Form CMS-10393 Appeals Survey

CMS Medicare Beneficiary and Family Centered Care Satisfaction Survey

Appeal

Your Medicare Appeal

1. Our records show that on [DATE] you filed an appeal about your or another person’s Medicare benefits. Is that right?

• Yes

• N o If No, please return the survey in the postage-paid envelope.

The questions in this survey refer to the Medicare appeal that you filed on [DATE] as “your appeal”.

2. Have you received the results or findings in response to your appeal?

• Yes

• N o If No, go to #4

3. How satisfied are you with the results or findings in response to your appeal?

• Very satisfied

• Satisfied

• Neither satisfied nor dissatisfied

• Dissatisfied

• Very dissatisfied

4. Please give us your comments on the results or findings in response to your appeal.

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Appeal Process

The next questions are about the way your appeal was handled and the process that [QIO NAME], the Quality Improvement Organization (QIO) in your state used to get information and coordinate the steps in the appeal process.

The questions will refer to the representative from [QIO NAME], the QIO in your state as the “QIO representative”. You may have spoken to the QIO representative when you filed your appeal, or in a follow-up conversation after your appeal was filed.

5. Did you speak to a QIO representative about your appeal?

• Yes

• No If No, go to #14

6. How satisfied were you that the QIO representative was as helpful as you thought he or she should be?

• Very satisfied

• Satisfied

• Neither satisfied nor dissatisfied

• Dissatisfied

• Very dissatisfied

7. How satisfied were you that the QIO representative explained things in a way you could understand?

• Very satisfied

• Satisfied

• Neither satisfied nor dissatisfied

• Dissatisfied

• Very dissatisfied

8. How satisfied were you that the QIO representative spent enough time with you?

• Very satisfied

• Satisfied

• Neither satisfied nor dissatisfied

• Dissatisfied

• Very dissatisfied

9. How satisfied were you that the QIO representative listened carefully to you?

• Very satisfied

• Satisfied

• Neither satisfied nor dissatisfied

• Dissatisfied

• Very dissatisfied

10. How satisfied were you that the QIO representative showed respect for what you said?

• Very satisfied

• Satisfied

• Neither satisfied nor dissatisfied

• Dissatisfied

• Very dissatisfied

How much do you agree or disagree with the following statements:

11. The QIO representative was as responsive to your appeal as you thought he or she should be.

• Strongly agree

• Agree

• Neither agree nor disagree

• Disagree

• Strongly disagree

12. The QIO representative understood the situation related to your appeal.

• Strongly agree

• Agree

• Neither agree nor disagree

• Disagree

• Strongly disagree

13. The QIO representative talked with you about programs and services in your community that are available to help you with your health and wellbeing.

• Strongly agree

• Agree

• Neither agree nor disagree

• Disagree

• Strongly disagree

Letter(s) about your Appeal

14. Did you get any forms or letters from the Centers for Medicare & Medicaid Services or the QIO about your appeal?

• Yes

• No If No, go to #19

15. How satisfied were you that the forms or letters you got about your appeal explained things in a way you could understand?

• Very satisfied

• Satisfied

• Neither satisfied nor dissatisfied

• Dissatisfied

• Very dissatisfied

16. How satisfied were you that the forms or letters you got about your appeal had all the information you needed?

• Very satisfied

• Satisfied

• Neither satisfied nor dissatisfied

• Dissatisfied

• Very dissatisfied

17. How satisfied were you that the forms or letters you got about your appeal showed respect for your concerns?

• Very satisfied

• Satisfied

• Neither satisfied nor dissatisfied

• Dissatisfied

• Very dissatisfied

18. How satisfied were you that the forms or letters you got about your appeal were consistent with the information you were told in telephone conversations with the QIO?

• Very satisfied

• Satisfied

• Neither satisfied nor dissatisfied

• Dissatisfied

• Very dissatisfied

• I did not have any telephone conversations with the QIO

Overall Appeal Process

19. In responding to your appeal [QIO NAME], the QIO in your state gathered information about your appeal, explained the appeal steps, and gave you the results or findings of your case. We are referring to this as the “appeal process”. Using any number from 0 to 10 where 0 is the worst appeal process possible and 10 is the best appeal process possible, what number would you use to rate the overall appeal process?

• 0 – Worst process possible

• 1

• 2

• 3

• 4

• 5

• 6

• 7

• 8

• 9

• 10 – Best process possible

20. Please give us your comments on the process that was used in responding to your appeal. Include any comments you have on what worked well, and suggestions you have on ways to improve the process.

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Thank you for your participation.

Public Burden Statement:  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this project is XXXX-XXXX.  Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:  CMS POINT OF CONTACT