Form CMS-10308 Complaints Resolution Survey (Spanish)

Part C and D Complaints Resolution Performance Measure
(HHSM-500-2009-00112G)

Centers for Medicare & Medicaid Services
2012 Complaints Resolution Survey
Website Spanish Screenshots

When beneficiaries enter the web address they will be directed to the Login Screen.
Screenshot 1: Login Screen

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Part C and D Complaints Resolution Performance Measure
(HHSM-500-2009-00112G)

If the beneficiary enters the wrong complaint ID, they will be directed to the Invalid Login Screen. The
can return the Login screen to try again. Directions of where to find their complaint ID are located on
the Login screen.
Screenshot 2: Invalid Login Screen

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Part C and D Complaints Resolution Performance Measure
(HHSM-500-2009-00112G)

If beneficiaries place their mouse arrow over to the Home tab, they will see link to “Survey Login” in a
green drop-down menu. When the mouse “hovers” over any of the tabs, the Spanish translation will
also be shown.
Screenshot 3: Home Tab Drop-Down Menu

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Part C and D Complaints Resolution Performance Measure
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Instructions for how to toggle the survey are located at the bottom of the Login Page. The instructions
direct them to the language toggle menu at the top of the page.
Screenshot 4: Language Toggle Menu

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Part C and D Complaints Resolution Performance Measure
(HHSM-500-2009-00112G)

Once beneficiaries log in with their complaint ID, they will see the Welcome Screen. The survey is
personalized with the beneficiary first name (e.g., Don) and the beneficiary plan name (e.g., UUU).
Screenshot 5: Welcome Screen

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Part C and D Complaints Resolution Performance Measure
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The Introduction Screen tells the respondent the purpose of the survey and is personalized with the
beneficiary first name (e.g., Don) and the month their complaint was filed in the CTM (e.g., May).
Screenshot 6: Introduction Screen

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Part C and D Complaints Resolution Performance Measure
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The Instructions Screen provides information on how to complete the web survey and is personalized
with the month their complaint was filed in the CTM (e.g., May).
Screenshot 7: Instructions Screen

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Part C and D Complaints Resolution Performance Measure
(HHSM-500-2009-00112G)

Q1 is personalized with the complaint category associated with the beneficiary’s complaint ID.
Screenshot 8: Q1 and Q2

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Part C and D Complaints Resolution Performance Measure
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If Q1 is not answered, the beneficiary will receive a pop up notification letting them know that they
must complete all questions before they can continue with the survey.
Screenshot 9: Pop-up Notification

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Part C and D Complaints Resolution Performance Measure
(HHSM-500-2009-00112G)

If Q2 is not answered fully (e.g. a response on all 5 lines), beneficiary will receive a pop up notification
(same as pop up from Q1, screenshot 9) letting them know that they must complete all questions before
they can continue with the survey. After clicking “OK”, beneficiaries will see that the missing part of the
question is in red. This will occur throughout the survey whenever a question is only partially answered
by the beneficiary.
Screenshot 10: Q2 Red Note

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Part C and D Complaints Resolution Performance Measure
(HHSM-500-2009-00112G)

If Q3 or Q4 are not answered (or answered only partially), beneficiaries will receive a pop up notification
(same as pop up from Q1, screenshot 9) letting them know that they must complete all questions before
they can continue with the survey. After clicking “OK”, beneficiaries see will that the missing part of Q3
is in red.
Screenshot 11: Q3 and Q4

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Part C and D Complaints Resolution Performance Measure
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Q5 is personalized with the beneficiary plan name (e.g., UUU). If Q5 or Q6 are not answered,
beneficiaries will receive a pop up notification (same as pop up from Q1, screenshot 9) letting them
know that they must complete all questions before they can continue with the survey.
Screenshot 12: Q5 and Q6

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Part C and D Complaints Resolution Performance Measure
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Q7 and Q8 are personalized with the beneficiary plan name (e.g., UUU). If Q7 or Q8 are not answered,
beneficiaries will receive a pop up notification (same as pop up from Q1, screenshot 9) letting them
know that they must complete all questions before they can continue with the survey.
Screenshot 13: Q7 and Q8

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Part C and D Complaints Resolution Performance Measure
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If Q9 is not answered, beneficiaries will receive a pop up notification (same as pop up from Q1,
screenshot 9) letting them know that they must complete all questions before they can continue with
the survey. Q10 is not a mandatory question. The beneficiary can submit the survey even if Q10 is
blank.
Screenshot 14: Q9 and Q10

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Part C and D Complaints Resolution Performance Measure
(HHSM-500-2009-00112G)

Once completed, beneficiaries will be taken to a Thank You screen. From here they can still access
additional menus but will not be able to access their survey data once it has been submitted.
Screenshot 15: Thank You

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Part C and D Complaints Resolution Performance Measure
(HHSM-500-2009-00112G)

When beneficiaries move the mouse arrow over to the FAQ tab, they will see a link to “Frequently Asked
Questions” in a green drop-down menu. After clicking the FAQ tab, beneficiaries can see the Frequently
Asked Questions Page which opens in a separate tab or browser window.
Screenshot 16: Frequently Asked Questions Page

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Part C and D Complaints Resolution Performance Measure
(HHSM-500-2009-00112G)

When beneficiaries move the mouse arrow over to the Help & Support tab, they will see “Contact Us”
link in a green drop-down menu. After clicking the “Contact Us” link, the CMS Survey Help & Support
page will open in a separate tab or browser window.
Screenshot 17: Help & Support Page

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Part C and D Complaints Resolution Performance Measure
(HHSM-500-2009-00112G)

If mandatory fields are not filled out, beneficiaries will receive a pop up notification (same as pop up
from Q1, screenshot 7) letting them know that they must complete all questions before they can submit
their help issue. After clicking “OK”, beneficiaries will see that the missing part of the question(s) is in
red.
Screenshot 18: CMS Survey Help & Support Red Notes

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Part C and D Complaints Resolution Performance Measure
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After beneficiaries fill out the CMS Help & Support page, they will see a “Thank you” page.
Screenshot 19: Help & Support Thank You page

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Part C and D Complaints Resolution Performance Measure
(HHSM-500-2009-00112G)

When beneficiaries move the mouse arrow over to the Resources tab, they will see several links in the
green drop-down menus. The Resources tab provides links to the following website:






Medicare.gov
HHS.gov
File a Complaint
(https://www.medicare.gov/MedicareComplaintForm/home.aspx)
Useful Phone & Websites
(http://www.medicare.gov/Contacts/Default.aspx)

Screenshot 20: Resources Drop-Down Menu

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Part C and D Complaints Resolution Performance Measure
(HHSM-500-2009-00112G)

You can access the survey using the following link:
http://medicare-comp-survey.cms.gov/index.php?sid=92132
Below are list of test IDs that you can use to login the survey.
PWVIVVKRRMBF
JZJWFCEJPQOW
AKCUGUYNFXLX
EDWAFSCEMKWG
NHVIHCCWTMUT
JGPNYWNKAAFS
QYHANKQFILLF
OXCZBSAKEVSA
AXPTYANBDGRU
GYVVWDLUYGUK
AABMTJWHMLIA
CSKLTICLZQBL
WQIWSMUHORMG
XKJTPJYCFJQF
CRCGZBNWHFHQ

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