Form VA Form 10-0473 VA Form 10-0473 Millennium Bill Emergency Care Provider Satisfaction Sur

VHA OHI Product Effectiveness
VHA Customer Satisfaction Survey of Non-VA Healthcare Providers

OMB 2900-XXXX
Estimated Burden: 5 min.

OMB 2900-XXXX

VHA Customer Satisfaction Survey of Non-VA Healthcare Providers
(VA Financial Service Center (FSC) Claim Processing)

Millennium Bill
Emergency Care Provider Satisfaction Survey

Veterans Health Administration
Office of Health Information, Product Effectiveness
THE PAPERWORK REDUCTION ACT of 1995. This information is collected in accordance with section 3507 of the Paperwork
Reduction Act of 1995. Accordingly, we may not conduct or sponsor, and you are not required to respond to a collection of
information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this
survey will average 5 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the
form. Customer satisfaction surveys are used to gauge customer perceptions of VA services as well as customer expectations
and desires. The results of this survey will lead to improvement in the quality of service delivery by helping to shape the direction
and focus of specific programs and services. Disclosure of information involves release of statistical data and other non-identifying
data for the improvement of services within the VA healthcare system and associated administrative purposes.

PRIVACY ACT INFORMATION: The information requested on this form is solicited under the authority of Title 38, U.S.C., Part I,
Chapter 5, Section 527 that authorizes the collection of data that will allow measurement and evaluation of the Department of
Veterans Affairs Programs. The purpose(s) for collecting the information is to evaluate the effectiveness of the Chief Business
Office (CBO) pilot project claims processing centralization effort and performance measures for non-VA Healthcare providers.
This survey information will be used to improve customer satisfaction with the claims process. The information you provide will be
used by the Department of Veterans Affairs to conduct a third-party survey through collaborative efforts by the Office of Health
Information, Product Effectiveness and Chief Business Office (CBO) in accordance with the Millennium Bill legislation (Title 38
U.S.C. Section 1725). Your obligation to respond is voluntary. Information from the data collection will become part of a system of
records that complies with the Privacy Act of 1974. This system is identified as "Veteran, Patient, Employee and Volunteer
Research and Development Project Records -VA (34VA11)" as set forth in the Compilation of Privacy Act Issuances via online
GPO access at http://www.gpoaccess.gov/privacyact/index.html.

VA FORM 10-0473
JUL 2009

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VHA OHI Product Effectiveness
VHA Customer Satisfaction Survey of Non-VA Healthcare Providers

OMB 2900-XXXX
Estimated Burden: 5 min.

(VA Financial Service Center (FSC) Claim Processing)

Millennium Bill Emergency Care Provider Satisfaction Survey
Claims Adjudication and Process Satisfaction:
1.

The letter I received regarding the VA’s new emergency medical care claims process clearly
notified me of the change in protocol for submitting *all* emergency medical care claims for
Veterans to the Financial Services Center (FSC) in Austin, TX.
a.
Strongly Agree
b.
Agree
c.
No opinion
d.
Disagree
e.
Strongly Disagree

2.

Since I began submitting claims to the FSC,, I am now more satisfied with the VA’s overall
timeliness of payment for emergency medical care claims.
a.
Strongly Agree
b.
Agree
c.
No opinion
d.
Disagree
e.
Strongly Disagree

3.

Since I began submitting claims to the FSC, I am now more satisfied with the Fee Schedules
used by the VA to pay emergency medical care claims.
a.
Strongly Agree
b.
Agree
c.
No opinion
d.
Disagree
e.
Strongly Disagree

4.

Since I began submitting claims to the FSC, I am now more satisfied with the VA’s Explanation of
Benefits (EOB) for emergency medical care claims.
a.
Strongly Agree
b.
Agree
c.
No opinion
d.
Disagree
e.
Strongly Disagree

5.

Since I began submitting claims to the FSC, I am now more satisfied with the VA’s eligibility
determinations for emergency medical care claims payment.
a.
Strongly Agree
b.
Agree
c.
No opinion
d.
Disagree
e.
Strongly Disagree

VA FORM 10-0473
JUL 2009

2 of 4

VHA OHI Product Effectiveness
VHA Customer Satisfaction Survey of Non-VA Healthcare Providers

OMB 2900-XXXX
Estimated Burden: 5 min.

6.

Since I began submitting claims to the FSC, I am now more satisfied with the number of medical
services (on a line item basis) per emergency medical care claim the VA deems eligible for
reimbursement.
a.
Strongly Agree
b.
Agree
c.
No opinion
d.
Disagree
e.
Strongly Disagree

7.

Since I began submitting claims to the FSC, I am now more satisfied with the number of paid
emergency medical care claims processed by the VA within 30 days.
a.
Strongly Agree
b.
Agree
c.
No opinion
d.
Disagree
e.
Strongly Disagree

8.

Since I began submitting claims to the FSC, I am now more satisfied with the VA’s timeliness of
response to claim appeals or Requests for Reconsideration I submitted.
a.
Strongly Agree
b.
Agree
c.
No opinion
d.
Disagree
e.
Strongly Disagree

9.

Since I began submitting claims to the FSC, I am now more satisfied with the emergency medical
care claims customer support.
a.
Strongly Agree
b.
Agree
c.
No opinion
d.
Disagree
e.
Strongly Disagree

10.

Since I began submitting claims to the FSC, I am now more satisfied overall with the emergency
medical care claims adjudication and reimbursement process.
a.
Strongly Agree
b.
Agree
c.
No opinion
d.
Disagree
e.
Strongly Disagree

Claims Processing Consolidation Impact:
11.

Since you began submitting claims to the FSC, has the number of emergency care claims denied
by the VA increased, decreased, or remained the same?
a.
Increased
b.
Decreased
c.
Remained the same
d.
Do not know

VA FORM 10-0473
JUL 2009

3 of 4

VHA OHI Product Effectiveness
VHA Customer Satisfaction Survey of Non-VA Healthcare Providers

OMB 2900-XXXX
Estimated Burden: 5 min.

12.

Since you began submitting claims to the FSC, has the number of emergency care claims
partially paid by the VA increased, decreased, or remained the same?
a.
Increased
b.
Decreased
c.
Remained the same
d.
Do not know

13.

Since you began submitting claims to the FSC, has the number of duplicate emergency medical
care claims processed by the VA increased, decreased, or remained the same?
a.
Increased
b.
Decreased
c.
Remained the same
d.
Do not know

14.

How long have you been submitting emergency medical care claims to the VA for processing and
payment?
a.
Less than 1 year
b.
1 – 3 years
c.
3 – 5 years
d.
Over 5 years

15.

Could you please tell us if you think it is important for the VA to develop an online web portal that
provides you with the capabilities to review a claim’s status, search for claim documentation, and
view an online EOB?
a.
Extremely important
b.
Very important
c.
Somewhat important
d.
Not important
e.
No Opinion

16.

Is there any other comment or suggestion you would like to provide regarding the VA’s new
emergency medical care claims process?

VA FORM 10-0473
JUL 2009

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