627 2013 627 CMS - Novitas JL MAC (5-20-13 initial survey)

---

Overview

Guidelines
Welcome and Thank You Text
MODEL Questions
Custom Questions

---

Sheet 1: Guidelines

Questionnaire Management Guidelines

Goals:

�

One consolidated document to track all model and CQ changes throughout the life of the project

�

Questionnaire always matches the live survey

�

Easy and error-free way to submit CQ changes

�

All changes tracked and reflected in one document (DOT will help)

Questionnaire Resources:

1

Questionnaire Design and Approval Process

2

Question Grouping Rules

3

OPS vs. Skip Logic Decision for "Other, Please Specify"

4

Foreign Language Survey Instructions

---

Sheet 2: Welcome and Thank You Text

Model Instance Name:
CMS - Novitas JL MAC
MID:	Existing Measure - Please fill in; New Measure - DOT will fill in
Date:	5/20/2013
Welcome and Thank You Text
	Directions:
	This welcome text is shown at the top of the questionnaire window and the thank you text at the bottom. This is a good place to mention the site/company/agency name so the visitor knows whom they are taking the survey for. Feel free to modify the standard Welcome and Thank you text shown in the boxes below. Please read comments before using any of the text.
					Examples
					Welcome Text Example
	Welcome Text
	bharati.hulbanni: if STORES MEASURE: do NOT use any welcome text. Thank you for visiting the Novitas Solutions, Inc. website. You have been randomly selected to take part in this brief website satisfaction survey. Please take a few minutes to share your opinions regarding our website elements, such as navigation, search, content, etc., which are essential in helping us provide the best online experience possible. Your comments and scores on this survey will be directed to the Medicare Internet Team. Therefore, please limit your comments and scores on this survey to your experiences and opinions on the Web Site only.
					Thank You Text Example
	DEFAULT Thank You Text
	bharati.hulbanni: TY text can be used for all measure types (call center, web, stores, mobile etc.)
	ALTERNATE WEB Thank You Text
	bharati.hulbanni: Use this TY text ONLY for WEB Thank you for your time in completing this survey. Your input is very valuable and will be taken into consideration.

---

Sheet 3: MODEL Questions

Model Instance Name:
CMS - Novitas JL MAC
MID:		Existing Measure - Please fill in; New Measure - DOT will fill in			THIS IS THE CMS APPROVED SET OF MODEL QUESTIONS
Partitioned (Y)
FPI Included(N)
NOTE: All non-partitioned surveys will NOT be imputed and the elements will be rotated as a default unless otherwise specified and approved by Research.					THIS IS THE CMS APPROVED SET OF MODEL QUESTIONS
Date:	5/20/2013
CMS - Novitas JL MAC
Model questions utilize the ACSI methodology to determine scores and impacts
		ELEMENTS (drivers of satisfaction)			CUSTOMER SATISFACTION			FUTURE BEHAVIORS	FPI
	MQ Label			MQ Label			MQ Label		Y?
		Content (1=Poor, 10=Excellent, Don't Know)			Satisfaction			Primary Resource (1=Very Unlikely, 10=Very Likely)
1	Content - Accuracy	Please rate the accuracy of information on this site.	21	Satisfaction - Overall	What is your overall satisfaction with this site? (1=Very Dissatisfied, 10=Very Satisfied)	24	Primary Resource	How likely are you to use this site as your primary resource for getting information on Medicare?
2	Content - Quality	Please rate the quality of information on this site.	22	Satisfaction - Expectations	How well does this site meet your expectations? (1=Falls Short, 10=Exceeds)			Recommend (1=Very Unlikely, 10=Very Likely)
3	Content - Freshness	Please rate the freshness of content on this site.	23	Satisfaction - Ideal	How does this site compare to your idea of an ideal website? (1=Not Very Close, 10=Very Close)	25	Recommend	How likely are you to recommend this site to someone else?
		Functionality (1=Poor, 10=Excellent, Don't Know)						Return (1=Very Unlikely, 10=Very Likely)
4	Functionality - Usefulness	Please rate the usefulness of the services provided on this site.				26	Return	How likely are you to return to this site?
5	Functionality - Convenient Services	Please rate the convenience of the services on this site.
6	Functionality - Accomplish Goal	Please rate the ability to accomplish what you wanted to on this site.
		Look and Feel (1=Poor, 10=Excellent, Don't Know)
7	Look and Feel - Readability	Please rate the ease of reading this site.
8	Look and Feel - Organization	Please rate the clarity of site organization.
9	Look and Feel - Layout	Please rate the clean layout of this site.
		Navigation (1=Poor, 10=Excellent, Don't Know)
10	Navigation - Steps	Please rate the degree to which the number of steps it took to get where you want is acceptable.
11	Navigation - Find	Please rate the ability to find information you want on this site.
12	Navigation - Layout	Please rate the clarity of the site map/directory.
13	Navigation - Ease	Please rate the ease of navigation on this site.
		Search (1=Poor, 10=Excellent, Don't Know)
14	Search - Usefulness	Please rate the usefulness of search results on this site.
15	Search - Comprehensive	Please rate how this site provides comprehensive search results.
16	Search - Organization	Please rate the organization of search results on this site.
17	Search - Narrow	Please rate how the search feature helps you to narrow the results to find the information you want.
		Site Performance (1=Poor, 10=Excellent, Don't Know)
18	Site Performance - Loading	Please rate the speed of loading the page on this site.
19	Site Performance - Consistency	Please rate the consistency of speed on this site.
20	Site Performance - Reliability	Please rate the reliability of site performance on this site.

---

Sheet 4: Custom Questions

Model Instance Name:

red & strike-through: DELETE

CMS - Novitas JL MAC

underlined & italicized: RE-ORDER

MID: Existing Measure - Please fill in; New Measure - DOT will fill in

pink: ADDITION

Date:

5/20/2013

blue + -->: REWORDING

CMS - Novitas JL MAC CUSTOM QUESTION LIST

bharati.hulbanni: Hide (DO NOT DELETE) this column before sending to a client. QID

FPI Y?

bharati.hulbanni: there should be NO MORE THAN ONE LETTER IN HERE (Skip Logic Label) Skip Logic Label

Question Text

bharati.hulbanni: Hide (DO NOT DELETE) this column before sending to a client. AnswerIDs (DOT)

Answer Choices (limited to 50 characters)

Skip to

Type (select from list)

Single or Multi

Required Y/N

bharati.hulbanni: Can not have more than one CQ GroupType (denoted by an *) within one colored group in 'Special Instructions' . Special Instructions

CQ Label

In the last 30 days, how many times have you visited this website?

This is my first time

Radio button, one-up vertical

Single

Y

Visit Frequency

Once or twice

Three or four times

More than once per week but not every day

Every day

Which best describes you?

Provider of medical services

Radio button, one-up vertical

Single

Y

Skip Logic Group*

Best describes you

Supplier of medical equipment or supplies

Staff of provider/supplier working primarily with billing/insurance

Administrative staff of a provider/supplier

Other staff of a provider/supplier

Consultant or attorney

Billing service

Other

A

A

Please explain briefly:

Text area, no char limit

N

Skip Logic Group*

Other-Role

What is your primary reason for visiting this site today?

Download forms

Radio button, one-up vertical

Single

Y

Skip Logic Group*

Reason for visiting

Learn of, or register for, workshops, seminars or other training events

Find contact information

Find general Medicare program information

Research a specific question on Medicare policy or billing

Find information on fees or fee schedules

Find out about a Local Coverage Determination (LCD)

Read Medicare publications such as newsletters, articles etc.

Find enrollment information

Take an on-line training course

Other

B

B

Please explain briefly:

Text area, no char limit

N

Skip Logic Group*

Other-Primary Reason

What information center(s) or topic(s) did you access on our Web site today (check all that apply)?

Appeals

Checkbox, one-up vertical

Multi

Y

OPS Group

Info Centers or Topics Access

Audit and Reimbursement (Part A Fees)

CERT

Claims/Eligibility

Electronic Billing (EDI)

Enrollment

Evaluation and Management

Part B Fee Schedules

Forms Catalog

Medical Policy

Medicare News & Bulletins

Self-Service Tools

Provider Training and Events

I did not use an information center, but was looking for information on this topic:

C

C

Other information of interest:

Text area, no char limit

N

OPS Group

Other info of Interest

Did you use any search features on this site today?

Yes

D, E, F

Radio button, one-up vertical

Single

N

Skip Logic Group*

Search Feature Usage

No

D

How would you rate the helpfulness of the search tool?

Very helpful

Radio button, one-up vertical

Single

N

Skip Logic Group*

Helpfulness of Search Tool

Somewhat helpful

Fair

Somewhat unhelpful

Very unhelpful

E

What search term(s) did you use?

Text area, no char limit

N

Skip Logic Group*

Search Terms Used

F

Please briefly explain your experience with the search tool.

Text area, no char limit

N

Skip Logic Group*

Search Tool Experience

How did you look for the information you wanted / needed on this site? (select all that apply)

Using the navigation menu on the left side of the page

Radio button, one-up vertical

Single

Y

Skip Logic Group*

Look for Information

Using links in the center of the page

Using the site search feature

Using the site map

Other

G

G

What other method did you use to look for the information you wanted / needed?

Text area, no char limit

N

Skip Logic Group*

Other Method to Look for Info

Were you able to accomplish your goal in visiting the Web site today?

Yes

Radio button, one-up vertical

Single

Y

Skip Logic Group*

Accomplish Goal

No

H

H

Please explain what you were unable to accomplish:.

Text area, no char limit

N

Skip Logic Group*

Unable to accomplish

How could the Web site be improved to make your job easier?

Text area, no char limit

N

One Improvement

Do you subscribe to Novitas' E-mail List (listserv)?

Yes

I

N

Skip Logic Group*

Subscribe to E-mail list

No

I

What enhancements could be made to our e-mail list to make it a more useful tool for you?

N

Skip Logic Group*

Email enhancements

If you are over the age of 18 and would like Novitas to respond to your feedback regarding this Web site, please provide your name, along with an e-mail address or telephone number here:

Text area, no char limit

N

Contact Information

Radio button, scale, has don't know