work up/further services
                             7 = Cervical Cancer diagnosed; patient referred for follow-up/treatment

                             NOTE: Only if a 7 is entered are Stage, TX Disposition and Date of TX Disposition required.
 DX Disposition Date (O)     Enter the date (MM/DD/YY) of the diagnostic disposition. This should be the date of the last
                             procedure used to determine the absence of cervical cancer (Dx disposition = 1) or presence of
                             cervical cancer (Dx Disposition = 7). If the case is closed for administrative reasons (Dx
                             disposition = 3,4,5,6), then use the date of administrative closure.
                             NOTE: If the DX Disposition is equal to 1, 3, 4, 5, 6, or 7, this field is required. Leave blank if
                             DX Disposition is 2.

 Stage (O)                   If a cervical cancer has been diagnosed, enter the clinical stage at diagnosis (code 1-4) according
                             to the American Joint Committee on Cancer (AJCC). If the clinical stage is not available,
                             summary stage codes (6-8) can be used. The AJCC stage is preferred for reporting, when
                             available.

                             0 = Stage 0 (Cervical Carcinoma in situ)
                             1 = Stage I
                             2 = Stage II
                             3 = Stage III
                             4 = Stage IV
                             5 = Unknown/Unstaged
                             6 = Summary Local
                             7 = Summary Regional
                             8 = Summary Distant
                             NOTE: If DX Disposition = 7, this field is required. This information is provided on the
                             pathology report
 TREATMENT




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 TX Disposition (O)           Enter the appropriate code as follows:
                              0 = Treatment not needed
                              1 = Treatment initiated
                              2 = Treatment pending
                              3 = Patient died
                              4 = Patient moved out of county/state
                              5 = Unable to obtain results from provider
                              6 = Patient refused or not responsive to treatment

                              NOTE: If DX Disposition is equal to 7 (Cervical cancer diagnosed), or if biopsy result is 4 (CIN
                              II), 5 (CIN II/CIS), 6 (Invasive Cervical Carcinoma), or 7 (Invasive Adenocarcinoma), this field
                              is required (even if no treatment is needed). If a biopsy procedure is performed and a treatment
                              is initiated as a result, regardless of the biopsy result this field may be entered (Optional).
 TX Date (O)                  Enter date (MM/DD/YY) of the treatment disposition
                              NOTE: If the TX Disposition is 0, 1, 3, 4, 5, or 6, this field is required. Leave blank if TX
                              Disposition = 2.




 CASE MANAGEMENT
 ( Case Management is required only for Abnormal PAP results)




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 Case Management Needs       Enter the appropriate code as follows:
 Assessment (O)              1 = Yes, 2 = No

                             NOTE: This field is required

                              If the pap test results are:
                              ( Bethesda 2001)
                             04= Atypical squamous cells (ASC-US) cannot exclude HSIL (ASC-H)
                             05= High grade SIL encompassing: moderate and severe dysplasia, CIS/CIN 2 and CIN 3
                             06= Squamous cell carcinoma
                             07= Abnormal glandular cells (including Atypical, Endocervical adenocarcinoma in situ and
                                   Adenocarcinoma.
                             08 =Other malignant neoplasms
                             12 = Recent abnormal Pap test result from non-program funded source

                             or
                              ( Bethesda 1991)
                             00 = Abnormal glandular cells (includes AGUS and adenocarcinoma)
                             05 = High Grade SIL.
                             06 = Squamous Cell Cancer.
                             07 = Other malignant neoplasms with normal glandular cells.
                             12 = Recent abnormal Pap test result




 Case Management Care        Enter the appropriate code as follows:
 Plan (O)                    1 = Yes, 2 = No
                             NOTE: This field is required only if CMN Assessment is “Yes”


 Comments                    Memo field (any special situation with the client’s screening or follow up that you want to
                             communicate with the case manager; up to 30 characters).




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BCCCP CERVICAL CANCER SCREENING AND FOLLOW-UP DATA ENTRY FORM (screen 31)                                                                                   Revised 1-Nov.-02
1.NAME                                                           2.ID                                                      3.VISIT DATE


4.BCCCP CLIENT?               1=Yes                 2=No         5.LAST PAP ____/_____/_________
                                                                                 MM    DD        YYYY

SCREENING        PROCEDURE              PROC DATE                        CHARGED                     RESULT DATE                                  RESULT
                                                                            TO
                6.PELVIC
                                                                 8.1=Paid in full by                                         1=Normal exam; no follow-up required
                EXAM                   7.                                                   9.                               2=Abnormal exam; follow-up required
                                                                CCCP
                                                                                                                             8=Pelvic/rectal exam not indicated
                                                                 2=Paid by Non BCCCP                                         9=Pelvic/rectal indicated but not provided
                                       ___ /___ /__              funds
                                                                                            ___ /___ /___
                                       MM      DD    YYYY                                       MM   DD      YYYY
                                                                                                                             (i.e. re fused)
                                                                 3=Partially paid by
                                                                CCCP
                                                                                            SP        SP            Res.    Bethesda1991                           18.
                10.SYS. USED                                                                AD        Type          Date    00=Abnormal glandular cells (AGUS
                                            11. 1=1991,
                                                                                            15.       16.           17.     Adenocarcinoma)
                                                                                                                             01=Negative (within normal limits)
                                               2=2001                                                                        02=Infection
                                                                                                                             03=Atypical squamous cells of undetermined
                                                                                                                              significance (ASC-US)
                                                                                                                             04=LGSIL including HPV changes
                                                                                            1         1                      05=High grade SIL (HGSIL/HSIL)
                12.PAP TEST            13.                                                                                   06=Squamous cell cancer
                                                                 14.                                                         07=Other malignant neoplasms w/norm
                                                                                            2         2         _ /__/__     glandular cells
                                       __ /___ /____             1       2       3
                                                                                                                             08=Unsatisfactory
                                       MM      DD        YYYY     (see codes above)         3         3                      09=Not Indicated
                                                                                                                            10=Indicated, but not performed (i.e. refused)
                                                                                            4         4                     11=Result is pending
                                                                                                                            12=Recent, nonBCCCP,
                                                                                                                            abn Pap requiring follow-up
                                                                                                                            13=Recent, nonBCCCP Pap
                                                                                                                               with no follow-up required
                                                                                                                            Bethesda 2001
                                                                                                                            01=Negative (within normal limits)
                                                                                                                            02=Atypical squamous cells of undetermined
                                                                                                                                significance (ASC-US)
                                                                                                                            03=Low grade SIL including HPV changes
                                                                                                                            04=Atypical squamous cells (ASCUS) cannot
                                                                                                                            exclude HSIL (ASC-H)
                                                                                                                            05=High grade SIL (HSIL)
                                                                                                                            06=Squamous cell carcinoma
                                                                                                                            07=Abnormal glandular cells (including
                                                                                                                            Atypical, Endocervical adenocarcinoma in situ
                                                                                                                            And Adenocarcinoma)
                                                                                                                            08=Other malignant neoplasms
                                                                                                                            09=Not Indicated
                                                                                                                            10=Indicated, but not performed (i.e. refused)
                                                                                                                            11=Result is pending
                                                                                                                            12=Recent, nonBCCCP,
                                                                                                                            abn Pap requiring follow-up
                                                                                                                            13=Recent, nonBCCCP Pap
                                                                                                                              with no follow-up required

                REPEAT                                                                      1,        1, 2      _/__/___      00 01       02    03     04    05   06     07    08

                                                                                                      3, 4
                                                                                                               mm dd yy        11
                PAP TEST               ___ /___ /____            1       2       3
                                                                                            3,
                init. Pap must=8      M M DD         YYYY         (see codes above)

                                                                                                                                    (same as Pap Test codes 1-8 or 11 above)




PLAN            DX WORK-UP                                       SHORT-TERM                                                  NEXT SCREENING PAP SMEAR DUE IN
                PLANNED?                    1=Yes                FU REQUIRED?           1=Yes                                  2 3 4 5 6 12 24 MONTHS
                                            2=No                                        2=No

DX              COLPOSCOPY                    __ /__ /_
WORKUP                                       MM     DD     YY                                                               1=Normal and/or no biopsy performed
                                                                                                                            2=Biopsy was performed with the colposcopy
                                                                 1       2       3          ___ /___ /_______
                                                                  (see codes above)             MM   DD        YYYY
                CERVICAL
                BIOPSY                                                                                                      1=Normal exam benign reaction
                                                                                                                            2=HPV/Condylomata/Atypia
                                                                                                                            3=CIN I

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                                                         1       2       3                                      4=CIN II
                                         __ /__ /_        (see codes above)              ___ /___ /_______      5=CIN III/Carcinoma in-situ (Stage=0)
                                       MM   DD     YY                                    MM   DD     YYYY
                                                                                                                6=Invasive cervical carcinoma
                                                                                                                7=Invasive adenocarcinoma
                                                                                                                8=Other (non-cervical) cancer
                                                                                                                (a biopsy result of 4-7 above MUST have Tx
                                                                                                             nformation completed)



BCCCP CERVICAL CANCER SCREENING AND FOLLOW-UP DATA ENTRY FORM (page 2)                                                                      Revised 1-Oct-02
NAME                                                     ID                                                  VISIT DATE

DIAGNOSIS      DX DISP                                   DX DISP DATE                    Comments:
               1=No cervical cancer;case closed
               2=Dx Workup/results are pending
               3=Patient Died
               4=Moved out of county/state
               5=Unable to obtain results                ___ /___ /_______
               6=Pt non-responsive/refuses FU             MM   DD      YYYY
               7=Cervical cancer diagnosed
ADDITIONAL     STAGE
DX INFO        0=Stage 0 (cervical carcinoma in-situ)
               1=Stage I
               2=Stage II
               3=Stage III
               4=Stage IV
               5=Stage Unknown/Unstaged
               6=Summary Local
               7=Summary Regional
               8=Summary Distant
               TX DISP                                                                                        TX INITIATED DATE
TREATMENT      0=Tx not needed
INFO           1=Tx Initiated                     4=Moved out of county or state
               2=Tx Pending                       5=Unable to obtain results from provider
               3=Patient Died                      6=Non-responsive/refused
                                                                                                              ___ /___ /_______
                                                                                                              MM   DD     YYYY
CASE   MGMT.   CMN ASSESS: 1=Yes ;                                                                            CMC PLAN: 1=YES;
                           2= No                                                                                        2=NO




                                                        Page 2 of 2
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         HSIS Administrators (see HSIS Privacy Administrator Guidelines) use the “60. Setup User Access”
         function to grant HSIS access to users. The Setup User Access function is only available to HSIS
         Administrators and other HSIS support staff (e.g. Help Desk).

         The function was added to HSIS to help users administer HIPAA Privacy Rule requirements. Specifically,
         the function relates to compliance with the Minimum Necessary standard, which restricts the use and
         disclosure of an individual’s health information (referred to as PHI – Protected Health Information).

         The HSIS Administrator uses the setup function to grant users access to screens and reports. Access to PHI
         should only be given to users who need access to PHI to do their job, as determined by the Privacy Official.
         As outlined in the HIPAA Privacy Rule, it is the responsibility of the Privacy Official to develop and
         implement the policies and procedures that protect the use and disclosure of PHI.

         The Setup User Access function is a series of three screens:
         Application Access Control – Screen One
         Application Access Control – Screen Two
         User Access Profile – List Screen

         The following guidelines include a screen print for each of the three screens following by an explanation
         for each data field. The USE code for each data field is as follows:
         R – Required
         O – Optional
         N – N/A
                                        Application Access Control – Screen One

         Identifies the user, indicates the county/site to which the user is assigned and indicates the Authorization
         Levels granted. With Screen One displayed, press ENTER to display Screen Two. In DELETE mode,
         once you Press ENTER, the delete occurs and there is no transfer to Screen Two.

         HSA600A         NORTH CAROLINA HEALTH SERVICES INFORMATION SYSTEM
                                   APPLICATION ACCESS CONTROL

         NEXT RECORD: COUNTY ___ SCREEN: __ ID:                DATE:         ACTION: __
         MESSAGE:
         USERID: _________ NAME: LAST ____________________ FIRST _______________ MI _
         PHONE: (    ) ___ - ____      EXT ____
         MAKE ACCESS PROFILE LIKE USERID: ________ LAST NAME: _____________________
         COUNTY: ___          COUNTY OVERRIDE: __      EMERGENCY OVERRIDE: _
         HSIS SITE: ______ XXXXXXXXXXXXXXXXXXXX
         AUTH LEVEL __            SYSTEM IDENT: HSIS _ WIC _ DEC _ NCIR _ NCSLPH _
         WIC PROGRAM: ___        WIC SITE: __
         PRINTER ID: ________



         FIELD                       USE      EXPLANATION
         SCREEN                        R      Enter ‘60’
         ID                            R      Enter the RACF ID of the user for whom access is being added, inquired,
                                              changed or deleted.




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         FIELD               USE   EXPLANATION


         DATE                N     Not applicable
         ACTION              R     Enter A, I, C or D
                                   A = add
                                   I = inquiry
                                   C = change
                                   D = delete
         USERID
                             N     Displays the RACF ID of the user being displayed – can not be changed.
         LAST
                             R     Enter user’s last name
         FIRST               R     Enter user’s first name
         MI                  O     Enter user’s middle initial
         PHONE               R     Enter user’s phone number
         EXT                 O     Enter user’s phone number extension, if applicable
         MAKE ACCESS         O     An optional cloning feature that allows a new user to be added with
         PROFILE LIKE              accesses like a current user (handy for adding/changing multiple people in
                                   same/similar roles). When MAKE LIKE is used the remaining fields on
                                   Screen One are populated with the values from the user being cloned. The
                                   populated fields can be changed with the exception of the SYSTEM IDENT
                                   programs. COUNTY and/or SITE can be changed within the guidelines
                                   listed below.
         MAKE LIKE: USERID   O     Enter the RACF ID of the user you wish to clone. An error message will
                                   display if the ID is not valid.
         MAKE LIKE: LAST     O     If the MAKE LIKE feature is used the LAST NAME of the user being
         NAME                      cloned must be entered and it must match the user’s LAST NAME on the
                                   HSIS database. If not, an error message is displayed. This is a safety check
                                   to verify that the intended RACF ID was entered.
         COUNTY              N     Displays the user’s “home” COUNTY
                                   •   ADD – defaults to “home” County of the HSIS Administrator
                                   •   CHANGE –value must equal County code in the HSIS SITE (see
                                       below)
         COUNTY OVERRIDE     O     Allows the user to access records from counties other than their “home”
                                   county. Valid values:
                                   • Blank – user can only access records for his/her “home county”
                                   • “D” = District Override – user can access records in any County within
                                       a District
                                            Can only be granted to users in a District
                                            HSIS Administrator must have District Override status in order to
                                            grant it
                                   • “S” = Statewide Override – user can access records in any County in
                                       the State
                                            Only granted to DPH Program Managers and support staff who
                                            have statewide responsibility
                                             HSIS Administrator must have Statewide Override status in order
                                            to grant it
         EMERGENCY           O     Y or N – Grants special security rights to support staff. Only certain
         OVERRIDE                  support staff can grant Emergency Override status




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         FIELD             USE   EXPLANATION


         HSIS SITE         R     Displays the user’s “home” Site. The first three positions of SITE is the
                                 COUNTY code. Changes to the SITE County must correspond to
                                 COUNTY code (see above)
                                 •   ADD – displays the Site for which the HSIS Administrator is signed on
                                 •   CHANGE – restricted by the HSIS Administrator’s COUNTY
                                     OVERRIDE (see above) value as outlined below:
                                          Blank – can be changed to another valid SITE in the COUNTY
                                          D – District Override – can be changed to another valid SITE in
                                          the District
                                          S – State Override – can be changed to another valid SITE
                                          anywhere in the State
         AUTH LEVEL        R     Identifies the user’s administration authorization level:
                                 •   Blank – no administration authorization (typical user)
                                 •   A – HSIS Administrator
                                          authorized to grant Access Levels for users in his/her County or
                                          District
                                          can not grant AUTH LEVELs
                                 •   P – Programmers who support the HSIS system (authorization is
                                     intended for support use only)
                                          authorized to grant Access Levels for all users
                                          can grant all authorization levels
                                 •   S – Help Desk and Technical HSIS Support staff (authorization is
                                     intended for support use only)
                                          authorized to grant Access Levels for all users except
                                          Programmers
                                          can grant A and S authorization levels
         SYSTEM IDENT:     R     There are five sets of screens/reports for business programs (listed below) to
                                 which a user may be granted access. Enter ‘Y’ to grant access. Enter ‘N’ or
                                 leave blank to deny access. A HSIS Administrator can only grant access to
                                 programs to which he/she has access. A user with access to NCSLPH can
                                 not be granted access to any other program.
                                 HSIS – typically for local health department use
                                 WIC – Women and Infant Children
                                 DEC – Developmental Evaluation Center
                                 NCIR – N C Immunization Registry
                                 NCSLPH – N C State Laboratory for Public Health
         WIC PROGRAM       O     Valid WIC Program required if WIC access is granted (see SYSTEM
                                 IDENT above) else should be blank
         WIC SITE          O     Valid WIC Site required if WIC access is granted (see SYSTEM IDENT
                                 above) else should be blank
         PRINTER ID        O     Entry value must be a valid network printer ID




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                                         Application Access Control – Screen Two

         Access to Screen Two is gained by pressing ENTER with Screen One displayed with no data edit errors.
         This screen identifies the various Menu Options and Access Levels. The first data field identifies the
         Access Level (see below) to which the user has for that specific Menu Option. The displayed access
         options and menu levels vary depending on the type of transaction (e.g. ADD) as outlined below.


         HSA600B         NORTH CAROLINA HEALTH SERVICES INFORMATION SYSTEM
         03/18/03            APPLICATION ACCESS CONTROL

         NEXT RECORD: COUNTY: SCREEN: 60 ID:              DATE:     ACTION: C
         MESSAGE: 017 ENTER CHANGES AND THEN PRESS "ENTER"
               SCREEN ACCESS OPTIONS - RED INDICATES SCREENS WITH PHI
         I 00. ALPHA NAME SEARCH                I 63. SETUP SERVICE GROUP
         D 01. PATIENT MASTER                   I 64. SETUP CPT RATES
         I 02. PATIENT FINANCIAL                D 65. ENCOUNTER AND SERVICES
         I 03. PATIENT INSURANCE                D 66. RISK FACTORS
         I 04. PATIENT ADDRESSES                D 67. MED & LAB SERVICES
         D 07. CHILD SERVICE COORDINATION       D 68. BILLING INQUIRY/BILLING ONLY
         D 09. PREGNANCY OUTCOME                D 69. COMPANY SERVICE BILLING
         D 12. PAYMENTS/ADJUSTMENTS             D 70. DENTAL ENCOUNTER & SERVICES
         I 14. INSURANCE/CONTRACTS              I 87. VIEW NOTIFICATION MESSAGE
         I 18. APPOINTMENT FUNCTIONS            I 89. SLIDING FEE SCALE
         I 19. REPORTS PROCESSING               I 95. MEDICAID ELIGIBILITY INQUIRY
         I     HCA120 BREAST & CERVICAL RPT
         I     BILLING REPORTS
         I 28. FORMS ALIGNMENT
         D 30. BREAST CANCER FOLLOW-UP
         D 31. CERVICAL CANCER FOLLOW-UP
         I 40. IMMUNIZATION REGISTRY
         I 61. SETUP STAFF PROVIDER

         ACCESS LEVELS

         •   Valid Access Levels – Access to the various Menu Options will be granted by assigning one of the
             following Access Levels:
                   N – no access
                   I – inquiry only
                   U – inquiry, add or change
                   D – inquiry, add, change or delete
         •   Assigning Access Level
                   Privacy Safeguards – HSIS and NCSLPH users have HIPAA Privacy Rule Access Level
                   considerations (see HSIS Privacy Administrator Guidelines for more detail). When adding a new
                   user, the default Access Level for a screen/report that contains PHI will be NO ACCESS. The
                   HSIS Administrator will grant access to these screens/reports only as authorized by the Privacy
                   Official.
                   Note – All HSIS Administrators should consider the role and HSIS experience level of the user
                   when granting Access Levels as outlined below:
                       UPDATE - Only trained users responsible for maintaining HSIS data
                       DELETE - Only experienced users in lead roles




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         MENU OPTIONS AND ACCESS LEVELS BASED ON TRANSACTION TYPE

         •   Add Transactions – All Menu Options available to the program area(s) and their default Access Levels
             will be displayed. The Menu Options vary depending on the business program(s) to which the user
             was granted access (see SYSTEM IDENT on the Screen One above). For example, a user granted
             access to both HSIS and WIC would have the Menu Options available from both programs.
         •   Inquiry/Delete - All Menu Options and Access Levels granted to the user will be displayed.
         •   Change - All Menu Options and Access Levels granted to the user are displayed. Any available Menu
             Options that the user was not granted access are displayed with a blank Access Level. The Access
             Level for any Menu Option displayed may be changed.
         •   Add/Change Transactions Using the Make Like Feature (see Screen One above) – For the RACF ID
             being cloned, Menu Options and Access Level are displayed as follows. Any Access Level can be
             changed before the new user is added/changed.
                   all granted Menu Options and Access Levels
                   any available Menu Option, to which access was not granted, is displayed with a blank Access
                   Level
         COMPLETING THE TRANSACTION

         Press ENTER to apply an ADD or CHANGE action or terminate the INQUIRY. Any updates will be
         applied and you will be transferred back to Screen One.




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                                               User Access Profiles – List Screen
         This is an inquiry-only screen that lists the users for which a HSIS Administrator is responsible for
         administering. The RACF IDs displayed depends on the various authorization levels of the HSIS
         Administrator according to the following table.

         HSA600C           NORTH CAROLINA HEALTH SERVICES INFORMATION SYSTEM
                                         USER ACCESS PROFILES

         NEXT RECORD: County ___ SCREEN: __ ID:                                     DATE:             ACTION: __
         MESSAGE:
                                                                                H
                                                                                S      D W   I   L
                                                            CNTY AUTH           I      E I   M   A
         USER ID        NAME                                OVR LEVEL           S      C C   M   B       PRINTER
         XXXXXXXX XXXXXXXXXXXXXXXXXXX                        N    X             X      X X   X   X       XXXXXXXX
         XXXXXXXX XXXXXXXXXXXXXXXXXXX                        N    X             X      X X   X   X       XXXXXXXX
         XXXXXXXX XXXXXXXXXXXXXXXXXXX                        N    X             X      X X   X   X       XXXXXXXX


         AUTH         COUNTY          SYSTEM                            User Records Displayed
         LEVEL       OVERRIDE          IDENT
           A           Blank            N/A         All users in the Sign-on County with AUTH LEVEL of ‘A’ or
                                                    blank
             A              D            N/A        All users in the Sign-on County with AUTH LEVEL of ‘A’ or
                                                    blank. District Administrators (County Override = ‘D’) can sign-
                                                    on to each County in their District to view the users in that
                                                    County.
             A              S            N/A        All users statewide with County Override of ‘S’ (statewide)
             A             N/A        NCSLPH        All users statewide with access to NCSLPH
             S             N/A           N/A        All users in the Sign-on County except those with AUTH
                                                    LEVEL of ‘P’
             P             N/A           N/A        All users in the Sign-on County.




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                                      HIPAA Privacy Rule
                      Health Service Information System (HSIS)
                          Privacy Administration Guidelines

                              Local Health Departments
                                         and
                   North Carolina State Laboratory for Public Health


    Prepared by:          Lou Cullipher

    Department:           North Carolina Department of Health and Human Services

    Division:             Division of Information Resource Management (DIRM)

    Submitted to:         Ann Nance, Liaison for Public Health

    Date:                 February 19, 2003

    Release Number:       1.0
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    1.      INTRODUCTION .........................................................................................................................3
    2.     ESTABLISHING A PRIVACY RULE COMPLIANT ORGANIZATION........................................3
         2.1 Privacy Official .....................................................................................................................................3
         2.2 HSIS Administrator ...............................................................................................................................3
            2.2.1       Requirement for HSIS Administrators.........................................................................3
            2.2.2       Designation Guidelines................................................................................................4
            2.2.3       Request HSIS Administrator Rights ............................................................................4
            2.2.4       HSIS Administrator Alternate(s) .................................................................................4
    3.     HSIS ADMINISTRATION DUTIES ..............................................................................................4
         3.1 New Employees – Request Network Access.........................................................................................5
         3.2 Privacy Official Authorizes HSIS-based PHI Access ...........................................................................5
            3.2.1       Determine the Need for HSIS-based PHI access.........................................................5
            3.2.2       Document Required Access.........................................................................................5
         3.3      Granting HSIS Access Control..............................................................................................................5
         3.4      Terminated Employees..........................................................................................................................6
         3.5      Resetting RACF ID ...............................................................................................................................6
    4.      EMERGENCY HSIS ADMINISTRATOR SUPPORT...................................................................6




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    1. INTRODUCTION
    The HSIS Privacy Administration Guidelines document provides an overview of HSIS
    administration duties, which were established to obtain compliance to the HIPAA Privacy Rule.
    Refer to the HIPAA Privacy Rule HSIS Impacts document for more background information.


    2. ESTABLISHING A PRIVACY RULE COMPLIANT
       ORGANIZATION

          2.1 Privacy Official
          The Privacy Rule (§ 164.530 (a)(1)) requires a covered entity to designate a privacy official
          who is responsible for the development and implementation of the policies and procedures
          of the entity.
           The senior executive for the covered entity (e.g. Local Health Department (LHD) Director)
          should designate the Privacy Official. To properly conduct their HSIS duties, the Privacy
          Official should:
          • Have a working knowledge of the Privacy Rule Minimum Necessary standards.
          • Be familiar with health care “best practices” for maintaining patient confidentially.
          • Understand the needs of the workforce to have access to HSIS-based Protected Health
            Information (PHI) in order to perform their duties.
          The Privacy Official is a covered entity internal position and the designation requires no
          Department of Health and Human Services (DHHS) coordination.


          2.2 HSIS Administrator
                   2.2.1 Requirement for HSIS Administrators
                   Access Control is the mechanism through which Minimum Necessary compliance will
                   be achieved. Access control means granting an HSIS user the right to access
                   specific screens and reports. Privacy Rule access control means granting each HSIS
                   user access only to the level of PHI he/she needs to do their job. In the perspective of
                   the Privacy Rule, the focus and responsibility of access control resides with the
                   covered entity (LHDs and NCSLPH). Therefore, HSIS now includes online tools to
                   grant access controls. Each LHD and the North Carolina State Laboratory for Public
                   Health (NCSLPH) will designate an HSIS administrator (designation guidelines and
                   duties follow) who will be responsible for granting access control to HSIS users within
                   their workforce.




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                   2.2.2 Designation Guidelines
                   The senior executive for the covered entity (e.g. LHD Director) should designate the
                   HSIS Administrator. The HSIS administrator may or may not be the same person as
                   the Privacy Official. To properly conduct their HSIS duties, the HSIS Administrator
                   should have:
                   • A working knowledge of the functions and processes in HSIS.
                   • A basic knowledge of the various HSIS menus and data screens and the ability to
                     navigate to a desired screen using menus, PF (program function) keys and “fast
                     path” options.

                   2.2.3 Request HSIS Administrator Rights
                   The HSIS administrator designation process requires coordination with the Customer
                   Support Center of the DIRM Computer Services Section (commonly referred to as
                   the Help Desk). The Help Desk will grant the designee HSIS Administrator rights.
                   Complete the attached form “Request for HSIS Administrator Rights” and fax to the
                   Help Desk (fax number is on the form).
                   Once the HSIS Administrator rights are granted, the designated individual will have
                   access to special menu options not available to other users. These menu options will
                   permit the HSIS Administrator to grant access control rights to HSIS screens and
                   reports. See the guidelines for menu option ”60 Setup User Access” in the HSIS
                   User’s Manual for detailed instructions.

                   2.2.4 HSIS Administrator Alternate(s)
                   The designating senior executive for the covered entity (e.g. LHD Director) is
                   encouraged to designate at least one alternate who will perform the HSIS
                   Administrator duties in the absence of the primary designee. In the case of a large
                   workforce with multiple qualified candidates, the designator may chose to designate
                   two alternates.
                   The alternate(s), like the primary HSIS Administrator, must be granted rights via the
                   attached “Request for HSIS Administrator Rights” form.


    3. HSIS ADMINISTRATION DUTIES
    The following HSIS Administration functions are required. A single person or multiple people
    can perform these functions. It is expected that the senior executive for each covered entity that
    uses HSIS (e.g. LHD Director) would assign these duties, as they deem appropriate. The
    initiation of these functions are typically activated by employee status changes as outlined
    below:




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          3.1 New Employees – Request Network Access
          The Help Desk permits users to access the HSIS system by granting them a RACF
          identification (RACF is the mainframe security software). To obtain network access for new
          employees, the HSIS Administrator completes the attached form, “Request for RACF ID”
          and faxes it to the Help Desk at (919) 715-8864. Both the user and the HSIS Administrator
          must sign the request form. The Help Desk will convey the new RACF ID and password to
          the HSIS Administrator by telephone (passwords will not be transmitted via voice mail) or e-
          mail. The HSIS Administrator will convey the RACF ID to the new employee and remind
          him/her of the importance of maintaining the confidentially of the RACF ID.


          3.2 Privacy Official Authorizes HSIS-based PHI Access
          The Privacy Official must authorize employee access to screens and reports containing
          PHI.

                   3.2.1 Determine the Need for HSIS-based PHI access
                   When a new employee is hired or a current employee is assigned new duties,
                   determine to which HSIS screens and reports the employee requires access in order
                   to perform her/his duties. Give specific consideration to providing access to screens
                   and reports that contain PHI. Confirm that the employee’s duties require access to
                   the level of PHI being granted per the Privacy Rule Minimum Necessary compliance
                   standard.

                   3.2.2 Document Required Access
                   The attached form, “Authorize Access to HSIS Screens and Reports” identifies the
                   screens and reports that contain PHI (there is a form for LHDs and another for
                   NCSLPH. Complete the form to document the Privacy Rule Minimum Necessary
                   decisions. The HSIS Administrator may be a different person than the Privacy
                   Official, if so, the completed form can be forwarded to the administrator as
                   authorization to establish the indicated accesses.
                   Note – When the Help Desk initially authorizes the HSIS Administrator, he/she will
                   only have default level access to the various HSIS menu options which may be less
                   access than they had before. The Privacy Official should authorize the HSIS
                   Administrator’s access to PHI just as he/she would any other new employee. The
                   HSIS Administrator will update his/her access levels as authorized by the Privacy
                   Official.


          3.3 Granting HSIS Access Control
          The HSIS Administrator shall grant access control for each user to the necessary screens
          and reports as approved by the Privacy Official (see paragraph 3.2 above). The process of
          granting access control will be performed using new HSIS screens and functionality



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          specifically developed to obtain HIPAA Privacy Rule compliance. See the “HSIS Users
          Guide” menu option “60 Setup User Access” for detailed instructions.


          3.4 Terminated Employees
          The HSIS Administrator shall take prompt action to process terminated employees as
          follows:
          •    Delete the employees access to HSIS.
          •    Notify the Help Desk to delete the employees RACF ID (e-mail
               DHHS.Customer.Support.Center@ncmail.net or call 919-855-3200, option #2).


          3.5 Resetting RACF ID
          The HSIS Administrator will be authorized to reset RACF IDs using a software product
          called ERIC (Enterprise Research, Inc). See the “HSIS User’s Manual” for detailed
          instructions.


    4. EMERGENCY HSIS ADMINISTRATOR SUPPORT
          The DHHS Customer Support Center (Help Desk) will provide emergency support when
          both the primary and alternate HSIS Administrators are not available. This should be a
          very infrequent exception. To obtain emergency HSIS Administrator support e-mail
          DHHS.Customer.Support.Center@ncmail.net or call (919) 855-3200, option #2 for
          assistance.




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Page 141 of 208                   Department of Health & Human Services
                               Division of Information Resource Management
                                      DHHS Customer Support Center
                                 Health Services Information System (HSIS)
                                       Request for HSIS Administrator Rights

    √ Administrator Action                 Add Rights                 Delete Rights

    Organization Name                                                                               Date

    HSIS County/Site Number                                  County Override Code

    √ for Program Access:              HSIS         NCIR          NCSLPH

        Primary Administrator              RACF ID                                   Effective Date              /      /

    Name                                                                Security Keyword

    Printer ID                          E-mail Address

    Phone Number           (       )           -                       Fax Number (             )            -

    Alternate Administrator                 RACF ID                                  Effective Date              /      /

    Name                                                                Security Keyword

    Printer ID                          E-mail Address

    Phone Number           (       )           -                       Fax Number (             )            -

    Organization Authorization                Print Name

    Signature                                                          Title

    Phone Number           (       )           -                       Fax Number (             )            -

    E-mail Address

    Instructions:
    •     Organization is the County or District Health Department or NCSLPH (NC State Laboratory for Public Health)
    •     County Override – Enter a “D” if the organization is a District (gives HSIS Administrator access to all counties in
          the District). Else, leave blank.
    •     HSIS Administrator should be given access to HSIS and NCIR (if applicable). Access to NCSLPH can not be
          combined with any other program.
    •     The Security Keyword (limit of 20 characters) will be used to confirm identity when the HSIS Administrator makes
          a security support call to the help desk (i.e. the administrator will be asked to state his/her security keyword).
          Use a keyword that is easy to remember but typically not known by others, such as mother’s maiden name. Do
          not use words that coworkers would typically know, such as the name of a spouse, child or pet.
    •     The senior executive for the HSIS user organization, or his/her designee, should authorize the “Request for HSIS
          Administrator Rights”.

    •     Complete and fax the “Request for HSIS Administrator Rights” to the DHHS Customer Support Center at               (919)
          715-8864. After the request is processed, the Support Center staff member will confirm the action to the
          authorizer via e-mail or phone.

             For Customer Support Center use only: Date __________ CSC # __________ Closed By __________

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                        Department of Health & Human Services
                      Division of Information Resource Management
                             DHHS Customer Support Center
                       Health Services Information System (HSIS)

                                      Request for RACF ID
    Please complete and fax to DHHS Customer Support Center at (919) 715-8864. If you have any
    questions, call (919) 855-3200, option #2.


                                     FOR OFFICE USE ONLY

                      RACF ID ASSIGNED: __________________________

                                   DATE: __________________________



    NAME: ______________________________________________________________
                 (First name, middle initial, last name)

    POSITION:         ______________________________________________________________

    PRINTER NODE: _______________ BILL CODE: _____________SITE NO:__________

    AGENCY:           _____________________________________________________________

    SECTION:          _____________________________________________________________

    LOCATION ADDRESS: _____________________________________________________

    PHONE NUMBER: ____________________ FAX NUMBER: _____________________


    I will not release my RACF ID and password to anyone nor will I sign-on and allow anyone to use my
    workstation to access or alter information in HSIS.

    _______________________________________________________________________
    USER SIGNATURE                                                   DATE


    I authorize the assignment of the above requested RACF ID for access to HSIS.

    _______________________________________________________________________
    HSIS ADMINISTRATOR SIGNATURE                                 DATE




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Page 143 of 208                        Department of Health & Human Services
                                     Division of Information Resource Management
                                            DHHS Customer Support Center
                                      Health Services Information System (HSIS)
                                      Authorize Access to HSIS Screens and Reports

                                                   Local Health Departments
                                                                                                   Access Level
                  Grant
                                                                                                      Defaults
               Access Level                         Menu Option                             PHI
                                                                                                  HSIS NCIR
                                 00 PATIENT ALPHA SEARCH                                            I         I
                                 01 PATIENT MASTER                                                  I         I
                                 02 PATIENT FINANCIAL                                               I
                                 03 PATIENT INSURANCE                                               I
                                 04 PATIENT ADDRESS                                                 I         I
                                 07 CHILD SERVICE COORDINATION                              X      N
                                 09 PREGNANCY OUTCOME                                       X      N
                                 12 PAYMENTS AND ADJUSTMENTS                                X      N
                                 13 DEC SUPPLEMENTAL
                                 14 INSURANCE CONTRACTS                                             I
                                 16 INFANT TODDLER
                                 18 APPOINTMENT FUNCTIONS                                          I
                                 19 REPORTS PROCESSING                                             I
                                     HCA120 BREAST & CERVICAL CANCER                        X      N
                                     BILLING REPORTS                                        X      N
                                 20 WIC CERTIFICATION
                                 21 WIC ISSUANCE/NUTRI. EDU.
                                 22 WIC MESSAGES AND COMMENTS
                                 23 WIC NOTICE HISTORY
                                 24 WIC SUMMARY PAGE PRINT
                                 25 WIC HISTORY
                                 26 WIC SPECIAL SITE MENU
                                 28 FORMS ALIGNMENT                                                I
                                 30 BREAST CANCER FOLLOW-UP                                 X      N
                                 31 CERVICAL CANCER FOLLOW-UP                               X      N
                                 32 DEC CLIENT HISTORY OF SERVICES
                                 40 IMMUNIZATION REGISTRY                                                  I
                                 51 WIC STATISTICAL REPORTS
                                 52 FARMERS MARKET ISSUANCE
                                 53 WIC STATE FUNDED ISSUANCE
                                 54 BLOOD LEAD LEVEL INQUIRY
                                 55 VENDOR VOUCHER REPLACEMENT
                                 60 SETUP USER ACCESS                                       HSIS Administrator
                                 61 SETUP STAFF PROVIDER                                          I
                                 63 SETUP SERVICE GROUP                                           I
                                 64 SETUP CPT RATES                                               I
                                 65 SERVICES SCREEN                                         X     N
                                 66 RISK FACTORS                                            X     N
                                 67 MED & LAB SERVICES                                      X     N
                                 68 ACCTS RECEIVABLE INQ/BILLING                            X     N
                                 69 COMPANY SERVICE BILLING                                 X     N
                                 70 DENTAL ENCOUNTER & SERVICES                             X     N
                                 87 VIEW NOTIFICATION MESSAGE                                     I
                                 89 SLIDING SCALE                                                 I
                                 95 MEDICAID ELIGIBILITY                                          I
   Access Levels: N = None           I = Inquiry     U = Inquiry, add and change       D = Inquiry, add, change and delete
                    Shaded block indicates menu option is not available for that program.

  Issued 04/28/03                                         Page 9 of 10
                                           Privacy Administration Guidelines                                          S210
v1.13 10/22/2008
                                      Department of Health & Human Services
Page 144 of 208                     Division of Information Resource Management
                                           DHHS Customer Support Center
                                     Health Services Information System (HSIS)
                                     Authorize Access to HSIS Screens and Reports

                                  North Carolina State Laboratory for Public Health
                     Grant                       Menu Option                                PHI     NCSLPH
                                  00 PATIENT ALPHA SEARCH                                              I
                                  01 PATIENT MASTER                                                    I
                                  02 PATIENT FINANCIAL
                                  03 PATIENT INSURANCE
                                  04 PATIENT ADDRESS
                                  07 CHILD SERVICE COORDINATION                              X
                                  09 PREGNANCY OUTCOME                                       X
                                  12 PAYMENTS AND ADJUSTMENTS                                X
                                  13 DEC SUPPLEMENTAL
                                  14 INSURANCE CONTRACTS
                                  16 INFANT TODDLER
                                  18 APPOINTMENT FUNCTIONS
                                  19 REPORTS PROCESSING
                                      HCA120 BREAST & CERVICAL CANCER                        X
                                      BILLING REPORTS                                        X
                                  20 WIC CERTIFICATION
                                  21 WIC ISSUANCE/NUTRI. EDU.
                                  22 WIC MESSAGES AND COMMENTS
                                  23 WIC NOTICE HISTORY
                                  24 WIC SUMMARY PAGE PRINT
                                  25 WIC HISTORY
                                  26 WIC SPECIAL SITE MENU
                                  28 FORMS ALIGNMENT
                                  30 BREAST CANCER FOLLOW-UP                                 X
                                  31 CERVICAL CANCER FOLLOW-UP                               X
                                  32 DEC CLIENT HISTORY OF SERVICES
                                  40 IMMUNIZATION REGISTRY
                                  51 WIC STATISTICAL REPORTS
                                  52 FARMERS MARKET ISSUANCE
                                  53 WIC STATE FUNDED ISSUANCE
                                  54 BLOOD LEAD LEVEL INQUIRY
                                  55 VENDOR VOUCHER REPLACEMENT
                                  60 SETUP USER ACCESS
                                  61 SETUP STAFF PROVIDER
                                  63 SETUP SERVICE GROUP
                                  64 SETUP CPT RATES                                                     I
                                  65 SERVICES SCREEN                                         X
                                  66 RISK FACTORS                                            X
                                  67 MED & LAB SERVICES                                      X
                                  68 ACCTS RECEIVABLE INQ/BILLING                            X
                                  69 COMPANY SERVICE BILLING                                 X
                                  70 DENTAL ENCOUNTER & SERVICES                             X
                                  87 VIEW NOTIFICATION MESSAGE
                                  89 SLIDING SCALE
                                  95 MEDICAID ELIGIBILITY                                                I
   Access Levels: N = None          I = Inquiry    U = Inquiry, add and change         D = Inquiry, add, change and delete
                    Shaded block indicates menu option is not available for that program.
  Default Access Level Hierarchy – Certain menu options are available to multiple programs. The hierarchy of
  assigning the default access level is set by program as listed above from left to right. For example, if a user has access
  to both HSIS and WIC, any common screens will have the HSIS default access level.

  Issued 04/28/03                                       Page 10 of 10
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                                               THE CORRECT WAY TO
                                                ENTER AN ADDRESS



                                                        JOHN DOE
                                                    125 N BLVD Apt 25
                                                       P O BOX 525
                                                   RALEIGH NC 23456



                                                   (The perfect address)




    The correct way to enter an address is shown above. Addresses should be entered as follows:

    1). Replace periods, commas, or hyphens with spaces
    2). Include apartment numbers when possible

    The above steps will provide all users with a consistent method when using the address field.




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                                          APPOINTMENT PRINT FUNCTIONS


    The Appointment Print Function (04) allows the user to print from the following selections:

    • Pending appointment letters for specific date(s)
    • Missed appointment letters for specific date(s)
    • Appointment list for specific date(s)
    • Missed appointment list for specific date(s)
    • Print clinic profiles



    HSA183A        NORTH CAROLINA HEALTH SERVICES INFORMATION SYSTEM                              09101
                     APPOINTMENT REPORT REQUEST      BILLCODE: xxx

    NEXT SCREEN: 04 NEXT ID:      CLINIC:   DATE:      ACTION: I
    MESSAGE: PLEASE ENTER PRINT SELECTION(S), OR NEXT KEY
      MSGCLASS: 0 COUNTY: 091 BILLCODE: xxx      REGION: P

               ENTER 'X' FOR APPROPRIATE REPORT SELECTION(S)

               _ PENDING APPOINTMENT CARDS _ LETTERS FOR SPECIFIC DATE(S)
               _ MISSED APPOINTMENT LETTERS FOR SPECIFIC DATE(S)
               _ APPOINTMENT LIST FOR SPECIFIC DATE(S)
               _ MISSED APPOINTMENT LIST FOR SPECIFIC DATE(S)
               _ APPOINTMENT STATISTICS FOR SPECIFIC DATE(S)
               _ PRINT CLINIC PROFILES

               ENTER - CLINIC:     (WILDCARD IS '?' - EX. FP??)
                  LOCATION:      (WILDCARD IS '?')
                 FROM DATE:       (MMDDYY FORMAT)
                 THRU DATE:       (MMDDYY FORMAT)
                  PRINTER: NAAP4002 (DEFAULT PRINTER)
                  TEXT ID:     (FOR CLIENT NOTICES)
                   CLASS: A
                   COPIES: 1



    FIELD                                                 EXPLANATION

    SCREEN (R)                                            Enter '04'

    NEXT ID                                               No entry required.

    CLINIC                                                No entry required.

    DATE                                                  No entry required.

    ACTION                                                No entry required.

    REPORT SELECTIONS                                     Enter an 'X' for report selection(s).



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PageFIELD                     EXPLANATION

    CLINIC (R)                Enter the 4-position clinic code you wish to print. All '????'
                              will print all clinic selections indicated.

    LOCATION (R)              Enter the 2-digit location code for the appointments you want to
                              print.

                              Example:
                              01 = Main Health Dept.
                              02 = Secondary Health Dept.
                              03 = WIC Satellite at FireDepartment
                              All '??' will print notices for all locations defined in the Return
                              Address file.

    FROM DATE (R)             Enter the beginning clinic date. (MMDDYY)

    THRU DATE (R)             Enter the ending clinic date. (MMDDYY)

                              NOTE: If printing a clinic for one day, the from
                              Date & thru Date will be the same.

    PRINTER (R)               No operator entry required.
                              The default printer number appears automatically. If changed,
                              must be a valid printer number.

    TEXT ID (O)               Not used at this time.

    CLASS (R)                 No operator entry required.
                              Defaulted to H. If changed, must be E.

                              CLASS H = Used for production.
                              • Can run at this time
                              • May run for more than 45 seconds.
                              • May print more than 2500 lines.

                              CLASS E = Used for production.
                              • Runs at night
                              • Unlimited time
                              • Unlimited lines

    COPIES (R)                No operator entry required.
                              Default is '1' if changed, must be numeric




    Revised 08/08/05         Page 3 of 15
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                                         CLIENT APPOINTMENT OPTION 01

    The Client Appointment selection (01) allows the user to set up valid appointment slots for clinics. This must be done
    after the Clinic Profiles have been entered.


    HSA181A/184A        NORTH CAROLINA HSIS - APPOINTMENT (ADD)

    NEXT SCREEN: 01 NEXT ID:                CLINIC:       DATE:         ACTION:
    MESSAGE:

             RETURN ADDRESS LOCATION: DAY:                              OVERBOOK:
    CLIENT NAME:
    COUNTY:    CLINIC CODE:  DESCRIPTION:

    STAFF:                       WEEKS:            DAYS:



     ADD ID                                 TO TIME SLOT                                  MAIL:                    NOTE:



    FIELD                                                 EXPLANATION

    SCREEN (R)                                            Enter "01"

    NEXT ID (R)                                           Enter client ID number

    CLINIC (R)                                            Enter 4 digit clinic code

    DATE (R)                                              Enter date you wish to schedule the client. If a date is entered
                                                          for a holiday or exception date, then the system automatically
                                                          goes to the next available date.

    ACTION (R)                                            Enter A, D, or B
                                                          A = ADD
                                                          B = BROWSE: Displays all appointments for a client. Clinic
                                                              code and date is not required for browse mode.
                                                          D = DELETE: Deletes a client appointment. Enter sequence
                                                               number of appointment at the bottom of     the screen
                                                               to be deleted..

    ADD ID (R)                                            No operator entry required. The client ID number is brought
                                                          forward from the ID field on the fast-path line.

    NOTE: This field can also be used to BLOCK TIME SLOTS on a given clinic date, however, if the Clinic
     Profile has a “y” in Overbook, which will override the block. In order to BLOCK ALL appointments for a
    specific time slot, type the word BLOCK over the ID number, space out the remaining number, then enter the
    time slot number you wish to block. No appointments can be entered for the time slots that have been blocked.

    To block a specific number of appointments within a given time slot, enter the number of appointments you
    wish to block For example: If you have 3 appointments scheduled for 8:00 a.m. and you wish o block 2 of these
    appointments, type BLOCK02 over the ID number and space out the remaining numbers, then enter the time
    slot 01. Slot 01 will now only allow for one appointment to be scheduled for 8:00 a.m.


    Revised 08/08/05                                     Page 4 of 15
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PageFIELD                                             EXPLANATION

    RETURN ADDRESS LOCATION (R)                       Defaults to 01. If changed, must be a location number
                                                      entered on the Return Address Screen.

    TIME SLOT (R)                                     Enter the time slot number that corresponds with the time you
    ish to schedule the clients appointment.

    MAIL (R)                                          Enter Y or N
                                                      Y = The client wishes to receive mail from the clinic.
                                                      N = The client does not want to receive mail from the clinic.

    NOTE (O)                                          Field may be used for any short note which will be
                                                      printed on the appointment notices.

    DATE                                              Pressing the F9 key will take you to the next available date for
                                                      entering appointments within a given clinic.

                                                      NOTE: FOR WIC CLINICS ONLY - Press F10 to go to
                                                      the next available clinic for entering appointments.

    USE                                               No entry required.
                                                      This field displays         the    number      of   appointments
                                                      scheduled for a slot.

    OVERBOOK                                          If this field is "N", you may not enter more appointments than
                                                      the maximum showing. If you try to enter more than allowed,
                                                      an error will be displayed at the top of the screen. If this field
                                                      is "Y", then you may schedule more appointments than the
                                                      maximum selected.
                                                      ** Overbook will override appointment blocking.




    Revised 08/08/05                                 Page 5 of 15
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                                                   Clinic Profile option 07

    The Clinic Profile (07) denotes the types of clinics being scheduled. The clinics are scheduled by assigning a 4 position
    alphanumeric code. Each clinic must have a code assigned before they can be added to the system. The Clinic Profile
    shows no client appointments.

    HSA189C            NORTH CAROLINA HSIS - CLINIC PROFILE                     COUNTY: 012

    NEXT SCREEN: 07 NEXT ID:      CLINIC:    DATE:       ACTION: I
    MESSAGE: PF8 TO DISPLAY MORE CLINICS, OR ENTER NEXT KEY
                           FROM THRU FROM THRU
    CLINIC DESCRIPTION        WEEKS DAYS DATE DATE TIME TIME
    XXXX XXXXXXXXXX           12345   T     02/01/93 04/21/98 01:00P 02:30P
    ZZZZZ ZZZZZZZZZZZZ        12345   T     04/23/98 12/31/98 08:15A 04:00P



    FIELD                                                  EXPLANATION

    SCREEN (R)                                             Enter "07"

    NEXT ID                                                No entry required

    CLINIC (R)                                             Entry required.

    CLINIC PROFILE                                         Enter a 4- position alpha/numeric code for each type of clinic
                                                           to be defined.
                                                           Ex: CH01 = Newborn Screening
                                                                CH02 = EPSDT Screening
                                                                FP01 = Family Planning Annual
                                                                FP02 = Family Planning Norplant
                                                                WC11= WIC Certification

                                                           NOTE: ONLY WIC users should begin a Clinic code with a
                                                           "W". WIC users refer to Page 3 before assigning a clinic
                                                           code.

    DATE (R)                                               Enter the ending date for the date range you want to set up the
                                                           appointments.
                                                           Ex: To schedule a clinic for a 6- month range, from 01-05-93
                                                           thru 06-05-93, the ending date is 06-05-93.

    ACTION (R)                                             Enter A, C, D, I, or E
                                                           A = ADD
                                                           C = CHANGE
                                                           D = DELETE
                                                           I = INQUIRE
                                                           E = EXTEND
                                                           NOTE: To extend a clinic, enter the thru date of the original
                                                           clinic, then enter new valid from and thru dates.

    COUNTY (R)                                             The county number is brought forward from the appointment
                                                           selection menu screen.

    CLINIC CODE (R)                                        The clinic code is brought forward from the appointment selection
    menu screen.

    Revised 08/08/05                                      Page 6 of 15
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    DESCRIPTION (O)              If completed, enter the description of the clinic.



    FIELD                        EXPLANATION


    MAIL (R)                     Enter Y for clinic mail.

    WEEKS (R)                    Enter 1,2,3,4, or 5 for the number of weeks that the clinic will be
                                 scheduled.

    DAYS (R)                     Enter M,T,W,T,F,S, or S for the day(s) of the week the
                                 clinic will be scheduled.

    VALID FROM DATE (R)          Enter the beginning date for the date range you are using for
                                 this clinic profile.

    VALID THRU DATE (R)          The ending date is brought forward from the appointment
                                 selection menu.

    TIME FROM (R)                Enter the time that the clinic will begin.
                                    A = AM
                                    P= PM

    TIME THRU (R)                Enter the time that the clinic will be over.

                                    A = AM
                                    P= PM

    OVERBOOK (R)                 Y = OVERBOOKING PERMITTED
                                 If "Y", then overbook will override appointment blocking.

                                 N = OVERBOOKING NOT ALLOWED
                                 NOTE: Press the enter key for time slots

    SLOTS (R)                    Enter 2 digits in field. Enter max number of appointments to be
                                 scheduled for each time period.

    EXCEPTION DATES (O)          Enter the dates to be excluded from the above
                                 profile. The holidays you enter through the holiday
                                 profile will be automatically excluded.
                                 NOTE: Press the enter key again for the record to
                                 apply.




    Revised 08/08/05            Page 7 of 15
v1.13 10/22/2008
                                                  Appointment Functions                                                 S130
Page 152 of 208                                 CLINIC PROFILES FOR WIC


    The WIC staff and HSIS staff have agreed that all WIC clinic codes will start with the letter W and the letter W will not
    be used in the first position of the clinic code for clinics that are not WIC.

    The second position of the clinic code will be either P, N, or C. P is for a visit that is WIC pick up only, N is for a visit
    that includes nutrition education and pick up, and C is for a visit that includes certification, nutrition education, and pick
    up.

    The third position of the clinic code will be used to indicate the site. This usually will be a number from 1 to 9. If you
    want to deviate from this, you should consult the state WIC office. However, if you have only one site and you do not
    plan to use the fourth position of the clinic code, you may leave the third and fourth positions blank.

    The fourth position of the clinic code can be used to indicate the day of the week if you want to have different profiles for
    different days of the week for the same type of clinic. For example, if your schedule for doing certifications is different
    for each day of the week, you could use the clinic code WC11 for WIC certification at site 1 for Monday, WC12 for
    Tuesday, WC13 for Wednesday, WC14 for Thursday, and WC15 for Friday. If you use this approach, the system will
    treat all five of these clinic codes as though they represent the same type of clinic when you use the F9 key to move from
    one day to the next. In other words, if you are trying to schedule an appointment for WC11 on June 6 and find that the
    clinic is full, you can press the F9 key and the screen will display the schedule for June 7 for the clinic code WC12. If
    you press the F9 key again, the schedule for June 8 for clinic code WC13 will be displayed.

    When you are creating the clinic profile for a WIC clinic, if you have 1 in the fourth position of the clinic code, the
    computer will not let you include any days of the week besides Monday. Likewise, if the fourth position of the clinic
    code is 2, you cannot include any days of the week besides Tuesday. If you make the fourth position of the clinic code
    something other than a number 1 through 7, then you can include any days of the week you want to include, but in that
    case, the F9 key will only show you schedules for the specific clinic code you have indicated instead of including other
    clinic codes with the same first three positions.




    Revised 08/08/05                                        Page 8 of 15
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                                      APPOINTMENT RESCHEDULE OPTION # 02
    This selection allows the user to reschedule or cancel the client for a specific clinic.


    FIELD                                                   EXPLANATION

    SCREEN (R)                                              Enter '02'

    NEXT ID (R)                                             Enter client ID number

    CLINIC (R)                                              Enter 4 digit clinic code

    DATE (R)                                                Enter the date you have scheduled the client’s
                                                            appointment.

    ACTION (R)                                              Enter C
                                                            C = Cancel or rescheduling

    DATE (R)                                                Reschedule: Enter the new appointment date and
                                                            press enter.

                                                            Cancel: Enter '999999' to cancel appointment for
                                                            the client.




    Revised 08/08/05                                       Page 9 of 15
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Page 154 of 208
                                   CLIENT APPOINTMENT BLOCKING FUNCTION

    Blocking can be entered using the fast-path line on the client appointment module. The following method will allow the
    user to block all appointments for a specific time slot for a selected clinic:


    FIELD                                                    EXPLANATION

    NEXT SCREEN                                              Enter `01'

    NEXT ID                                                  Enter BLOCK

    CLINIC                                                   Enter the clinic name you wish to block.

    DATE                                                     Enter Date of Clinic you wish to block.

    ACTION                                                   Enter `A'

    Tab to the time slot field and enter the time slot number you wish to block. No appointments can be scheduled for the
    time slots that have been blocked if your Clinic profile has an `N' in the overbook field. If the Clinic profile has a `Y' in
    the overbook field, then overbook will override the blocking. To check blocks for selected clinic, enter the following on
    the fast-path line:


    NEXT SCREEN                                              Enter `01'

    NEXT ID                                                  Enter BLOCK

    CLINIC                                                   Enter clinic name for blocked appointments.

    DATE                                                     No date needed.

    ACTION                                                   Enter `B'


    All appointments blocked for different dates of the clinic will show on the screen.

    To block a specific number of appointments within a given time slot, please refer to page 2, add ID explanation.




    Revised 08/08/05                                        Page 10 of 15
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                                                Appointment Functions                                              S130
                                      APPOINTMENT HOLIDAY SCHEDULE OPTION 06


    The Holiday Schedule (06) allows the user to enter holidays for specific years. The system will automatically skip these
    dates when the Clinic Profile date range is entered. The user can display, then add or delete from the list of holidays.

    FIELD                                                  EXPLANATION
    SCREEN (R)                                             ENTER '06'

    NEXT ID                                                No Entry Required


    CLINIC                                                 No Entry Required

    DATE (R)                                               Enter last 2 digits of the year in which holidays are
                                                           to be scheduled in YY format.

                                                           Ex: Year = 00, 01, 02.
                                                           Holidays can be entered thru 2099.

    ACTION (R)                                             ENTER A, C, D, OR I
                                                           A = ADD
                                                           C = CHANGE
                                                           D = DELETE
                                                           I = INQUIRE

    MONTH AND DAY (R)                                      ENTER VALID MONTHS AND VALID DAYS
                                                           (MONTHS AND DAYS ARE NOT EDITED)

                                                           ENTER VALID MONTHS AND VALID DAYS
                                                           (MONTHS AND DAYS ARE NOT EDITED)

                                                           NOTE: Up to 15 holidays can be entered per calendar year.For
                                                                 example, enter 01 01 for January 1st.

                                                           THE YEAR IS PLUGGED AND CANNOT BE CHANGED.
                                                           IF KEYED INCORRECTLY, DELETE AND START OVER.




    Revised 08/08/05                                      Page 11 of 15
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                                                  Appointment Functions                                                S130

                                      CLIENT MISSED APPOINTMENT ENTRY 03


    The Client Missed Appointment entry selection allows the user to change or inquire on the status of the client's
    appointment.


    FIELD                                                    EXPLANATION

    SCREEN (R)                                               Enter '03'

    NEXT ID (R)                                              Enter client ID number

    CLINIC (R)                                               Enter 4 digit clinic code

    DATE (R)                                                 Enter the scheduled appointment date.

    ACTION (R)                                               Enter C or I
                                                             C = CHANGE MODE
                                                             I = INQUIRE

    STATUS (O)                                               If completed, must enter an 'M' for missed or 'R' to reschedule.

    RESCHEDULE TO-DATE (O)                                   If completed, enter date you wish to reschedule the client's
                                                             appointment.

    TIME (O)                                                 Enter new time if it changes for the rescheduled appointment date.



    NOTE: If an 'M' is entered on this screen and the client receives mail from the clinic, he will receive a 'missed
    appointment' letter reminding the client that they need to reschedule their appointment. If an 'R' is entered then the client
    will receive a new appointment notice.




    Revised 08/08/05                                        Page 12 of 15
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                                                 Appointment Functions                                               S130

                                                   RETURN ADDRESS 09

    The Return Address selection allows the user to enter the return address, which prints, on the patient notices (4x6 cards)
    such as appointment and missed appointment letters.

    FIELD                                                   EXPLANATION

    SCREEN (R)                                              Enter '09'

    NEXT ID                                                 No entry required

    CLINIC                                                  No entry required

    DATE                                                    No entry required

    ACTION (R)                                              Enter A, C, D, or I

                                                            A = ADD
                                                            C = CHANGE
                                                            D = DELETE
                                                            I = INQUIRE

    LOCATION (R)                                            Enter a 2 position numeric code for each location address
    where                                                          the patient will be receiving services.
                                                            EX: 01 = Main Health Dept. location
                                                            01 = Main DEC Site
                                                            02 = Secondary Health Dept. location
                                                            02 = DEC Satellite Office
                                                            03 = WIC Satellite at Fire Dept.

    DEPARTMENT NAME (R)                                     Entry required.
                                                            Enter department name.

    SUB-DEPT NAME (O)                                       No operator entry required.
                                                            If completed, enter the sub-department name.

    ADDRESS1 (R)                                            Entry required.
                                                            Enter department address.

    ADDRESS2 (O)                                            No operator entry required.

    CITY (R)                                                Entry required
                                                            Enter city.

    STATE (R)                                               No operator entry required.
                                                            Default is 'NC'.
                                                            If changed, enter 2-position state abbreviation.

    ZIP (R)                                                 Entry required.
                                                            Enter valid zip for health department.



    Revised 08/08/05                                       Page 13 of 15
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                          Appointment Functions                                 S130


    PRIMARY PHONE (O)            No operator entry required.
                                 May enter phone number of health department.

    ALTERNATE PHONE (O)          No operator entry required.

    EXT (O)                      No operator entry required.




    Revised 08/08/05            Page 14 of 15
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                                                Appointment Functions                                  S130
                                     VIEW APPOINTMENTS FOR A GIVEN DATE


    View Appointment selection (08) allows the user to review the daily clinic appointment schedule.


    FIELD                                                  EXPLANATION

    SCREEN (R)                                             Enter '08'

    NEXT ID                                                No entry required

    CLINIC (R)                                             Enter 4 digit clinic code

    DATE (R)                                               Enter appointment date you want to view.

    ACTION (R)                                             Enter I
                                                           I = Inquire

    ** Inquire allows the user to view appointments for this clinic on the selected date.




                                                    Page 15 of 15
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                                                 STAFF PROVIDER                                             S220
    The Staff Provider screen (61) is used to assign a provider ID number to all applicable staff members that provide
    services, referring physicians and LME’s (for behavioral health referrals). The ID number is locally assigned and
    can be alpha/numeric. Enter up to five (5) characters (letters and/or numbers) for each provider.

    *** All Behavioral Health providers, referring physicians and LME’s must also have a Medicaid provider
        number entered on the staff provider setup screen.


    HSA610A 09201 NORTH CAROLINA HSIS - STAFF PROVIDER  ADDED:
     10/21/08                     CHANGED:
    NEXT RECORD: COUNTY 092 SCREEN 61 ID     DATE     ACTION
    MESSAGE: 010 ENTER NEXT KEY
         STAFF PROVIDER NUMBER:
                      LAST NAME:
                      FIRST NAME:
                              MI:
           ORGANIZATIONAL NAME:
     MEDICAID PROVIDER NUMBER:
           BCBS PROVIDER NUMBER:
       REFERRING PHYSICIAN ONLY:
        MEDICAL DISCIPLINE CODE:

     VALID MEDICAL DISCIPLINE CODES:
     AID AUD CAR CAS CCS CED CHA CHT CNM CSC
     DA DDS DEN DIA ENT GEN HED HYG ITP LAB
     LCS LME LPA LPC LPN LPS MFT MOW NEU NP
     NUT OCC ORT OTH PA PCN PED PHA PHY PNP
     PRO PSY PT RAD RD RN ROS RTC SOC SPL
     SN SUR VEN XRT


    DECS: FOR REASSIGNMENT - (ADD OR CHANGE)
         REASSIGN THIS STAFF NUMBER TO CLIENTS WITH OLD PROVIDER NUMBER OF: _____




    FIELD                                                    EXPLANATION

    SCREEN (R)                                               Enter ’61’

    ID         (R)                                          Enter up to 5 alpha/numeric positions for the
                                                            clinical provider number.

    DATE        (O)                                         Date not required for staff provider screen.

    ACTION (R)                                              Enter A, C, D, OR I.
                                                            A = Add
                                                            C = Change
                                                            D = Delete
                                                            I = Inquiry


    Revised 9/19/01                                  Page 1 of 2
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                                   STAFF PROVIDER                                             S220
    STAFF PROVIDER NO.      (R)             No entry required.
                                            Entered from ID field on fast- path line.

    LAST NAME         (R)                    Must be alpha. Cannot be more than twenty characters.
                                             (name not required if setting up LME provider record)

    FIRST NAME (R)                           Must be alpha. Cannot be more than fifteen characters.

    MIDDLE INITIAL (O)                       Must be an alpha character.

    ORGANIZATIONAL NAME (O)                  Enter LME name (field for LME’s only).

    MEDICAID PROVIDER NUMBER (O)             Enter if applicable – required if behavioral health provider.

    BCBS PROVIDER NUMBER (O)                 Enter number assigned to provider by Blue Cross
                                             Blue Shield for insurance billing (CDSA and HSIS online
                                             AR sites only).

    REFERRING PHYSICIAN (O)                  Enter ‘Y’ if the staff provider is a referring physician only.
         ONLY
                                             NOTE: If ‘Y’ provider number can be used as
                                                       referring physician only on services
                                                        screen (65).

    MEDICAL DISCIPLINE CODE (R)              Enter provider’s medical discipline from list.


                                             NOTE: CDSA Contract Agencies must have
                                                   medical discipline of ‘OTH’.

                                             NOTE: All behavioral health physicians must use
                                                   medical discipline ‘PHY’ for appropriate
                                                   reimbursement.


    REASSIGN CASE                            Enter four-digit provider number of new case
    COORDINATOR (O)                          coordinator. Must be valid number from staff
                                              provider file.

                                             NOTE: Allows reassignment of complete caseloads to
                                                   another staff provider. The staff provider
                                                   number on the will change on the patient
                                                   master records only will) FOR DEC USE
                                                   ONLY.)




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    The Set-up Service Group Screen (63) allows the user to enter up to a 5-position alpha/numeric program codes and the
    specific CPT codes used within the program. Required fields are denoted by (R). Optional fields are denoted by (O). A
    line-by-line explanation of each field follows:


    HSA630A 09901 NORTH CAROLINA HSIS - SETUP SERVICE GROUP                       ADDED:
                                                                               CHANGED:
    NEXT RECORD: COUNTY               SCREEN 63 ID              DATE         ACTION
    MESSAGE:

    EFFECTIVE DATE:            THRU DATE: ______

    SERVICE GROUP:          GROUP DESC: _____________________________________________


    PGM CPT          PROV UNITS POS          PGM      CPT      PROV UNITS POS
    __ _____       _____ __ __    __       _____     _____    __ __
    __ _____       _____ __ __    __       _____     _____    __ __
    __ _____       _____ __ __    __       _____     _____    __ __
    __ _____       _____ __ __    __       _____     _____    __ __
    __ _____       _____ __ __    __       _____     _____    __ __
    __ _____       _____ __ __    __       _____     _____    __ __
    __ _____       _____ __ __    __       _____     _____    __ __
    __ _____       _____ __ __    __       _____     _____    __ __
    __ _____       _____ __ __    __       _____     _____    __ __
    __ _____       _____ __ __    __       _____     _____    __ __
    __ _____       _____ __ __    __       _____     _____    __ __
    __ _____       _____ __ __    __       _____     _____    __ __
    __ _____       _____ __ __    __       _____     _____    __ __


    FIELD                                       EXPLANATION

    SCREEN                    (R)                Enter ‘63’

    ID                         (R)               Enter up to a 5-position alpha/numeric code.
                                                         Ex: Ch001 = Child Health
                                                              FP001 = Family Planning Annual
                                                              FP002 = Family Planning Initial

    DATE                      ( R)               Enter the month, date, and year in
                                                 MMDDYY format.

    ACTION                    (R)                Enter A, C, D, or I.
                                                        A = Add
                                                        C = Change
                                                        D = Delete
                                                         I = Inquiry

    EFFECTIVE DATE             ( R)              No operator intervention required.
                                                 Effective date is automatically entered
                                                 from the fast-path date field.

    THRU DATE                 (O)                 Enter the ending date in MMDDYY format for

                                                          Page 1 of 2
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                                the date range you want this profile to end.

    SERVICE GROUP      (O)      No operator intervention required.
                                Group code is automatically entered
                                from the fast-path date field.

    GROUP DESCRIPTION ( O)       No entry required. If completed, enter
                                 the description of the clinic

    SERVICE DATE       (R)       No operator intervention required.
                                 Service date is automatically entered
                                 from the fast-path date field.

    PGM       (R)                Enter the appropriate two- character program code.
                                 Values = AH, BC, CC, CE CH, CL, DH, FP, IM, MH,
                                           EP, RH, ST, TB, OS, PC


    CPT (R)                      Enter the CPT/HCPCS code(s) from the encounter form.


    SERVICE PROVIDER   (O)       Enter the code for the provider of this service.


    UNITS              (R)       System automatically defaults to 01.

    PLACE of SERVICE
        ( POS )        (O)        Enter the appropriate code.




                                        Page 2 of 2
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         The CPT/Service Rate screen (64) allows the user to enter service code information for all billable and
         nonbillable services. All Service/CPT or ADA codes must be entered on screen 64. No services can be
         billed or reported on the Services/Encounter screen if it is not in the individual site’s rate table. Enter the
         rate established for your site not the Medicaid rate. Applicable actions for this screen are: A=add,
         C=change, E=extend, and I=inquire.



         HSA640A        09901                NORTH CAROLINA HSIS
                                             SETUP CPT/SERVICE RATE(S)

         NEXT RECORD: COUNTY:              SCREEN: 64 ID:                DATE:       ACTION:
         MESSAGE:


                     COUNTY:
                    CPT CODE:
               PGM TYPE/MOD:
                 DESCRIPTION:
              EFFECTIVE DATE:                          THRU DATE:
                                    MMDDCCYY
           SERVICE CHARGE:
         C ADDENDUM RATE:                              EFFECTIVE DATE:               (FOR STATE USE ONLY)
             FLAT FEE RATE:
          DEC FAMILY RATE:                              (FOR DEC USE ONLY)
          IT REIMBUR RATE:                             (FOR DEC USE ONLY)
              TYPE SERVICE:
             PLACE SERVICE:
               ENTRY DATE:
              CHANGE DATE:
                    USER ID:


         FIELD                                                             EXPLANATION
         SCREEN (R)                                                        Enter ‘64’

         ID    (R)                                                         Enter the CPT, ADA, HCPC,
                                                                           or state approved local code.

                                                                           Separate rates can be established for the
                                                                           same CPT code for different programs by
                                                                           adding the program code to the CPT code on
                                                                           the ID field – ex: 99201fp and 99201gb.
                                                                           The program will bill based on the rate for
                                                                           the particular program when the program
                                                                           code is entered on the Services/Encounter
                                                                           Screen (do not enter the program code in
                                                                           the modifier field on screen 65).

         DATE (R)                                                          Enter the month, date, and year in
                                                                           MMDDYY format.




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         ACTION        (R)                               Valid entry A, C, E or I.
                                                         A = Add
                                                         C = Change
                                                         I = Inquiry
                                                         E = Extend

                                                         The extend function allows the user to enter
                                                         a new CPT rate and end date the existing
                                                         CPT rate, when applicable without having to
                                                         reenter the other CPT information.

                                                         When new rates are received bring up the
                                                         CPT code through ‘Extend’ (action’E’), tab
                                                         to the date field and enter the new effective
                                                         date and new rate hit the enter key. On
                                                         inquiry (‘I’) both rates will be displayed, the
                                                         old rate with a ‘Through Date’ created by
                                                         the program and the new rate just entered
                                                         with new effective date. This allows billing
                                                         for appropriate rate based on the effective
                                                         date and date of service.

                                                         Use the “Change” (action ‘C’) function
                                                         only for the following:
                                                         1. To only End Date a CPT rate use the
                                                             ‘C’ action and add a Thru Date.
                                                         2. If user makes mistake or to correct
                                                             rate on a CPT rate use the ‘C’ action.

         CPT CODE (R)                                    No entry required.

         PGM TYPE/MOD (O)                                No entry required.




         FIELD                                           EXPLANATION
         DESCRIPTION (R)                                 No entry required. The description will be
                                                         entered by program.

         EFFECTIVE DATE (R)                              Enter the effective date for CPT or
                                                         ADA codes - MMDDCCYY format.

         THRU DATE           (O)                         No entry required unless you want to end-
                                                         date a rate. If you leave this blank the rate
                                                         will be effective until the next rate change.
                                                         MMDDCCYY format.

         SERVICE CHARGE (O)                              Enter the rate charged for your facility.

         CONTRACT ADDENDUM RATE (O)                      No entry required.
                                                         (Contract addendum data entered by
                                                         program office)




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         FLAT FEE RATE (O)                            Enter the flat rate charged for the service by
                                                      your site. (Flat fee rate charges are not
                                                      applied to patient’s sliding fee scale
                                                      percentage.)


         TYPE OF SERVICE (O)                          Enter applicable code for type of service
                                                      provided.

         PLACE OF SERVICE (O)                         Enter code for applicable type of service

         ENTRY DATE (R)                               No entry allowed*

         CHANGE DATE (R)                              No entry allowed*

         USER ID (R)                                  No entry allowed*

                                                      *(These fields are protected – used for
                                                      system tracking of entries and changes to
                                                      file)




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                                                            Screen One

    The Encounter/Service screen(s) (65) allow the user to report or bill any CPT code(s) or HCPC code(s) used within the Agency.
    The two service screens will allow up to twenty-four entries per service date. Maternal Health / Family Planning history data and
    required data needed by the Child Health and CSHS programs are also reported on this screen. Data elements should be updated
    as needed.

    HSA650A 01201 NORTH CAROLINA HSIS - ENCOUNTER INFORMATION ADDED:
     09/22/05                                 CHANGED:
    NEXT RECORD: COUNTY                  SCREEN                ID            DATE 080505 ACTION
    MESSAGE: 306 ENTER ENCOUNTER INFORMATION AND PRESS "ENTER"


    NAME:                                  SERVICE DATE:
    RELEASE OF INFORMATION:                 SIGNATURE ON FILE: _
    MEDICAID? Y MEDICAID ID:                     MEDICARE? N MEDICARE ID: ____________
    OTHER INS: N SELF-PAY: N INS A: 001_ INS B: ____ HEALTH CHOICE: Y CONTRACT: ___
    SSI: _
    SERVICE SITE: 01201          SERVICE GROUP: _____           DEC TRACKING DATE: ______
                                    HEARING AID DATE: ______
    HEIGHT: __ IN _ /8 IN OR ___ . _ CM WEIGHT: ___ LB __ OZ OR ___ . __ KG


    CHILD HEALTH: PAT TYPE: _ HGB: __ . _ GRAMS HCT: __ . _ % BLOOD LEAD DRAWN: _
                       NEXT PERIODIC SCREENING APPT: ______
    FAMILY PLANNING: PAT TYPE: _ CONTRA METHOD: __ PAT SCREENED? _ PAT AT RISK? _
                       FAM SIZE: __ ANNUAL FAM INCOME: _____ FPW: _
    MATERNAL HEALTH: PAT TYPE: _ MARITAL STATUS: _ LIVE BIRTHS: __ SPON ABOR: __
                       LIVING CHILDREN: __ FETAL DEATHS: __ O/P:
    CHILD SPEC HLTH: PAT TYPE: _ CLINIC CODE: __                OUTREACH: _ NEXT VISIT: ______
                       SERVICE TYPES: ASSESSMENT _ TREATMENT _ THERAPY _
    HIGHEST GRADE COMPLETED: __ LOCAL USE CODES: _____ _____ _____ _____ _____



    Required fields are denoted by (R). Optional fields are denoted by (O). A line-by-line explanation of each field follows:

    FIELD                                                   EXPLANATION

    SCREEN (R)                                              Enter ‘65’

    ID          (R)                                         Enter the patient ID number.

    DATE        ( R)                                        Enter the month, date, and year in
                                                           MMDDYY format.



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    FIELD                              EXPLANATION

    ACTION         (R)                  Enter A, C, D, or I.
                                        A = Add
                                        C = Change
                                        D = Delete
                                        I = Inquire

    LAST NAME                          No entry allowed. Displayed from Patient Master.

    FIRST NAME                         No entry allowed. Displayed from Patient Master.

    MI                                  No entry allowed. Displayed from Patient Master.

    ID NUMBER                           No entry allowed. Displayed from Patient Master.

    SERVICE DATE                       No entry allowed. Service date is automatically displayed from the fast-
                                       path date field.

    RELEASE OF INFORMATION (O)         A code indicating whether the provider has on file a signed statement
                                       by the patient authorizing the release of medical data to other
                                       organizations. Value may have been entered on Patient Master.
                                       Required for Medicaid billing – update if billing Medicaid and value
                                       is blank.

                                       Allowable Values:
                                       A – Appropriate Release of Information on file at health care service
                                       provider or at utilization review organization
                                       I – Informed consent to release medical information for conditions or
                                       diagnoses regulated by federal statutes
                                       M – The provider has limited or restricted ability to release data
                                       related to a claim
                                       N – Provider is not allowed to release data
                                       O – On file at Payer or at Plan Sponsor
                                       Y – provider has signed statement permitting release

    SIGNATURE ON FILE (O)              Code indicating how the patient or subscriber authorization
                                       signatures were obtained and how the provider is retaining them.
                                       Value may have been entered on Patient Master. Required for
                                       Medicaid billing – update if billing Medicaid and value is blank.

                                       Allowable Values:
                                       Blank – If Release of Information value is ‘N’ (no release)
                                       B – Signed signature authorization form or forms for both CMS-
                                       1500 Claim form blocks 12 and 13 are on file
                                       C – Signed CMS-1500 Claim form on file
                                       M – Signed signature authorization form for CMS-1500 Claim form
                                       block 13 on file




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    Field                                 Explanation



                                          P – Signature generated by provider because the patient was not
                                          physically present for services
                                          S – Signed signature authorization form for CMS-1500 Claim form
                                          block 12 on file.

    MEDICAID         (R)                  No entry allowed. Displayed from Patient Master.

    MEDICAID ID (O)                        No entry allowed. Displayed from Patient Master.

    MEDICARE (R)                          Enter ‘Y’ or ‘N’

                                          Note: Not required for WIC or DEC’S.

    MEDICARE ID (O)                       Enter Medicare ID if applicable.

    OTHER INS (R)                         No entry allowed. Displayed from Patient Master.

    SELF PAY             (R)              No entry allowed. Displayed from Patient Master.

    INS A          (O)                     No entry allowed. Displayed from Patient Insurance.

    INS B          (O)                    No entry allowed. Displayed from Patient Insurance.

    HEALTH CHOICE (R)                     Enter Y= Yes or N= No.
                                          Note: Required for Child Health, CSHS and
                                                 DEC Program.

    CONTRACT                   (O)        Enter 0001-9999
                                           Must be valid number from Insurance/Contracts file.

    SSI                    (R)            Enter Y= Yes or N= No.
                                          Note: Required entry for all children under 18
                                                 years of age.

    SERVICE SITE               (R)        No entry required.
                                          Providers with more than one service site can
                                          change the last two digits in the field to indicate
                                          the location where services were provided.

    SERVICE GROUP (O)                     Enter the 5-positions alpha/numeric code for the type of clinic to be
                                          entered. The CPT codes entered on the service group screen will
                                          automatically display on the service screen(s).

    DEC TRACKING DATE (O)                 No operator intervention required.
                                          Automatically entered from DEC Master.

                                          The tracking date can be changed and the master will be updated
                                          with new date. If tracking is no longer required enter zeros in date
                                          field using MMDDYY format.

    HEARING AID DATE (O)                  Required on claims where a prescription has been written
                                          for hearing devices and it is being billed on this claim.
                                          Format is MMDDYY.
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    Field                           Explanation

    HEIGHT (O)                     Entry is in inches or centimeters. The valid
                                    range is 10-90 for inches and 0-7 for eighths.
                                    The valid range is 025.0- 230.0 for Centimeters.

                                    Note: Required for Child Health Program.
                                    99 may be entered if service is a treatment.

    WEIGHT (O)                      Entry is in pounds, ounces, or kilograms.
                                    Valid range is 002-999 pounds and 00-15
                                    ounces, or 001.00-454.00 in kilograms.

                                    Note: Required for Child Health Program.
                                    999 may be entered in pounds, and 00 in
                                   ounces if service is a treatment.
                                   Note: Height and weight are required
                                       for the CSHS program when the
                                    Clinic Code = 12,18,22, or 48.

    CHILD HEALTH:

    PAT TYPE:            (R)       1 = NEW
                                     Patients making an initial clinic visit.

                                    2 = CONTINUATION
                                    Patients making a return visit.

                                    O = ZERO
                                    SUPPORT SERVICES ONLY

    HBG OR HCT (O)                 Valid range for the hemoglobin count is 04.9-20.0 or blank.
                                   The range for the hematocrit percentage is 19-60 or blank.

    BLOOD LEAD DRAWN (R)           Valid entry is Y= Yes; N= No.

    NEXT SCREENING APPT (O)        Valid entry is in MMDDYY format. If entered date must be
                                   greater than current day’s date.


    FAMILY PLANNING:

    PAT TYPE       (R)             1 = NEW
                                    Patients making an initial clinic visit.

                                   2 = CONTINUATION
                                   Patients making a return visit.




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    Field                                             Explanation



    CONTRA METHOD (R)                               Enter the primary method from the following:
                                                    01 = Contracept Pill-Daily          11 = Hormonal Implant
                                                    02 = Contraceptive foam             12 = Hormonal Injection
                                                    03 = IUD                            13 = Sterilization – Partner
                                                    04 = Diaphragm                      14 = No Method - Pregnant
                                                    05 = Contraceptive Jelly            15 = No Method- Other Reason
                                                    06 = Natural Family Planning        16 = Abstinence
                                                    07 = Contraceptive Sponge           17 = Emergency Contraception
                                                    08 = Vaginal Ring                   18 = Infertility
                                                    09 = Sterilization- Patient         19 = Code Not Used
                                                    10 = Method Unknown                 20 = Contraceptive Patch
                                                                                        21 = Condom

    NOTE: If sex data field on patient master is 1 (male), contraceptive method may be 09, 10, 13, 15, 16 or 21.

    NOTE: Contra method for Mirena = 03, Nuva Ring = 08; Ortho Eva = 20.



    PATIENT SCREENED (O)                             Valid entry is Y = Yes or N = No when reporting
                                                     Preconceptional Health Activity.

    PATIENT AT RISK         (O)                       Valid entry is Y = Yes or N = No.
                                                      Required if Patient screen =Y.


    FAMILY SIZE           (O)                         Enter the number of family members supported by the family’s
                                                      annual income.

    ANNUAL FAMILY INCOME (O)                         Enter the family’s annual income in whole dollars.
                                                     Convert weekly or monthly figures to annual figures.

    Note: Family size and Income are required when a Family Planning Initial CPT codes (99383-99386) or Annual
    CPT code (99393-99396) is billed or reported.


    FWP (O)                                            Valid entry is Y or space.
                                                       (Required for Family Planning Waiver Client)




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    Field                                       Explanation



    MATERNAL HEALTH:

    PAT TYPE       (R)                      1 = NEW
                                               Patients making an initial clinic visit
                                               for this pregnancy.

                                             NOTE: If patient type = 1 - marital status, live births, spon abor,
                                             living children, fetal deaths, and highest grade completed are
                                             required.

                                             2 = CONTINUATION
                                                 Patients making a return visit
                                                 for this pregnancy.

                                            O = ZERO - SUPPORT SERVICES ONLY

    MARITAL STATUS          (O)             Enter one of the following codes:
                                            1 =Married
                                            2 =Separated
                                            3 =Divorced
                                            4 =Widowed
                                            5 =Never Married

     LIVE BIRTHS (O)                        Enter the number of children born live to this patient. Enter 00 if
                                            none.

    SPON ABOR: (O)                          Spontaneous Abortion: enter the number of abortions/miscarriages
                                            experienced by a client when fetus is less than 15 weeks old.

     LIVING CHILDREN (O)                    Enter the number of living children that this patient has. Enter 00 if none.

     FETAL DEATHS        (O)                Enter the number of fetal deaths experienced by this
                                            patient. Enter 00 if none.

   O/P (R)                                  No operator intervention required. If field is Y, then a pregnancy outcome
                                            must be completed before a new pregnancy can be entered.


    Children Special Health Service(s):

    PATIENT TYPE (R)                          1 = NEW
                                                   Patients making an initial clinic visit.

                                             2 = CONTINUATION
                                                 Patients making a return visit.

    CLINIC CODE          (R)                Enter the two-digit Children's Special Health
                                            Services clinic code from the following:

                                                10=PULMONARY (CF) 32=SPEECH & HEARING
                                                12=CARDIOLOGY     40=MYELODYSPLASIA
                                                18=NEUROLOGY       22=ORTHOPEDIC
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    Field                          Explanation
                                    48=NEUROMUSCULAR


    OUTREACH           (O)         Valid codes are "Y" = Yes, "N"= No
                                   Note: Required if clinic code = 32.

    NEXT VISIT         (O)         Enter the month, day, and year of the next
                                   scheduled appointment.

    SERVICE TYPES       (R)        Enter "Y" to indicate the service(s) provided:
                                   Assessment, Treatment, or Therapy

    HIGHEST GRADE                  Enter the 2-digit response that reflects the
    COMPLETED     (O)              highest grade of school completed.
                                   Valid range is 01-20.

                                  Note: Required for Maternal Health

    LOCAL USE CODES (O)           If completed the first two position must be
                                  associated with a program, i.e. MH, FP.
                                  These are alpha/numeric fields.




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                                                   SCREEN TWO
                                                  Services Screen


      HSA650B 09201 NORTH CAROLINA HSIS - SERVICE INFORMATION        ADDED: __/__/__
       08/24/05                                                     CHANGED:
      NEXT RECORD: COUNTY ___     SCREEN 65    ID _________    DATE ______   ACTION _
      MESSAGE: 307 ENTER SERVICE INFORMATION AND PRESS "ENTER"
               PF8 FOR MORE DATA; ENTER TO FINISH
      NAME:                                                 DATE OF DIAB EVAL: ______
      SERVICE GROUP:                                        FPW FIRST TX DATE: ______
      DIAG CODES A: ___ __ B: ___ __ C: ___ __ D: ___ __ E: ___ __ F: ___ __ G: ___ __
                 H: ___ __
      PHY ORDER DATE FOR AT: ______   OT: ______   PT: ______   SPL: ______
      B/R/           MODIFIERS DIAG     SVC              ATN   TYP REF    SERVICE
       D PGM CPT     M1 M2 M3 1 2 3 4 PROV UNITS POS PHY       SVC PHY     SITE
       _ __ _____ __ __ __ _ _ _ _ _____ __         __ _____ __ _____      _____
       _ __ _____ __ __ __ _ _ _ _ _____ __         __ _____ __ _____      _____
       _ __ _____ __ __ __ _ _ _ _ _____ __         __ _____ __ _____      _____
       _ __ _____ __ __ __ _ _ _ _ _____ __         __ _____ __ _____      _____
       _ __ _____ __ __ __ _ _ _ _ _____ __         __ _____ __ _____      _____


    FIELD                                               EXPLANATION

    NAME (R)                                            No entry allowed. Displayed from Patient Master.

    SERVICE GROUP (O)                                   No entry allowed. Displayed from Encounter screen.

    DATE OF DIAB EVAL (O)                               Enter date of diabetes evaluation.

    FPW FIRST TX DATE (O)                               Enter in mm/dd/yy format.
                                                        Required if FPW = Y on encounter screen.

    NOTE: First Treatment Date must be completed on the first FPW service record. The date will be populated
    thereafter until the 365 day eligibility period ends. After the eligibility period ends a new treatment date will be
    required.

    DIAG CODE(S) (R)                                    Enter the appropriate ICD-9 code for the service
                                                        provided.

    PHYSICIAN ORDER DATE (O)                            Enter date of physician’s order for therapy provided by OT, PT,
                                                        Speech Pathologist & Audiologist (CDSA sites only).

    B/R/D COLUMN (R)                                    Enter the appropriate character for this service.
                                                        Values: B = Billing
                                                                 R = Report service only for statistics
                                                                 D = Delete line.


    NOTE # 1: Services/encounters that are deleted after the accounting period has closed will be marked as “Soft
          Deletes”. A Soft Delete is not physically deleted from the system; however, it will be excluded from the
          program reports. Soft Deleted services are displayed through "Inquiry" or "Change" and will appear
          with “D” in the B/R/D field. Soft Deleted services/encounters can not be changed; however, additional
          services can be added to the service date using the “Change” action.

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    Field                                              Explanation


     NOTE # 2: If the Setup-Service Group screen is used the CPT Codes default to the service screen, the B/R/D/
             column may be left blank when a service included in the group is not being provided to the patient on this
            visit.

    PGM (R)                                            Enter the appropriate two- character program
                                                       code found in the S900c Program Type table.

                                                       Note: Program type CA allowed only for service site 33 (CDSA)

                                                       Note: Services entered under program types BC (Breast
    Cancer)                                            and CE (Cervical Cancer) are reportable only. When program
                                                       type = BC or CE - HSIS requires ‘R’ for report and CPT code
                                                       only - NO OTHER FIELDS ARE REQUIRED.

    CPT (R)                                            Enter CPT code(s) must be a valid code from the CPT
                                                       code table.

    MODIFIERS        (O)                                Enter modifier(s) associated with the CPT code.
                                                        If Health Check, see the Health Check Manual
                                                        for the appropriate modifiers.

    NOTE – RE: Health Check Referral -When the provider has identified at least one health problem during the
    periodic or interperiodic Screening, enter “S2” in 2nd modifier field following the EP modifier to indicate client is
    currently under treatment for referred diagnostic or corrective health problem. Enter “ST” to indicate a referral
    to another provider for diagnostic or corrective treatment.

    DIAG 1 2 3 4 (R)                                   Enter the appropriate Alpha Character in field 1- 4 to indicate which
                                                       diagnostic code is associated with the CPT code. The first field
                                                       must be the primary diagnostic code.

    SERVICE PROVIDER (R)                               Enter the code for the provider of this service. Must be valid code
                                                       from staff provider table.

    UNIT’s     (R)                                     Enter units 01 - 99.

    PLACE OF SERVICE (O)
      (POS)                                            Enter the appropriate code from POS table.

    ATTENDING PROVIDER             (O)                 Enter the attending provider’s local assigned staff number.
                                                       Required for Behavioral Health service codes.



    TYPE OF SERVICE         (O)                        Enter two position code as appropriate.
      (TOS)

     REFERRING PHYSICIAN (O)                           Enter the service provider number of referring
                                                       physician.
                                                       Required for Behavioral Health Services provided to
                                                       clients under 21 – must be PCP, LME or Medicaid
                                                       enrolled psychiatrist. The PCP or psychiatrist must
                                                       be identified in the staff provider file with discipline
                                                       code of ‘PHY.’
    Revised 10/19/05                             Page 9 of 11
v1.13 10/22/2008                                    Encounter/Service                                          S250
Page 176 of 208
    FIELD                                              EXPLANATION



    SERVICE SITE       (R)                             No entry required.
                                                       The last two positions of service site field can be changed
                                                       To record services provided at a different location.

    Note: Press F8 to move forward to next screen if additional services need to be entered.




    Revised 10/19/05                            Page 10 of 11
v1.13 10/22/2008                                    65. Encounter/Service                                               S250
Page 177 of 208


                                                  CSHS SERVICES SCREEN

    All contract providers for Children's Special Health Services must report services provided to each person who attends the
    clinic, i.e., both children and adults, regardless of income or source of payment.

    FIELD                                                EXPLANATION

    NAME                    (R)                          No entry allowed. Displayed from Patient Master.

    REFERRED FOR ADDITIONAL ASSESSMENT (O)
                                      Enter "Y" in as many fields as appropriate.
                                      Additional assessment definitions are as follows:

    EDUCATIONAL/COGNITIVE                                The child's ability to problem solve through
                                                          conscious thought and the development of
                                                         intelligence.

    EMOTIONAL/SOCIAL                                     The child's behavior as related to social
                                                         relationships and expressions of emotions.

    GENETIC                                              Condition(s) acquired through gene transmission
                                                         from parent to offspring.

    HEARING                                              Pertains to the child's ability to perceive sound.

    MEDICAL                                              Pertains to the child's general physical well being.

    MOTOR DEVELOPMENT                                    The development of sequential steps of movement
                                                         patterns based on an ordinal process that is
                                                         commensurate with chronological and/or
                                                         developmental age.

    NUTRITION                                            Pertains to the status of the child's growth, feeding skills
                                                         and dietary intake.

    SPEECH/LANGUAGE                                      The expression of words and conveyance of ideas of a quantity and
                                                         quality commensurate with age
    REFERRED FOR
    OTHER PROCEDURES              (O)                    Enter "Y" to indicate a referral was made for
                                                         other procedures.




    Revised 10/19/05                              Page 11 of 11
v1.13 10/22/2008                                    RISK FACTORS                                                   S260
Page 178 of 208

    The Risk Factor (66) allows the user to enter the risk status and history data on individuals. Data elements should be
    updated as needed. Required fields are denoted by (R). Optional fields are denoted by (O). Note: At least one field must
    be entered. A line-by-line explanation of each field follows:



    HSA660A         09901         NORTH CAROLINA HSIS - RISK FACTORS                         ADDED:
                                                                                           CHANGED:
    NEXT RECORD: COUNTY               SCREEN 66         ID          DATE                     ACTION
    MESSAGE:

    NAME:                                                                                 SERVICE DATE:

    HIGHEST GRADE COMPLETED:                FP FAMILY SIZE:             FP ANNUAL FAMILY INCOME:

    MARITAL STATUS:            LIVE BIRTHS:           LIVING CHILDREN:             FETAL DEATHS:




     HIGH BLOOD PRESSURE:                HIGH CHOLESTEROL:                              DIABETES:

       BREAST CANCER HIST:                      ALCOHOL USE:                   CIGARETTE USE:

         OTHER TOBACCO USE:              PHYSICAL EXERCISE:                       SEAT BELT USE:

                   FRUITS/VEGS:                           LEAD:                           ASTHMA:

    HISTORY OF FRACTURES:                              WEIGHT:                             HEIGHT:



    FIELD                                         EXPLANATION

    SCREEN (R)                                     Enter 66

    ID             (R)                             Enter the patient ID number.

    DATE       (R)                                 Enter the month, date, and year in     MMDDYY format.


    ACTION         (R)                             Enter A, C, D, or I.
                                                   A = Add
                                                   C = Change
                                                   D = Delete
                                                    I = Inquire

    LAST NAME ( R)                                   No operator intervention required.

    FIRST NAME ( R)                                  No operator intervention required.

    MI (O)                                         No operator intervention required.

    ID NUMBER ( R)                                   No operator intervention required.



    May 2000                                              Page 1 of 4
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    SERVICE DATE (R)            No operator intervention required.
                               Service date is automatically entered
                                from the fast-path date field.
    HIGHEST GRADE
    COMPLETED (O)               Enter the 2-digit response that reflects the
                                highest grade of school completed.
                                Valid range is 01-20.

    FP FAMILY SIZE (O)          Enter the number of family members supported by the
                                family’s annual income.

                                    Note: Do not update             if   using   the   Account
                                         Receivable module.


    ANNUAL FAMILY INCOME (O)      Enter the family’s annual income in whole dollars. Convert
                                  weekly or monthly figures into annual figures.

                                  NOTE: Do not update if using the Account
                                  Receivable module.

    MARITAL STATUS (O)            Enter one of the following codes:
                                  1 =Married
                                  2 =Separated
                                  3 =Divorced
                                  4 =Widowed
                                  5 =Never Married
                                  R =Refused to answer

     LIVE BIRTHS (O)              Enter the number of children born live to this patient. Enter
                                  00 if none.

    LIVING CHILDREN (O)           Enter the number of living children that this patient has.
                                  Enter 00 if none.

    FETAL DEATHS       (O)          Enter the number of fetal deaths experienced by this patient.
                                    Enter 00 if none.

    HIGH BLOOD PRESSURE (O)         Enter one of the following:
                                    Y= Yes
                                    N= No
                                    8= Unable to answer
                                    R= Refused to answer

    HIGH CHOLESTEROL (O)            Enter one of the following:
                                    Y= Yes
                                    N= No
                                    8= Unable to answer
                                    R= Refused to answer

    DIABETES (O)                    Enter one of the following:
                                    Y = Yes
                                    N = No
                                    8 = Unable to answer
                                    R = Refused to answer

    May 2000                         Page 2 of 4
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Page 180 of 208




    FIELD                        EXPLANATION

    BREAST CANCER HIST (O)       Enter one of the following:
                                 1 = No personal or family history of cancer
                                 2 = Patient has had breast cancer
                                 3 = Mother, daughter, and/or sister(s) have had breast cancer
                                 8 = Unable to answer
                                 R = Refused to answer

    ALCOHOL USE (O)              Enter one of the following:
                                 0 =None
                                 1 =7 or less drinks per week
                                 2 =8 to 20 drinks per week
                                 3 =More than 20 drinks per week
                                 R=Refused to answer

    CIGARETTE USE (O)            Enter one of the following:
                                 0 =None
                                 1 =20 or less cigarettes per day
                                 2 =More than 20 cigarettes per day
                                 R =Refused to answer

    OTHER TOBACCO USE (O)        Enter one of the following:
                                 0 =None
                                 1 =Occasional
                                 2 =Almost every day
                                 3 =Several times per day
                                 R =Refused to answer

    PHYSICAL EXERCISE (O)        Enter one of the following:
                                 0 =None
                                 1 = 1 to 2 times per week
                                 2 =3 or more times per week
                                 R =Refused to answer

    SEAT BELT USE (O)            Enter one of the following:
                                 0 =Never
                                 1 =Sometimes
                                 2 =Always
                                 R =Refused to answer

    FRUITS/VEGETABLES (O)        Enter the total number of serving of fruits and vegetables the
                                 patient reports eating per day.
                                 Acceptable range is 0-6, with 6 =any number more than 5.
                                  R =Refused to answer

    LEAD (O)                     Valid entry is Y, N, or space.

    ASTHMA (O)                   Valid entry is Y, N, or space.

    HISTORY OF FRACTURES (O)     Valid entry is Y, N, or space.

    WEIGHT (O)                   Valid entry is Y, N, or space.

    May 2000                      Page 3 of 4
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Page 181 of 208

    HEIGHT (O)       Valid entry is Y, N, or space.




    May 2000          Page 4 of 4
v1.13 10/22/2008                              RISK FACTORS II (PAN)                                               S270
Page 182 of 208

    The Risk Factors II (PAN) (67) screen is used to enter services independent from the encounter screen. The screen was
    changed in 2004 to also enter PAN data. Required fields are denoted by (R). Optional fields are denoted by (O). A line-
    by-line explanation of each field follows:



    HSA670A 09901          NORTH CAROLINA HSIS - RISK FACTORS II (PAN)                         ADDED:
                                                                                             CHANGED:
    NEXT RECORD: COUNTY               SCREEN 67 ID               DATE                         ACTION
    MESSAGE:

    NAME:                                                      SERVICE DATE:


    HEIGHT:           IN   /8 IN OR       .   CM         WEIGHT:           LB OZ        OR    .   KG

    HGB:      .       GRAMS OR HCT:           %    B/P     /               BLOOD LEAD DRAWN:

    HDL CHOLESTEROL:                HBA1C:

    SERVICE SETTING:                   MOST CURRENT HGT/WGT:
    ACTIVITY LEVEL:                   EXERCISE DAYS:
    TV WEEKDAY:                       TV WEEKEND:
    SODA TIMES:                       SWEETENED BEVERAGE TIMES:                    SODA AMOUNT:
    FAST FOOD:                        CHIPS:
    MILK AMOUNT:                      MILK TYPE:
    VEGETABLES:                       FRUITS:


    FIELD                                         EXPLANATION

    SCREEN (R)                                     Enter “67”

    ID             (R)                             Enter the patient ID number.

    DATE       ( R)                                Enter the month, date, and year in
                                                   MMDDYY format.

    ACTION         (R)                              Enter A, C, D, or I.
                                                   A = Add
                                                   C = Change
                                                   D = Delete
                                                   I = Inquiry

    LAST NAME ( R)                                 No operator intervention required.

    FIRST NAME ( R)                                No operator intervention required.

    MI (O)                                         No operator intervention required.

    ID NUMBER ( R)                                 No operator intervention required.

    SERVICE DATE (R)                               No operator intervention required.
                                                   Service date is automatically entered
                                                   from the fast-path date field.


    April 2004                                             Page 1 of 4
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    HEIGHT (O)                   Entry is in inches or centimeters. The valid
                                 range is 10-90 for inches and 0-7 for eighths.
                                 The valid range is 025.0- 230.0 in centimeters.
                                  Note: when adding a record if the MOST CURRENT
                                           HGT/WGT field = Y, the height can only be added in
                                           inches and eights.

    WEIGHT (O)                   Entry is in pounds, ounces, or kilograms. Valid range is
                                 002-999 pounds and 00-15 ounces, or 001.00-454.00
                                 in kilograms.
                                 Note: when adding a record if the MOST CURRENT
                                           HGT/WGT field = Y, the weight can only be added in
                                           pounds and ounces.


   HBG OR HCT (O)                 The valid range for the hemoglobin count is 04.9-20.0 or blank.
                                  The range for the hematocrit percentage is 19-60 or blank.

    BLOOD PRESSURE (O)            Range for Systolic (1st entry) is 010-300, and for Diastolic
                                 (2nd entry) the range is 010-200.

    BLOOD LEAD DRAWN (O)         Valid entry is Y or space.

    HDL CHOLESTEROL (O)          Valid entry range is 010-999 or space.

    HBA1C          (O)            Valid entry range is 0-100.

    SERVICE SETTING (O)           No edit checks (user defined field)

    MOST CURRENT HGT/WGT (O)      Valid values are Y or space. This fields is used during the add
                                  function to recall the most current height or weight within the last six
                                  months from either the mobs table or the WIC certification file. The
                                  height and weight will be displayed in the height and weight fields
                                       and
                                  the date of measure will be displayed.

    ACTIVITY LEVEL (O)            Valid values are:
                                  01 – a lot more physically active than most
                                  02 – a little more physically active than most
                                  03 – average – same as most
                                  04 – a little less physically active than most
                                  05 – a lot less physically active than most
                                  09 – don’t know/not sure

    EXERCISE DAYS (O)             Valid values are:
                                  01 – 1 day
                                  02 – 2 days
                                  03 – 3 days
                                  04 – 4 days
                                  05 – 5 days
                                  06 – 6 days
                                  07 – 7 days
                                  08 – 0 days
                                  09 – don’t know/not sure

    TV WEEKDAY (O)                 Valid values are:
                                   01 – 1 hour or less

    April 2004                           Page 2 of 4
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Page 184 of 208
                                   02 – 2 hours
                                   03 – 3 hours
                                   04 – 4 hours
                                   05 – 5 hours
                                   06 – 6 hours
                                   08 – none
                                   09 – don’t know/not sure

    TV WEEKEND (O)                 Valid values are:
                                   01 – 1 hour or less
                                   02 – 2 hours
                                   03 – 3 hours
                                   04 – 4 hours
                                   05 – 5 hours
                                   06 – 6 hours
                                   08 – none
                                   09 – don’t know/not sure

    SODA TIMES (O)                 Valid values are:
                                   01 – 1 time
                                   02 – 2 times
                                   03 – 3 or more times
                                   08 – none
                                   09 – don’t know/not sure




    SWEETENED BEVERAGE TIMES (O)   Valid values are:
                                   01 – 1 time
                                   02 – 2 times
                                   03 – 3 or more times
                                   08 – none
                                   09 – don’t know/not sure


    SODA AMOUNT (O)                Valid values are:
                                   01 – small glass (4-6 ounces)
                                   02 – medium glass (8-12 ounces)
                                   03 – large glass (16-20 ounces)
                                   04 – 1 can (12 ounces)
                                   05 – 1 bottle (16-20 ounces)
                                   08 – don’t typically drink soft drinks or soda
                                   09 – don’t know/not sure


    FAST FOOD (O)                  Valid values are:
                                   00 – less then once a week
                                   01 – once a week
                                   02 – 2 times a week
                                   03 – 3 to 5 times a week
                                   05 – more than 5 times a week
                                   09 – don’t know/not sure

    CHIPS (O)                      Valid values are:
                                   01 – 1 time
                                   02 – 2 times

    April 2004                          Page 3 of 4
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Page 185 of 208
                                                 03 – 3 or more times
                                                 08 – none
                                                 09 – don’t know/not sure

    MILK AMOUNT (O)                              Valid values are:
                                                 00 – <1 glass
                                                 01 – 1 glass
                                                 02 – 2 glasses
                                                 03 – 3 glasses
                                                 04 – 4 or more
                                                 08 – none
                                                 09 – don’t know/not sure

    MILK TYPE (O)                                Valid values are:
                                                 01 – 1 time
                                                 02 – lowfat (1/2 – 1%)
                                                 03 – reduced fat (2%)
                                                 04 – whole
                                                 05 – flavored lowfat or skim
                                                 06 – flavored 2% or whole
                                                 09 – don’t know/not sure

    VEGETABLES (O)                               Valid values are:
                                                 01 – 1 serving
                                                 02 – 2 serving
                                                 03 – 3 or more servings
                                                 08 – none
                                                 09 don’t know/not sure



    FRUITS (O)                                   Valid values are: 01 – 1 serving
                                                 02 – 2 serving
                                                 03 – 3 or more servings
                                                 08 – none
                                                 09 don’t know/not sure



    Note1: At least one field must be entered.

    February 21, 2006Note2: The Physical Activity and Nutrition (PAN) fields are optional but if one is entered
                                                   they all must be
    entered.

    The PAN fields are: ACTIVITY LEVEL, EXERCISE DAYS, TV WEEKDAY, TV WEEKEND,
    SODA TIMES, SWEETENED BEVERAGE TIMES, SODA AMOUNT, FAST FOOD, CHIPS,
    MILK AMOUNT, MILK TYPE, VEGETABLES and FRUITS.




    April 2004                                        Page 4 of 4
v1.13 10/22/2008                  68. BILLING ONLY/BILLING INQUIRY                                         S280
Page 186 of 208


         Billing Only/Billing Inquiry (screen 68) allows inquiry and rebill capability. Services previously
         billed can be rebilled using the billing only function on screen 68. Insurance payments for Med/Ins
         clients should be entered on this screen also. Action codes are I (inquire) or C (change) P (post
         insurance payment).


          HSA680C            BILLING INQUIRY / BILLING ONLY

          NEXT RECORD: COUNTY             SCREEN 68 ID               DATE          ACTION
          MESSAGE:

           LAST NAME               FIRST NAME:          MI:
                                  ACCOUNT BALANCE:        .00
              SERVICE PROC PAY PROG BILLED BILLED PAYMENT PAYMENT EOB
          B/O/P DATE CODE SRCE TYPE DATE AMOUNT DATE AMOUNT CODE
            _ ________ _____ ____ __ ________ _________ ________ _________ _____
           _ ________ _____ ____ __ ________ _________ ________ _________ _____
           _ ________ _____ ____ __ ________ _________ ________ _________ _____
           _ ________ _____ ____ __ ________ _________ ________ _________ _____
           _ ________ _____ ____ __ ________ _________ ________ _________ _____
           _ ________ _____ ____ __ ________ _________ ________ _________ _____
           _ ________ _____ ____ __ ________ _________ ________ _________ _____
           _ ________ _____ ____ __ ________ _________ ________ _________ _____
           _ ________ _____ ____ __ ________ _________ ________ _________ _____
           _ ________ _____ ____ __ ________ _________ ________ _________ _____
           _ ________ _____ ____ __ ________ _________ ________ _________ _____
           _ ________ _____ ____ __ ________ _________ ________ _________ _____




         FIELD                                             EXPLANATION

         ID (R)                                            Enter patient’s ID number.

         DATE (O)                                          Leave date blank for complete list or enter date of
                                                           service or payment.

                                                           When changes need to be made for rebilling,
                                                           Bring cursor down to service date with action ‘I’ and
                                                           hit enter key to display service.

         NAME (R)                                          No entry allowed.
                                                           Name displayed from patient master file.

         B/O/P     (O)                                     Enter ‘B’ to rebill all services applicable (billing
                                                           only) services billed in prior billing period.

                                                           NOTE: To rebill service(s) enter B in B/O/P field
                                                           and enter, action ‘I’ or ‘C’. A new billing record
                                                           will be created with new bill date for all services
                                                           with ‘B’ in the B/O/P field. More than one service
                                                           can be rebilled on an entry.




         Revised 05/20/04                             Page 1 of 9
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Page 187 of 208

         FIELD                                EXPLANATION
                                              Enter ‘P’ and hit enter key to display payment
                                              screen (68B) for posting insurance payment for
                                              med/ins clients and to create bill for Medicaid.
                                              Refer to screen 3 (68b) for instructions for posting
                                              payments.



         SERVICE DATE (R)                     No entry allowed.
                                              Service dates displayed from Encounter/Services and
                                              Payment Screen.

         PROC CODE (R)                        No entry allowed.
                                              Procedure codes displayed from the
                                              Services/Encounter screen.

         PAY SOURCE (R)                       No entry allowed.
                                               Pay source code(s) M-Medicaid, I-insurance, C-
                                              contract, P-patient are entered from billing
                                              information.

         PROGRAM TYPE (R)                     No entry allowed.
                                              Program type displayed from services screen.

         BILLED DATE (R)                      No entry allowed.
                                              Generated by program when tape is created for
                                              Medicaid.

         BILLED AMOUNT (R)                    No entry allowed.
                                              (Charge for service from CPT rate screen)

         PAYMENT DATE (O)                     No entry allowed.

         PAYMENT AMOUNT (O)                   No entry allowed.


         EOB CODE (O)                         No entry allowed.
                                              Explanation of Benefits code from EDS for
                                              Medicaid payments/denials.




         Revised 05/20/04                Page 2 of 9
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                                        SCREEN TWO - SERVICES

         HSA680A                    BILLING INQUIRY / BILLING ONLY                      ADDED:
                                                                                        CHANGED:

         NEXT RECORD: COUNTY: ___ SCREEN: __ ID: __________ DATE: ______ ACTION: _
         MESSAGE:

         LAST NAME: ____________________ FIRST NAME: _______________ MI: _
         CPT CODE: _____ __ __ __ _________________________________________________
         SERVICE DATE: ________        ENTRY DATE: __________ ______                    UNITS: __
         PAY SOURCE: _         PROGRAM TYPE: __ REL OF INFO:__ SIGNATURE ON FILE:__
         BILL DATE: ________ BILL TYPE: _        TYPE OF SERV: __ PLACE SERV: __
         BILL AMT: _________ SFSCALE PCT: ___
         ATTEND PHY: _______           REFER PHY: _______             CLIA NUMBER: ____________
         DIAG CODES: PRI: ___ __ SEC: ___ __ ___ __ ___ __ TOOTH: __ SURFACE: _ _ _ _ _
         MED ID: __________ INSA: ___ INSB: ___ CONTRACT: ___ PAT PAY: _
         COND RELATED TO: EMPLOYMENT? _ AUTO ACCIDENT? _ ST: __ OTHER ACCIDENT?: _
         EDS IND: _ PAID DATE: ________ PAID AMT: _________
         EDS ICN: _____________ EOB: _____ _____________________________________________
         BILL PROV: _______ ______________________________ ACCT BALANCE: __________
         RECORD SOURCE IND: _          DHS ICN: ____________ BILL ONLY: _ AR-SKIP-IND: _
         PRIOR APPROVAL: DATE: ______ NUMBER: ___________
         APPLIANCE: STATUS: _ PLACEMENT DATE: ______ ORAL CAVITY: __
         HEARING AID DATE: ______ BANDING DATE: ______
         CHAN-GE DATE: ________        USER ID: ________      ACCOUNTING PERIOD: ______

         FIELD                                        EXPLANATION

         COUNTY (R)                                   No entry allowed.

         SCREEN (R)                                   No entry allowed.

         ID (R)                                       No entry allowed.

         DATE (R)                                     No entry allowed.
                                                      Date entered from first screen.

         ACTION (R)                                   Applicable actions are ‘I’ or ‘C.’
                                                      Changes allowed only on service records

         NAME (R)                                     No entry allowed.
                                                      Name changes must be made on patient master

         CPT CODE (O)                                 No entry allowed.
                                                      Modifiers can be added, changed or deleted.

         SERVICE DATE (R)                             No entry allowed.

         ENTRY DATE (R)                               No entry allowed.

         UNITS (R)                                    Units can be changed for billing updates or
                                                      corrections.

         PAY SOURCE (R)                               No entry allowed.


         Revised 05/20/04                        Page 3 of 9
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Page 189 of 208

         FIELD                                  EXPLANATION


         PROGRAM TYPE (R)                       No entry allowed.

         PATIENT TYPE (O)                       No entry allowed.

         VISIT TYPE (O)                         No entry allowed.

         BILL DATE (R)                          No entry allowed.

         BILL TYPE (R)                          No entry allowed.

         TYPE OF SERVICE (R)                    No entry required.
                                                (TOS can be changed when rebilling if applicable.)

         PLACE OF SERVICE (R)                   No entry required.
                                                (POS can be changed when rebilling if applicable.)

         BILL AMOUNT (R)                        No entry allowed.

         SFSCALE PCT (O)                        No entry allowed.

         ATTEND PROV (O)                        No entry allowed.

         REFERRING PROV (O)                     No entry allowed.

         CLIA NUMBER (O)                        No entry allowed.

         DIAG CODE (S) (O)                      No entry required.
                                                Can be changed for rebilling if applicable.

         MEDICAID ID (O)                        No entry required.
                                                Can be changed for rebilling if applicable.

         INS A/INS B/                           No entry required.
         CONTRACT                               Can be changed for rebilling if applicable.

         PATIENT PAY (0)                        No entry allowed.

         CONDITIONS RELATED TO (O)              No entry allowed.

         EMPLOYMENT/AUTO ACCIDENT
         ST (state)/OTHER ACCIDENT (O)          No entry allowed.

         EDS IND (O)                            No entry allowed.
                                                Medicaid = ‘D’ denied = ‘P’ paid

         PAID DATE (O)                          No entry allowed.

         PAID AMOUNT (O)                        No entry allowed.

         EDS ICN (0)                            No entry allowed.

         EOB (O)                                No entry allowed.

         LOCAL PROV (O)                         No entry allowed.

         Revised 05/20/04                  Page 4 of 9
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Page 190 of 208

         FIELD                                 EXPLANATION

         ACCOUNT BAL (O)                       No entry allowed.

         RECORD SOURCE IND/ DHS ICN (O)        No entry allowed.

         BILL ONLY (O)                         No entry allowed.

         AR-SKIP IND (O)                       No entry allowed.

         PRIOR APPROVAL (O)                    The following PRIOR APPROVAL fields are
                                               required if billing Medicaid and service requires prior
                                               approval.
             DATE                              Prior approval date (MMDDYY).
             NUMBER                            Prior approval number.

             APPLIANCE (O)                     The following two fields are required for billing
                                               Medicaid for dental appliance services.

             STATUS                            Code specifying the placement status for the dental
                                               appliance. Allowable Values:
                                               I – Initial Placement
                                               R – Replacement

             PLACEMENT DATE                    Required if the services performed are prosthetic
                                               services that were previously placed. (MMDDYY)

         ORAL CAVITY (O)                       Required for Medicaid billing of oral cavity services.
                                               A code identifying the area of the mouth that is being
                                               treated.
                                               Allowable values:
                                               00 Entire Oral Cavity
                                               01 Maxillary Area
                                               02 Mandibular Area
                                               09 Other Area of Oral Cavity
                                               10 Upper Right Quadrant
                                               20 Upper Left Quadrant
                                               30 Lower Left Quadrant
                                               40 Lower Right Quadrant
                                               L Left
                                               R Right

         HEARING AID DATE (O)                  Required for billing Medicaid for hearing devices
                                               where a prescription has been written. (MMDDYY)

         BANDING DATE (O)                      Date the orthodontic appliances were placed.
                                               Required for billing Medicaid for orthodontic
                                               appliances. (MMDDYY)

         AR-SKIP IND (O)                       No entry allowed.




         Revised 05/20/04                 Page 5 of 9
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         FIELD                               EXPLANATION

         CHANGE DATE (O)                     No entry allowed.

         USER ID (0)                         No entry allowed.

         ACCOUNTING PERIOD (O)               No entry allowed.




         Revised 05/20/04               Page 6 of 9
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Page 192 of 208


                                                      Screen Three
                                          Insurance Payments and Adjustments
                                          For Clients Who Also Have Medicaid

         The Insurance Payments and Adjustment screen is completed for Coordination of Benefits billing to
         Medicaid following payments/adjustments by a patient’s insurance plan. Certain fields on the screen can
         be updated if the site is an online A/R site.

         CDSA sites must use this screen to record ALL insuurance payments including payments for
         insurance clients who have a patient pay responsibility.
         •   A/R Sites – all fields can be updated
         •   Non-A/R Sites – only the following fields which are UNDERLINED can be updated.

         Applicable action codes are A = Add, C = Change, I = Inquire and D = Delete.


      HSA680B                         INSURANCE PAYMENTS AND ADJUSTMENTS
                                       FOR CLIENTS WHO ALSO HAVE MEDICAID
                                                                                            ADDED:
                                                                                            CHANGED:
      NEXT RECORD: COUNTY____ SCREEN ____                  ID ____________ DATE _________ ACTION __
      MESSAGE:
      NAME:                                                                 ID NUMBER: __________
      INS COMPANY: ____ ________________________ SERVICE CODE: _____ __/__/__
      DATE OF PAYMENT: ______                 WRITE-OFF: _            WRITE-OFF AMT: ________
      PAYMENT/CR TYPE: _ (I,C,P,M)                   CASH RECEIPT: ____           RECEIVED BY: __________
      BILLED AMOUNT: ________               PAYMENT/CR AMOUNT: ________                 PROGRAM TYPE: __
      OTHER ADJ AMT: ________            OTHER ADJ DESCRIPTION: _______________
      BILL REMAINDER TO: _ (P)               REMAINDER AMOUNT: ________
      SFSCALE PCT: ___             SFSCALE AMOUNT: ________               SFSCALE ADJ AMOUNT: __________
      MEDICAID: _         INSURANCE: _                       CURRENT ACCT. BALANCE: ________

                                                HIPAA DATA FIELD
      ADJUSTED UNITS: __




         FIELD                                                         EXPLANATION

         NAME                                                NO ENTRY ALLOWED – name is displayed from
                                                             the Patient Master.

         ID NUMBER                                           NO ENTRY ALLOWED – ID Number is displayed
                                                             from the Patient Master.

         INS COMPANY                                         Insurance company ID is displayed from the Patient
                                                             Insurance record. X is displayed beside the primary
                                                             insurance company number. If the insurance
                                                             payment being entered is from the secondary insurer


         Revised 05/20/04                               Page 7 of 9
v1.13 10/22/2008             68. BILLING ONLY/BILLING INQUIRY                             s280
Page 193 of 208

             FIELD                            EXPLANATION
                                              the X must be spaced out of the primary insurance
                                              company field and entered beside the secondary
                                              company.


         SERVICE CODE                         NO ENTRY ALLOWED – service code and date is
                                              displayed from the service record.

         DATE OF PAYMENT (R)                  Enter date of payment (MMDDYY)

         WRITE-OFF                            NO ENTRY ALLOWED.

         WRITE-OFF AMT                        NO ENTRY ALLOWED.

         PAYMENT/CR TYPE                      NO ENTRY ALLOWED.

         CASH RECEIPT                         Enter if applicable.

         RECEIVED BY                          Enter if applicable..

         BILLED AMOUNT                        NO ENTRY ALLOWED – billed amount is
                                              displayed from the Services record.

         PAYMENT/CR AMOUNT (R)                Enter amount of payment.

                                              If insurance denies charge, the only entry
                                              required for insurance/medicaid client is the date
                                              of payment and adjusted units for HIPAA.

                                              For CDSA sites only – insurance payments for
                                              nonmedicaid insurance clients - if insurance
                                              denies enter and there is no patient responsibility,
                                              enter the date of the payment and hit enter and
                                              the program will compute the “other adjustment”
                                              amount.

                                              If insurance denies/pays enter the payment date,
                                              the payment amount if applicable and “Bill
                                              Remainder” to “P”, the program will calculate the
                                              sliding fee amount and other adjustment if
                                              applicable.

         PROGRAM TYPE                         NO ENTRY ALLOWED – program type is displayed
                                              from the service record.

         OTHER ADJ AMOUNT (O)                 NO ENTRY ALLOWED.

         OTHER ADJ DESCRIPTION (O)            NO ENTRY ALLOWED.

         BILL REMAINDER TO                    CDSA sites only - enter bill remainder to ‘P’

                                              Bill remainder to ‘P’ will compute the patient’s
                                              charge based on the patients sliding fee scale
                                              percentage and CDSA Family Payment
                                              calculations.


         Revised 05/20/04                Page 8 of 9
v1.13 10/22/2008            68. BILLING ONLY/BILLING INQUIRY                             s280
Page 194 of 208

             FIELD                           EXPLANATION

         SFSCALE PCT                         NO ENTRY ALLOWED.

         SFSCALE AMOUNT                      NO ENTRY ALLOWED.

         SFSCALE ADJ AMOUNT                  NO ENTRY ALLOWED.

         MEDICAID                            NO ENTRY ALLOWED.

         INSURANCE                           NO ENTRY ALLOWED.

         CURRENT ACCT BALANCE                NO ENTRY ALLOWED.

         HIPAA DATA FIELD (O)
             ADJUSTED UNITS                  Enter units of service being adjusted.
                                             Required for Medicaid & insurance patient




         Revised 05/20/04               Page 9 of 9
v1.13 10/22/2008                            COMPANY SERVICE BILLING                                            S290
Page 195 of 208
                                            ( program being developed)

         Company Service Billing (Screen 69) should be used to collect billing information for health departments
         providing services to companies at an agreed upon rate per employee. A bill will be generated based on
         ‘Charge Per Person’ and number of employees listed. An ID number must be assigned through the
         Insurance/Contract screen for all companies
         the health department has an agreement with. Applicable actions are Add, Change, and Delete.


         HSA690A     NORTH CAROLINA HSIS - COMPANY SERVICE BILLING ADDED:
                                                                  CHANGED:
         NEXT RECORD: COUNTY      SCREEN 69 ID       DATE     ACTION
         MESSAGE:
             PF3 TO RETURN TO PREVIOUS SCREEN
         COMPANY NAME:               CPT CD CHARGE      CPT CD CHARGE
         SERVICE DATE: __________     1. _____ _____ 2. _____ _____
         TOTAL CHARGE: __________     3. _____ _____ 4. _____ _____
                                      5. _____ _____ 6. _____ _____
                                      7. _____ _____ 8. _____ _____

         EMPLOYEE FIRST         MI LAST        -1----2----3----4----5----6----7----8-
         _______________ _      _______________ _ _ _ _ _ _ _ _
         _______________ _      _______________ _ _ _ _ _ _ _ _
         _______________ _      _______________ _ _ _ _ _ _ _ _
         _______________ _      _______________ _ _ _ _ _ _ _ _
         _______________ _      _______________ _ _ _ _ _ _ _ _
         _______________ _      _______________ _ _ _ _ _ _ _ _
         _______________ _      _______________ _ _ _ _ _ _ _ _
         _______________ _      _______________ _ _ _ _ _ _ _ _
         _______________ _      _______________ _ _ _ _ _ _ _ _
         _______________ _      _______________ _ _ _ _ _ _ _ _
         _______________ _      _______________ _ _ _ _ _ _ _ _
         _______________ _      _______________ _ _ _ _ _ _ _ _




         FIELD                                       EXPLANATION

         ID (R)                                               Enter 3 position code from Insurance Table for
                                                              company being billed (must be valid number from
                                                              insurance table).

         DATE (R)                                             Enter date of service provided to employee(s).

         COMPANIY NAME (R)                                    No entry required.
                                                              Name entered from insurance table.

         SERVICE DATE (R)                                     No entry required. Date entered from fast path line.

         CPT CODE (R)                                         At least 1 CPT/Service code is required.
                                                              Must be valid code from CPT/Service Rate table.
                                                              Up to 8 codes can be billed per patient.

         CHARGE (R)                                           Enter amount charged for service.
                                                              Must enter charge for each CPT code entered.


         10/21/08                                       Page 1 of 2
v1.13 10/22/2008                            COMPANY SERVICE BILLING                                         S290
Page 196 of 208
                                            ( program being developed)

         TOTAL CHARGE (R)                                     No entry required.
                                                              Total charge will be calculated based on the
                                                              number of employees and total charge per person.

                                                              For counties using HSIS accounts receivable
                                                              program these charges will be added to the Other
                                                              Services account’s receivable report s (GB).

         EMPLOYEE NAME (R)                                    Enter name(s) of all employees receiving services for
                                                              service date in first/mi/last name format.

                                                               Enter the corresponding item number for each CPT
                                                              (service) received by each patient for visit date.


         Bills for services provided under Company Billing will be generated from the Reports Processing
         Screen. Bills will be calculated for the period within the from and through dates requested. All
         screens dates within the requested period will be totaled to generate a bill for the period. To see a list
         of all service dates for a specific company, enter company ID, space out the date and Action ‘I’.




         10/21/08                                       Page 2 of 2
v1.13 10/22/2008                        70. DENTAL ENCOUNTER & SVCS                                             S300
Page 197 of 208



          The Dental Encounter & Service screen (70) is used to bill Dental Health claims. Up to five service screens is
          available for data entry. Required fields are denoted by (R). Optional fields are denoted by (O). A line-by-
          line explanation of each entry follows:

          HSA700A        NORTH CAROLINA HSIS - DENTAL ENC & SVC INFO
                                                                                           ADDED:
                                                                                           CHANGED:
          NEXT RECORD: COUNTY ___              SCREEN 70       ID _________ DATE ______ ACTION _
          MESSAGE:

          NAME:                         SERVICE DATE: ______
          RELEASE OF INFORMATION: __        SIGNATURE ON FILE:__
          MEDICAID? _ MEDICAID ID: _________ MEDICARE? _ MEDICARE ID: ____________
          OTHER INS: _ SELF-PAY: _ INS A: ____ INS B: ____ PLACE OF SERVICE: __
          ACCIDENTAL INJURY? _ ACCIDENT DATE: ______ AUTO ACCIDENT? _ STATE: __
          ON-THE-JOB INJURY? _          SPECIAL PROGRAM INDICATOR __
          PRIOR APPROVAL DATE: ______ PRIOR APPROVAL NUMBER: _________
          SERVICE SITE: _____        ORTHODONTIC BANDING DATE: ______
                                             PRIOR
            B/     PROC TOOTH ORAL          SURFACE      SERV APPLIN PLACE
            D      CODE NUM CAVITY           CODE        PROV STATUS DATE
            _      _____  __    __          _____        _____  _    ______
            _      _____  __    __          _____        _____  _    ______
            _      _____  __    __          _____        _____  _    ______
            _      _____  __    __          _____        _____  _    ______
            _      _____  __    __          _____        _____  _    ______
            _      _____  __    __          _____        _____  _    ______
            _      _____  __    __          _____        _____  _    ______


          FIELD                                                  EXPLANATION

          SCREEN (R)                                             Enter `70'

          ID (R)                                                 Enter the patient ID number.

          DATE (R)                                               Enter the month, date, and year in MMDDYY format.

          ACTION (R)                                             Enter A, I, C, or D
                                                                 A = Add
                                                                 I = Inquiry
                                                                 C = Change
                                                                 D = Delete

          LAST NAME                                              NO ENTRY ALLOWED. Displayed from Patient
                                                                 Master.

          FIRST NAME                                             NO ENTRY ALLOWED. Displayed from Patient
                                                                 Master.

          MI                                                     NO ENTRY ALLOWED. Displayed from Patient
                                                                 Master.

          SERVICE DATE: (R)                                      Enter date services were rendered (MMDDYY).


          Revised 04/28/03                                       Page 1 of 5
v1.13 10/22/2008              70. DENTAL ENCOUNTER & SVCS                                 S300
Page 198 of 208

          FIELD                            EXPLANATION

          RELEASE OF INFORMATION (O)       A code indicating whether the provider has on file a
                                           signed statement by the patient authorizing the
                                           release of medical data to other organizations.
                                           Value may have been entered on Patient Master.
                                           Required for Medicaid billing – update if billing
                                           Medicaid and value is blank.

                                           Allowable Values:
                                           A – Appropriate Release of Information on file at
                                           health care service provider or at utilization review
                                           organization
                                           I – Informed consent to release medical information
                                           for conditions or diagnoses regulated by federal
                                           statutes
                                           M – The provider has limited or restricted ability to
                                           release data related to a claim
                                           N – Provider is not allowed to release data
                                           O – On file at Payer or at Plan Sponsor
                                           Y – provider has signed statement permitting
                                           release

          SIGNATURE ON FILE (O)            Code indicating how the patient or subscriber
                                           authorization signatures were obtained and how the
                                           provider is retaining them. Value may have been
                                           entered on Patient Master. Required for Medicaid
                                           billing – update if billing Medicaid and value is
                                           blank.

                                           Allowable Values:
                                           Blank – If Release of Information value is ‘N’ (no
                                           release)
                                           B – Signed signature authorization form or forms
                                           for both CMS-1500 Claim form blocks 12 and 13
                                           are on file
                                           C – Signed CMS-1500 Claim form on file
                                           M – Signed signature authorization form for CMS-
                                           1500 Claim form block 13 on file
                                           P – Signature generated by provider because the
                                           patient was not physically present for services
                                           S – Signed signature authorization form for CMS-
                                           1500 Claim form block 12 on file.

          MEDICAID                         NO ENTRY ALLOWED. Displayed from Patient
                                           Master.

          MEDICAID ID                      NO ENTRY ALLOWED. Displayed from Patient
                                           Master.

          MEDICARE (R)                     Enter ‘Y’ or ‘N’

          MEDICARE ID (O)                  Enter Medicare ID if applicable.

          Revised 04/28/03                 Page 2 of 5
v1.13 10/22/2008                 70. DENTAL ENCOUNTER & SVCS                                 S300
Page 199 of 208

          FIELD                               EXPLANATION


          OTHER INS                           NO ENTRY ALLOWED. Displayed from Patient
                                              Master.

          SELF PAY                            NO ENTRY ALLOWED. Displayed from Patient
                                              Master.

          INS A                               NO ENTRY ALLOWED. Displayed from Patient
                                              Master.

          INS B                               NO ENTRY ALLOWED. Displayed from Patient
                                              Master.

          PLACE OF SERVICE (R)                Enter a “3” for an office visit.

          ACCIDENTAL INJURY (O)               Defaults to ’N’.
                                              Note – Change to ‘Y’ if client being seen as result
                                              of an accident. Required if a value is entered in
                                              ACCIDENT DATE field. Valid entry = ‘Y’, ‘N’ or
                                              space.

          ACCIDENT DATE (O)                   Date of the accident. Required if condition is
                                              accident or employment related and billing
                                              Medicaid. Required if a value is entered in
                                              ACCIDENT INJURY field.

          AUTO ACCIDENT (O)                   Enter ‘Y’ or ‘N’

          STATE (O)                           Enter State in which the auto accident occurred.
                                              Must be a valid state or province code. Required if
                                              client being seen as result of auto accident.
                                              Required if billing Medicaid.

          ON-THE JOB INJURY (R)               No operator intervention required. Defaults to ‘N’.

          SPECIAL PROGRAM INDICATOR (R)       Enter on of the following program types or leave
                                              blank if not applicable:
                                              01 = Early & Periodic Screening, & Diagnosis and
                                                   Treatment (EPSDT)
                                                   OR
                                                   Child Health Assessment Program
                                              02 = Physically Handicapped Children’s Program
                                              03 = Special Federal Funding
                                              05 = Disability
                                              NOTE – Required if the services rendered were
                                                        under one of the above circumstances,
                                                        programs or projects.

          PRIOR APPROVAL DATE (O)             Enter date from the prior approval form
                                              Received from DMA.

          PRIOR APPROVAL NUMBER (O)           Enter the number from the prior approval form
                                              Received from DMA.
          SERVICE SITE (R)                    No entry required.
                                              Providers with more than one service site can
                                              change the last two digits in the field to indicate


          Revised 04/28/03                    Page 3 of 5
v1.13 10/22/2008                    70. DENTAL ENCOUNTER & SVCS                                 S300
Page 200 of 208

          FIELD                                  EXPLANATION

                                                 the location where services were provided.

          ORTHODONTIC BANDING DATE (O)           Date the orthodontic appliances were placed.
                                                 Required if service is billed to Medicaid.



          B//D COLUMN (R)                        Valid codes are:
                                                  B = Billing
                                                  D = Delete the line.


                                                 NOTE # 1: Services/encounters that are deleted
                                                 after the accounting period has closed will be
                                                 marked as “Soft Deletes”. A Soft Delete is not
                                                 physically deleted from the system; however, it
                                                 will be excluded from the program reports. Soft
                                                 Deleted services are displayed through
                                                 "Inquiry" or "Change" and will appear with
                                                 “D” in the B/D field. Soft Deleted
                                                 services/encounters can not be changed;
                                                 however, additional services can be added to the
                                                 service date using the “Change” action.

          PROCEDURE CODE (R)                     Enter the five (5) digit ADA/CPT code (s)
                                                 identifying the procedure.
                                                 NOTE: Code must be in the ADA/CPT rate
                                                 table.

          TOOTH NUMBER (O)                       Enter the appropriate indicator from the Dental
                                                 Health manual (page 101).

          ORAL CAVITY (O)                        A code identifying the area of the mouth that is
                                                 being treated.
                                                 Allowable values:
                                                 00 Entire Oral Cavity
                                                 01 Maxillary Area
                                                 02 Mandibular Area
                                                 09 Other Area of Oral Cavity
                                                 10 Upper Right Quadrant
                                                 20 Upper Left Quadrant
                                                 30 Lower Left Quadrant
                                                 40 Lower Right Quadrant
                                                 L Left
                                                 R Right

          SURFACE CODE       (O)                 Enter the appropriate indicator form the Dental
                                                 Health manual (page101).

          SERVICE PROVIDER         (R)           Enter the code for the provider of this service. Must
                                                 be valid code from staff provider table.

          APPLIN STATUS (O)                      Enter code specifying the placement status for the
                                                 dental work. Required if billing Medicaid.

          Revised 04/28/03                       Page 4 of 5
v1.13 10/22/2008                          DENTAL ENCOUNTER & SVCS                                           S300
Page 201 of 208

          FIELD                                                 EXPLANATION
                                                                Allowable Values:
                                                                I – Initial Placement
                                                                R – Replacement

          PRIOR PLACE DATE (O)                                  Enter Prior Placement Date (MMDDYY).
                                                                Required if the services performed are prosthetic
                                                                services that were previously placed. Required if
                                                                billing Medicaid.

          Note: Press F8 to move forward to next screen if additional services need to be entered.




          Revised 04/28/03                                      Page 5 of 5
v1.13 10/22/2008
Page 202 of 208


                                                  SLIDING FEE SCALE                                              S320

    The Sliding Fee Scale screen (89) allows local agencies to enter a 'county specific' sliding fee scale. The screen
    enables the local agencies to determine the sliding fee scale percentages based on a county scale. A default scale can
    be entered that will be applicable to all programs or individual fee scales can be set up for each program type if
    necessary.


    HSA890A                  NORTH CAROLINA HSIS                ADDED: __________
                               POVERTY LEVEL                  CHANGED: __________

    NEXT RECORD: COUNTY               SCREEN 89      ID            DATE      ACTION
    MESSAGE:

               PATIENT FEE CATEGORY - ANNUAL NET INCOME
            COUNTY:    PROGRAM TYPE: 11 EFFECTIVE DATE:

    FAM.                           PERCENTAGES
    SIZE 0%            20%        40%    60%   80%                 100%

      1      0         0      0       0       0       0              0
      2      0         0      0       0       0       0              0
      3      0         0      0       0       0       0              0
      4      0         0      0       0       0       0              0
      5      0         0      0       0       0       0              0
      6      0         0      0       0       0       0              0
      7      0         0      0       0       0       0              0
      8      0         0      0       0       0       0              0
      9      0         0      0       0       0       0              0
     10      0         0      0       0       0       0              0
     11      0         0      0       0       0       0              0
     12      0         0      0       0       0       0              0



    FIELD                                                 EXPLANATION

    COUNTY (R)                                            Enter 3-digit county or DEC code.

    PROGRAM TYPE (O)                                      Enter 2-digit program code as follows:

                                                           CH = Child Health
                                                           CC = Children's Special Health Services
                                                           AH = Adult Health
                                                           FP = Family Planning
                                                           DH =Dental Health
                                                           EP = Epidemiology
                                                           MH = Maternal Health




    Revised 03/06/06                                 Page 1 of 2
v1.13 10/22/2008
Page 203 of 208


                                              SLIDING FEE SCALE                                               S320

                                                          IM = Immunization
                                                          CL = Children’s Developmental Services Agency
                                                          RH =Rural Health
                                                          OS = Other Services
                                                          PC = Primary Care
                                                          ST = Sexually Transmitted Disease
                                                          TB = Tuberculosis

                                                         (Required if fee scale needed for specific program)
                                                         County scale can be enter by leaving the program type
                                                         blank. The fee scale will be applicable to all programs for
                                                         the site.

                                                         *** The CDSA state scale will be entered by HSIS staff
                                                             and will apply for all CDSA sites. Entry is no longer
                                                              required for the local CDSA staff.

    EFFECTIVE DATE (R)                                   Enter date fee scale becomes effective.
                                                         Enter MMDDYY format.

                                                         **** If no local scale is entered for the current fiscal year
                                                              the program will use the state default sliding fee scale
                                                              which is the FP scale of 100 – 250% of povery.

    FAMILY SIZE                                          NO ENTRY REQUIRED.

    PERCENTAGES                                          Enter maximum income required to meet criteria for each
                                                         percentage & family size.


    NOTE --- PERCENTAGES MUST BE IN INCREMENTS OF $1,000 (EX: IF MAXIMUM INCOME FOR
             A FAMILY OF 1, at 0% IS $10,000 THEN MAXIMUM INCOME FOR A FAMILY OF 1 AT 20%
             MUST BE AT LEAST $11,000).

                   MAXIMUM INCOME FOR FAMILY SIZE RANGES MUST BE IN INCREMENTS OF $2,000
                   (EX: FAMILY OF 1 AT 0% MAXIMUM INCOME IS $10,000 THEN THE MAXIMUM FOR A
                   FAMILY OF 2 AT 0% MUST BE AT LEAST $12,000).

               *****ALL INCOME FIELDS MUST BE COMPLETED TO ENTER RECORD************




    NOTE --- The program will use the most current scale for your site. If the local fee scale effective date is not
            within 1 year of the current state fee scale the program will use the state scale. It is very important
             for sites to enter a new scale each year if applicable.

               To view the state scale space out the county number and program type and enter effective date of
                the state scale.
    Revised 03/06/06                                Page 2 of 2
v1.13 10/22/2008
Page 204 of 208Place of Service (HCFA1500) Reference Table                  s900a
    Code Description

    11         Office
    12         Home
    21         Inpatient Hospital
    22         Outpatient Hospital
    23         Emergency Room - Hospital
    24         Ambulatory Surgery Center
    25         Birthing Center
    26         Military Treatment Facility
    31         Skilled Nursing Facility
    32         Nursing Facility
    33         Custodial Care Facility
    34         Hospice
    41         Ambulance - Land
    42         Ambulance - Sea or Air
    51         Inpatient Psychiatric Facility
    52         Psychiatric Facility; Partial Hospitalization
    53         Community Mental Health Center
    54         Intermediate Care Facility/Mentally Retarded
    55         Residential Substance Abuse Treatment Facility
    56         Psychiatric Residential Treatment Center
    61         Comprehensive Inpatient Rehabilitation Facility
    62         Comprehensive Outpatient Rehabilitation Facility
    65         End Stage Renal Disease Treatment Facility
    71         State or Local Public Health Clinic
    72         Rural Health Clinic
    81         Independent Laboratory
    99         School




    Revision Date: 03/01/2000            Page 1 of 1        Release Date: 11/26/2002
    s900a POS Table
v1.13 10/22/2008
Page 205 of 208    County of Residence Reference Table            s900b
   County Nbr       County Name


   001              ALAMANCE
   002              ALEXANDER
   003              ALLEGHANY
   004              ANSON
   005              ASHE
   006              AVERY
   007              BEAUFORT
   008              BERTIE
   009              BLADEN
   010              BRUNSWICK
   011              BUNCOMBE
   012              BURKE
   013              CABARRUS
   014              CALDWELL
   015              CAMDEN
   016              CARTERET
   017              CASWELL
   018              CATAWBA
   019              CHATHAM
   020              CHEROKEE
   021              CHOWAN
   022              CLAY
   023              CLEVELAND
   024              COLUMBUS
   025              CRAVEN
   026              CUMBERLAND
   027              CURRITUCK
   028              DARE
   029              DAVIDSON
   030              DAVIE
   031              DUPLIN
   032              DURHAM
   033              EDGECOMBE
   034              FORSYTH
   035              FRANKLIN
   036              GASTON
   037              GATES
   038              GRAHAM
   039              GRANVILLE
   040              GREENE
   041              GUILFORD
   042              HALIFAX
   043              HARNETT
   044              HAYWOOD

   Revision Date: 03/02/2000         Page 1 of 3    Release Date: 11/26/2002
   s900b County of Residence table
v1.13 10/22/2008
Page 206 of 208    County of Residence Reference Table            s900b
   County Nbr       County Name


   045              HENDERSON
   046              HERTFORD
   047              HOKE
   048              HYDE
   049              IREDELL
   050              JACKSON
   051              JOHNSTON
   052              JONES
   053              LEE
   054              LENOIR
   055              LINCOLN
   056              MACON
   057              MADISON
   058              MARTIN
   059              MCDOWELL
   060              MECKLENBURG
   061              MITCHELL
   062              MONTGOMERY
   063              MOORE
   064              NASH
   065              NEW HANOVER
   066              NORTHAMPTON
   067              ONSLOW
   068              ORANGE
   069              PAMLICO
   070              PASQUOTANK
   071              PENDER
   072              PERQUIMANS
   073              PERSON
   074              PITT
   075              POLK
   076              RANDOLPH
   077              RICHMOND
   078              ROBESON
   079              ROCKINGHAM
   080              ROWAN
   081              RUTHERFORD
   082              SAMPSON
   083              SCOTLAND
   084              STANLY
   085              STOKES
   086              SURRY
   087              SWAIN
   088              TRANSYLVANIA

   Revision Date: 03/02/2000         Page 2 of 3    Release Date: 11/26/2002
   s900b County of Residence table
v1.13 10/22/2008
Page 207 of 208    County of Residence Reference Table            s900b
   County Nbr       County Name


   089              TYRRELL
   090              UNION
   091              VANCE
   092              WAKE
   093              WARREN
   094              WASHINGTON
   095              WATAUGA
   096              WAYNE
   097              WILKES
   098              WILSON
   099              YADKIN
   100              YANCEY
   888              OUT-OF-STATE
   999              MIGRANT




   Revision Date: 03/02/2000         Page 3 of 3    Release Date: 11/26/2002
   s900b County of Residence table
v1.13 10/22/2008
Page 208 of 208          Program Type Reference Table   s900c
   Code      NC Public Health Program Name

   AH        Adult Health
   BC        Breast Cancer
   CH        Child Health
   CC        Child Special Health Services
   CA        Contract Agency
   CE        Cervical Cancer
   DH        Dental Health
   CL        Childrens Developmental Service Agency
   EH        Environmental Health
   EP        Epidemiology
   FP        Family Planning
   IM        Immunization
   MH        Maternal Health
   OS        Other Services
   PC        Primary Care
   RH        Rural Health
   ST        Sexually Transmitted
   SL        State Lab
   TB        Tuberculosis




   Revision Date: 03/06/06            Page 1 of 1
   Release Date: 11/26/2002
   s900c Program Type table

				
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