Crosswalk

CMS Medicare Beneficiary and Family Centered Care Satisfaction Survey Revision Crosswalk

Question Number		Original Wording	Revision for Complaint Beneficiaries	Revision for Appeal Beneficiaries	Rationale for Revision
Original	Revised
Q1	Q1	Our records show that on [DATE] you filed [a complaint about the quality of care you or another person received under Medicare / an appeal about your or another person’s Medicare benefits]. Is that right?	Our records show that on [DATE] you filed a complaint about the quality of care you or another person received under Medicare. Is that right?	Our records show that on [DATE] you filed an appeal about your or another person’s Medicare benefits. Is that right?	No change – shown with 2 variations (complaint and appeal)
Intro to Q2	Intro to Q2	The questions in this survey will refer to the [Medicare quality of care complaint that you filed on the date shown in Question 1 as “your quality of care complaint” / Medicare benefits appeal that you filed on the date shown in Question 1 as “your appeal”].	The questions in this survey will refer to the Medicare quality of care complaint that you filed on [DATE] as “your quality of care complaint”.	The questions in this survey will refer to the Medicare benefits appeal that you filed on [DATE] as “your appeal”.	Simplified language
Q2	Q2	Have you gotten a resolution on your quality of care complaint / appeal? If No, please return the survey in the postage-paid envelope.	Have you gotten a resolution on received the results or findings in response to your quality of care complaint. If No, please return the survey in the postage-paid envelope go to #4.	Have you gotten a resolution on received the results or findings in response to your appeal? If No, please return the survey in the postage-paid envelope go to #4.	Improved specificity of question Based on cognitive testing findings, respondent could describe their experience even if they didn’t report having final findings of their case
Q3	Q3	How satisfied are you with the resolution of your [quality of care complaint / appeal]?	How satisfied are you with the resolution of results or findings in response to your quality of care complaint?	How satisfied are you with the resolution of results or findings in response to your appeal?	Improved specificity of question
Q4	Q4	Please give us your comments on the resolution of your [quality of care complaint / appeal].	Please give us your comments on the resolution of results or findings in response to your quality of care complaint and concerns.	Please give us your comments on the resolution of results or findings in response to your appeal.	Improved specificity of question
Intro to Q5	Intro to Q5	Interactions with the Intake Specialist The next questions are about the way your [quality of care complaint/appeal] was handled from the start. The questions will refer to the person you first spoke with when you called to file your [quality of care complaint/appeal] as the “Intake Specialist”. The Intake Specialist would have collected the details about your [quality of care complaint/appeal].	Quality of Care Complaint Process These next questions are about the way your quality of care complaint was handled from the start and the process that [QIO NAME], the Quality Improvement Organization (QIO) in your state used to get information and coordinate the steps in the 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 quality of care complaint, or in a follow-up conversation after your quality of care complaint was filed.	Appeal Process These next questions are about the way your appeal was handled from the start 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.	Changed reference to QIO representative “from the start” removed based on cognitive testing. Respondent could consider the “start” to be significantly before s/he filed a complaint/appeal
Q5	-	When you spoke with the Intake Specialist, how satisfied were you that he or she was as helpful as you thought they should be?	REMOVED FROM SURVEY	REMOVED FROM SURVEY	Not measuring interactions with “Intake Specialist” given CMS change in processing of cases
Q6	-	When you spoke with the Intake Specialist, how satisfied were you that he or she explained things in a way you could understand?	REMOVED FROM SURVEY	REMOVED FROM SURVEY	Not measuring interactions with “Intake Specialist” given CMS change in processing of cases
Q7	-	When you spoke with the Intake Specialist, how satisfied were you that he or she spent enough time with you?	REMOVED FROM SURVEY	REMOVED FROM SURVEY	Not measuring interactions with “Intake Specialist” given CMS change in processing of cases
Q8	-	When you spoke with the Intake Specialist, how satisfied were you that he or she listened carefully to you?	REMOVED FROM SURVEY	REMOVED FROM SURVEY	Not measuring interactions with “Intake Specialist” given CMS change in processing of cases
Q9	-	When you spoke with the Intake Specialist, how satisfied were you that he or she showed respect for what you had to say?	REMOVED FROM SURVEY	REMOVED FROM SURVEY	Not measuring interactions with “Intake Specialist” given CMS change in processing of cases
Intro to Q10	-	Interactions with the Case Manager The next questions will refer to the person who called you back after your [quality of care complain / appeal was filed as the “Case Manager”. The Case Manager would have contacted you about the resolution of your [quality of care complaint / appeal].	REMOVED FROM SURVEY	REMOVED FROM SURVEY	No longer distinguishing between Case Manager and Intake Specialist given CMS change in processing of cases
Q10	Q5	Did you speak to a Case Manager about your [quality of care complaint / appeal] on the phone? If No, go to Q20	Did you speak to a Case Manager QIO representative about your quality of care complaint on the phone? If No, go to Q20 #14	Did you speak to a Case Manager QIO representative about your appeal on the phone? If No, go to Q20 #14	Changed reference to QIO representative Removed “on the phone” as process does not require telephone follow-up in all cases
Q11	-	The Case Manager had all the information that you gave to the Intake Specialist about you [quality of care complaint/appeal].	REMOVED FROM SURVEY	REMOVED FROM SURVEY	No longer distinguishing between Case Manager and Intake Specialist given CMS change in processing of cases
Q12	Q11	The Case Manager was as responsive to your [quality of care complaint / appeal] as you thought they should be.	The Case Manager QIO representative was as responsive to your quality of care complaint as you thought they he or she should be.	The Case Manager QIO representative was as responsive to your appeal as you thought they he or she should be.	Changed reference to QIO representative Improved grammar
Q13	Q12	The Case Manager understood your situation.	The Case Manager QIO representative understood your the situation related to your quality of care complaint.	The Case Manager QIO representative understood your the situation related to your appeal.	Changed reference to QIO representative Improved specificity of question
Q14	Q13	The Case Manager talked with you about resources that were available to help you.	The Case Manager QIO representative talked with you about resources that were programs and services in your community that are available to help you with your health and wellbeing.	The Case Manager QIO representative talked with you about resources that were programs and services in your community that are available to help you with your health and wellbeing.	Changed reference to QIO representative Improved specificity of question. Based on cognitive testing findings, beneficiaries did not have a clear and consistent understanding of the term “resources”
Q15	Q6	When you spoke with the Case Manager, how satisfied were you that he or she was as helpful as you thought they should be?	When you spoke with the Case Manager, How satisfied were you that he or she the QIO representative was as helpful as you thought they he or she should be?	When you spoke with the Case Manager, How satisfied were you that he or she the QIO representative was as helpful as you thought they he or she should be?	Changed reference to QIO representative
Q16	Q7	When you spoke with the Case Manager, how satisfied were you that he or she explained things in a way you could understand?	When you spoke with the Case Manager, How satisfied were you that he or she the QIO representative explained things in a way you could understand?	When you spoke with the Case Manager, How satisfied were you that he or she the QIO representative explained things in a way you could understand?	Changed reference to QIO representative
Q17	Q8	When you spoke with the Case Manager, how satisfied were you that he or she spent enough time with you?	When you spoke with the Case Manager, How satisfied were you that he or she the QIO representative spent enough time with you?	When you spoke with the Case Manager, How satisfied were you that he or she the QIO representative spent enough time with you?	Changed reference to QIO representative
Q18	Q9	When you spoke with the Case Manager, how satisfied were you that he or she listened carefully to you?	When you spoke with the Case Manager, How satisfied were you that he or she the QIO representative listened carefully to you?	When you spoke with the Case Manager, How satisfied were you that he or she the QIO representative listened carefully to you?	Changed reference to QIO representative
Q19	Q10	When you spoke with the Case Manager, how satisfied were you that he or she showed respect for what you had to say?	When you spoke with the Case Manager, How satisfied were you that the QIO representative showed respect for what you had to say said?	When you spoke with the Case Manager, How satisfied were you that he or she the QIO representative showed respect for what you had to say said?	Changed reference to QIO representative Simplified language
Q20	Q14	Did you receive any letters about your [quality of care complaint / appeal]? If No, go to Q25	Did you receive get any forms or letters from the Centers for Medicare & Medicaid Services or the QIO about your quality of care complaint? If No, go to Q25#19	Did you receive get any forms or letters from the Centers for Medicare & Medicaid Services or the QIO about your appeal? If No, go to Q25#19	Simplified language Improved specificity of question Added “forms” based on cognitive testing findings: beneficiaries referred to written materials they received as letter, form letters, and forms
Q21	Q15	How satisfied were you that the letter(s) you got about your [quality of care complaint / appeal] explained things in a way you could understand?	How satisfied were you that the letters(s) forms or letters you got about your quality of care complaint explained things in a way you could understand?	How satisfied were you that the letters(s) forms or letters you got about your appeal explained things in a way you could understand?	Added “forms” based on cognitive testing findings: beneficiaries referred to written materials they received as letter, form letters, and forms
Q22	Q16	How satisfied were you that the letter(s) you got about your [quality of care complaint / appeal] contained all the information you needed?	How satisfied were you that the letters(s) forms or letters you got about your quality of care complaint contained had all the information you needed?	How satisfied were you that the letters(s) forms or letters you got about your appeal contained had all the information you needed?	Added “forms” based on cognitive testing findings: beneficiaries referred to written materials they received as letter, form letters, and forms Simplified language
Q23	Q17	How satisfied were you that the letter(s) you got about your [quality of care complaint / appeal] showed respect for your concerns?	How satisfied were you that the letters(s) forms or letters you got about your quality of care complaint showed respect for your concerns?	How satisfied were you that the letters(s) forms or letters you got about your appeal showed respect for your concerns?	Added “forms” based on cognitive testing findings: beneficiaries referred to written materials they received as letter, form letters, and forms
Q24	Q18	How satisfied were you that the letter(s) you got about your [quality of care complaint / appeal] had the same information that you were told in telephone conversations? Very satisfied Satisfied Neither satisfied nor dissatisfied Dissatisfied Very dissatisfied	How satisfied were you that the letters(s) forms or letters you got about your quality of care complaint had the same information that 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.	How satisfied were you that the letters(s) forms or letters you got about your appeal had the same information that 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.	Added “forms” based on cognitive testing findings: beneficiaries referred to written materials they received as letter, form letters, and forms Improved specificity of question Added a tailored inapplicable response based on cognitive testing findings.
Q25	Q19	Using any number from 0 to 10 where 0 is the word [quality of care complaint / appeal] process possible and 10 is the best [quality of care complaint / appeal] process possible, what number would you use to rate the overall [quality of care complaint / appeal] process?	In responding to your quality of care complaint [QIO NAME], the QIO in your state gathered information about your quality of care complaint, explained the complaint steps, and gave you the results or findings of your case. We are referring to this as the “quality of care complaint process”. Using any number from 0 to 10 where 0 is the word quality of care complaint process possible and 10 is the best quality of care complaint process possible, what number would you use to rate the overall quality of care complaint process?	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 word appeal process possible and 10 is the best appeal process possible, what number would you use to rate the overall appeal process?	Added clarification on definition of process to improve specificity of question
Q26	Q20	Please give us your comments on the process that was used to resolve your [quality of care complaint / appeal]. Include any comments you have on what worked well, and suggestions you have on ways to improve how the process.	Please give us your comments on the process that was used to resolve in responding to your quality of care complaint. Include any comments you have on what worked well, and suggestions you have on ways to improve how the process.	Please give us your comments on the process that was used to resolve in responding to your quality of care complaint. Include any comments you have on what worked well, and suggestions you have on ways to improve how the process.	Simplified language
Thank you	Thank you	Thank you: Those are all the questions we have for you now	Thank you for your participation.	Thank you for your participation.	Simplified language