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pdfTRICARE STANDARD SURVEYS‐PROVIDERS (TSS‐P)
FY2014 WEB SURVEY
1.
MD SURVEY
SCREEN 1
SCREEN 2:
SCREEN 3:
IF NO AT SCREEN 3:
IF YES AT SCREEN 3, GO TO SCREEN 4:
SCREEN 5:
SCREEN 6:
IF NO AT SCREEN 6, GO TO SCREEN 7:
IF YES OR I DON’T KNOW AT SCREEN 6, GO TO SCREEN 8:
SCREEN 9:
SCREEN 10:
IF YES AT SCREEN 10, GO TO “COMPLETE” SCREEN:
IF NO AT SCREEN 10, GO TO SCREEN 11 AND THEN FOLLOW TO SCREEN 12
SCREEN 11:
IF “DON’T KNOW” AT SCREEN 10, GO TO SCREEN 12:
SCREEN 13:
ALL RESPONSES GO TO “COMPLETE” SCREEN:
END OF MD SURVEY
2. BEHAVIORAL HEALTH PROVIDER SURVEY
SCREEN 1:
SCREEN 2:
SCREEN 3:
IF NO AT SCREEN 3, GO TO “COMPLETE” SCREEN:
IF “NOT IN PRIVATE PRACTICE AT SCREEN 3, GO TO SCREEN 15:
ALL RESPONSES TO SCREEN 15 AND IF YES AT SCREEN 3 GO TO SCREEN 4:
SCREEN 5:
SCREEN 6:
SCREEN 7:
IF NO AT SCREEN 7, GO TO SCREEN 8:
IF YES OR “DON’T KNOW” AT SCREEN 7, GO TO SCREEN 9:
SCREEN 10:
SCREEN 11:
IF YES AT SCREEN 11, GO TO COMPLETE SCREEN:
IF NO AT SCREEN 11, GO TO SCREEN 12:
IF “DON’T KNOW” AT SCREEN 11, GO TO SCREEN 13:
SCREEN 14:
COMPLETE SCREEN:
OMB NO.:0720-0031
EXPIRATION DATE: XX/XX/XXXX
OFFICE OF THE ASSISTANT SECRETARY OF DEFENSE
HEALTH AFFAIRS
[FOR REVIEWERS: BH Mailing #1]
DEFENSE
HEALTH AGENCY
[Unique Provider ID Number]
FOR: [Insert Provider Name]
Street Address
City, State, and Zip
Month Date, 2015
Dear [Insert Provider Name],
Hello! You have been selected to participate in a very important survey effort. In support of U.S. military men and
women, Congress has directed the Department of Defense to survey civilian mental and behavioral health care providers
across the U.S. to determine whether military service members and their families have access to the care they need. A
substantial amount of mental and behavioral health care provided to our military and their families is delivered by private,
civilian providers like yourself. The DoD has contracted Ipsos to conduct this survey.
We are asking you to please answer the questions on the back of this letter and return it within five days. We suggest
that the survey be completed by the person in your office who is most knowledgeable about billing and insurance. We
recognize that there may be more than one provider in your office and ask that this survey be completed for the provider
listed above.
There are several ways to complete this survey, which should only take five minutes of your time:
Complete the survey on the reverse side of this letter and return it via postal mail in the enclosed postage paid
envelope
Complete the survey on the reverse side of this letter and fax it to 1-800-409-7681
Complete the survey on the internet at the following URL: http://www.dodcv08.com
Your unique login name: xxxxxxxx
Your unique password: xxxxxxxx
Thank you in advance for your cooperation and help as we examine this important issue that impacts our American
service men and women. If you have questions about this survey, please call Ipsos between the hours of 8AM and
5PM Eastern Time at 1-800-228-6764.
Sincerely yours,
Capt. Jamie Lindly, MSC, USN
Chief, Analytics Division
SURVEY QUESTIONS ON REVERSE SIDE
The public reporting burden for this collection of information is estimated to average five (5) minutes to complete, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, 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 the burden, to the Department of Defense, Washington
Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA
22350-3100 (0720-0031]. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to
comply with a collection of information if it does not display a currently valid OMB control number. This Official DoD survey may be confirmed at the TRICARE
website http://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Health-Care-Program-Evaluation/TRICARE-Patient-Satisfaction-Surveys, click
on Current Active Surveys, and find "Survey of Civilian Provider Acceptance of TRICARE Standard."
PRIVACY ADVISORY STATEMENT
Information collected for this Survey will be used to help TRICARE health policy makers gauge civilian provider awareness and acceptance of the TRICARE
Standard health care benefit option, and provide aggregated input to improve the Military Health System. All information will be de-identified prior to being
reported. Completing the Survey is voluntary; you may stop the Survey at any time and skip any questions you choose. There is no penalty if you choose
not to respond, although maximum participation is encouraged so the data will be complete and representative.
OMB NO.:0720-0031
EXPIRATION DATE: XX/XX/XXXX
Q1. Does [Insert Provider Name]
provide treatment or counseling to patients through
private practice? (Is he/she working in a setting where
providers, individually or as a group, decide or influence
which health insurance to accept?)
Q6. If you answered “no” to Q5 below, why is
[Insert Provider Name]
not accepting new TRICARE Standard patients?
Please list all the reasons. If you need additional space,
please include a separate sheet of paper.
Yes (Go to Q2)
No, does not provide treatment or counseling, or has
retired (Thank you, please return the questionnaire)
No, not in private practice
(Go to Q1a)
Q1a. What type of practice is [Insert Provider Name]
in? (Please choose one)
Government: Federal, State or other municipality
School, University or other academic institution
Hospital staff
Contractor providing services exclusively to
government clients
Rehab Facility, Nursing Home, or Home Health
Provider
Closed Panel HMO
Other ______________
Q2. What type of health care provider is
[Insert Provider Name]?
MARK ALL THAT APPLY.
Certified Clinical Social Worker
Certified Psychiatric Nurse Specialist
Clinical Psychologist
Certified Marriage and Family Therapist
Pastoral Counselor
Mental Health Counselor
Other _____________
Q3. Is [Insert Provider Name]
aware of the TRICARE health care program?
Yes
No
I Don't Know
Q4. As of today, is [Insert Provider Name]
a contracted member of the TRICARE network of
health care providers?
Yes
No
I Don't Know
Q5. As of today, is [Insert Provider Name] accepting
new TRICARE Standard patients?
No
(Go to Q6)
Yes, on a claim by claim basis only (Go to Q7)
Yes, for all claims
(Go to Q7)
I Don't know
(Go to Q7)
Q7. What percentage of patients seen by
[Insert Provider Name]
use any form of TRICARE? If unsure, please
write down your best guess.
None: [Insert Provider Name]
has no TRICARE patients
___________ percent use some form of TRICARE
I Don’t Know
Q8. Does [Insert Provider Name]
accept Medicare patients?
Yes
No
I Don't Know
Q9. As of today, is [Insert Provider Name] accepting
new Medicare patients?
Yes
Thank you, please return
the questionnaire
No
I Don't Know
(Go to Q10)
(Go to Q11)
Q10. If you answered “no” to Q9 above, why is
[Insert Provider Name]
not accepting new Medicare patients?
Please list all the reasons. If you need additional space,
please include a separate sheet of paper.
Q11. Does [Insert Provider Name]
accept payment from government or private
health insurance plans?
Yes
No
Q12. As of today, is [Insert Provider Name] accepting
new patients?
Yes
No
I Don't Know
Thank you for taking the time to complete this survey. Please put this in the enclosed postage-paid envelope and return it to
the Survey Processing Center or fax the survey to Ipsos at 1-800-409-7681. If you have any questions about TRICARE, its
specific health plans, or the benefits it provides, please visit the TRICARE web site at www.tricare.mil for assistance.
OMB NO.: 0720-0031
EXPIRATION DATE: XX/XX/XXXX
OFFICE OF THE ASSISTANT SECRETARY OF DEFENSE
HEALTH AFFAIRS
[FOR REVIEWERS: MD/DO Mailing #1]
DEFENSE
HEALTH AGENCY
[Unique Provider ID Number]
FOR: [Insert Provider Name] [Credentials]
Street Address
City, State, and Zip
Month Date, 2015
Dear BILLING MANAGER for [Insert Provider Name] [Credentials],
Hello! The physician named above has been selected to participate in a very important survey effort. In support of U.S.
military men and women, Congress has directed the Department of Defense to survey civilian physicians across the U.S.
to determine whether military service members and their families have access to the health care they need. A substantial
amount of health care to service members and their families is delivered by private, civilian physicians like [Insert Provider
Name] [Credentials], and we need your help.
We are asking you to please answer the questions on the back of this letter on behalf of the physician above and
return it within five days. There are several ways to complete this survey, which should only take five minutes of your
time:
Complete the survey on the reverse side of this letter and return it via postal mail in the enclosed postage paid envelope
Complete the survey on the reverse side of this letter and fax it to 1-800-409-7681
Complete the survey on the internet at the following URL: http://www.dodcv08.com
Your unique login name: xxxxxxxx
Your unique password: xxxxxxxx
We recognize that there may be more than one provider in your office and ask that you complete the survey for the
provider listed above. Since we may survey more than one provider in your office, please complete each survey for the
appropriate provider named above. If you are not the appropriate person to answer these questions, please pass this on
to the person in your office most familiar with the [Insert Provider Name] [Credentials]’s billing and insurance.
Thank you in advance for your cooperation and help as we examine this important issue that impacts our American
service men and women. If you have questions about this survey, please call Ipsos between the hours of 8AM and 5PM
Eastern Time at 1-800-228-6764.
Sincerely yours,
Capt. Jamie Lindly, MSC, USN Chief, Analytics Division
SURVEY QUESTIONS ON REVERSE SIDE
The public reporting burden for this collection of information is estimated to average five (5) minutes to complete, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, 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 the burden, to the Department of Defense, Washington Headquarters Services, Executive Services
Directorate, Information Management Division, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 (07200031]. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for
failing to comply with a collection of information if it does not display a currently valid OMB control number. This Official DoD survey
may be confirmed at the TRICARE website http://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Health-CareProgram-Evaluation/TRICARE-Patient-Satisfaction-Surveys, click on Current Active Surveys, and find "Survey of Civilian Provider
Acceptance of TRICARE Standard."
PRIVACY ADVISORY STATEMENT
Information collected for this Survey will be used to help TRICARE health policy makers gauge civilian provider awareness and acceptance of the TRICARE
Standard health care benefit option, and provide aggregated input to improve the Military Health System. All information will be de-identified prior to being
reported. Completing the Survey is voluntary; you may stop the Survey at any time and skip any questions you choose. There is no penalty if you choose
not to respond, although maximum participation is encouraged so the data will be complete and representative.
OMB NO.: 0720-0031
EXPIRATION DATE: XX/XX/XXXX
Q1. Does [Insert Provider Name] [Credentials]
provide treatment to patients through private
practice? (Is he/she working in a setting where
providers, individually or as a group, decide or influence
which health insurance to accept?)
Yes
(Go to Q2)
No, does not provide treatment , or has retired
(Thank you, please return the questionnaire)
No, not in private practice (Go to Q1a)
Q1a. What type of practice is [Insert Provider Name]
[Credentials] in? (please choose one)
Government: Federal, State or other municipality
School, University or other academic institution
Hospital staff
Contractor providing services exclusively to
government clients
Rehab Facility, Nursing Home, or Home Health
Provider
Closed Panel HMO
Other ______________
Q2. Is [Insert Provider Name] [Credentials]
aware of the TRICARE health care program?
Yes
No
I Don't Know
No
Yes, on a claim by
claim basis only
Yes, for all claims
I Don't know
None: Dr. [Insert Last Name] [Credentials] has no
TRICARE patients
________ percent use some form of TRICARE
I Don’t Know
Q7. Does [Insert Provider Name] [Credentials]
accept Medicare patients?
Yes
No
I Don't Know
Q8. As of today, is [Insert Provider Name]
[Credentials] accepting new Medicare patients?
Q4. As of today, is [Insert Provider Name]
[Credentials] accepting new TRICARE Standard
patients?
Q6. What percentage of patients seen by
[Insert Provider Name] [Credentials]
use any form of TRICARE? If unsure, please
write down your best guess.
Yes
Yes
No
I Don't Know
Q3. As of today, is [Insert Provider Name]
[Credentials] a contracted member of the
TRICARE network of health care providers?
Q5. If you answered “no” to Q4 below, why is
[Insert Provider Name] [Credentials]
not accepting new TRICARE Standard patients?
Please list all the reasons. If you need additional space,
please include a separate sheet of paper.
(Go to Q5)
(Go to Q6)
(Go to Q6)
(Go to Q6)
No
I Don't Know
Thank you, please return
the questionnaire
(Go to Q9)
(Go to Q10)
Q9. If you answered “no” to Q8 above, why is
[Insert Provider Name] [Credentials]
not accepting new Medicare patients?
Please list all the reasons. If you need additional space,
please include a separate sheet of paper.
Q10. Does [Insert Provider Name] [Credentials]
accept payment from government or private
health insurance plans?
Yes
No
Q11. As of today, is [Insert Provider Name]
[Credentials] accepting new patients?
Yes
No
I Don't Know
Thank you for taking the time to complete this survey. Please put this in the enclosed postage-paid envelope and return it to
the Survey Processing Center or fax the survey to Ipsos at 1-800-409-7681. If you have any questions about TRICARE, its
specific health plans, or the benefits it provides, please visit the TRICARE web site at www.tricare.mil for assistance.
OMB NO.: 0720-0031
EXPIRATION DATE: XX/XX/XXXX
OFFICE OF THE ASSISTANT SECRETARY OF DEFENSE
HEALTH AFFAIRS
[FOR REVIEWERS: BH Mailing #2]
DEFENSE
HEALTH AGENCY
[Unique Provider ID Number]
FOR: [Insert Provider Name]
Street Address
City, State, and Zip
Month Date, 2015
Dear [Insert Provider Name],
Hello! [Insert Provider Name] was randomly selected to participate in this very important effort. In support of the
thousands of U.S. military men and women who are currently defending our communities at home and abroad, Congress
is interested in whether family members of active duty military, and military retirees and their families, have sufficient
access to the health care they need. Much of their care is delivered at military facilities; however, a substantial amount of
health care is delivered by private, civilian physicians.
Congress has directed the Department of Defense's health benefits program called TRICARE to survey civilian providers
across the U.S to determine the adequacy of private health care access for its military beneficiaries. The DoD has
contracted Ipsos to conduct this survey. If there is more than one provider in your office, please complete each survey for
the appropriate provider. If you are not the appropriate person to answer these questions, please pass this on to person in
your office most familiar with the provider’s billing and insurance for completion. If you have already completed your
survey and returned it to Ipsos, thank you and please excuse this reminder.
If you have not yet had a chance to respond, please take a few minutes now to answer the questions on the back of this
letter and return it within five days. There are several ways to complete this survey, which should only take five minutes
of your time:
Complete the survey on the reverse side of this letter and return it via postal mail in the enclosed postage paid
envelope
Complete the survey on the reverse side of this letter and fax it to 1-800-409-7681
Complete the survey on the internet at the following URL: http://www.dodcv08.com
Your unique login name: xxxxxxxx
Your unique password: xxxxxxxx
We recognize that there may be more than one provider in your office and ask that you complete the survey for the
provider listed above. Since we may survey more than one provider in your office, please complete each survey for the
appropriate provider named above. If you are not the appropriate person to answer these questions, please pass this on
to the person in your office most familiar with [Insert Provider Name]’s billing and insurance.
Thank you in advance for your cooperation and help as we examine this important issue that impacts our American
service men and women. If you have questions about this survey, please call Ipsos between the hours of 8AM and 5PM
Eastern Time at 1-800-228-6764.
Sincerely yours,
Capt. Jamie Lindly, MSC, USN Chief, Analytics Division
SURVEY QUESTIONS ON REVERSE SIDE
The public reporting burden for this collection of information is estimated to average five (5) minutes to complete, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, 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 the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate,
Information Management Division, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 (0720-0031]. Respondents
should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection
of information if it does not display a currently valid OMB control number. This Official DoD survey may be confirmed at the TRICARE website
http://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Health-Care-Program-Evaluation/TRICARE-Patient-SatisfactionSurveys, click on Current Active Surveys, and find "Survey of Civilian Provider Acceptance of TRICARE Standard."
PRIVACY ADVISORY STATEMENT
Information collected for this Survey will be used to help TRICARE health policy makers gauge civilian provider awareness and acceptance of the TRICARE
Standard health care benefit option, and provide aggregated input to improve the Military Health System. All information will be de-identified prior to being
reported. Completing the Survey is voluntary; you may stop the Survey at any time and skip any questions you choose. There is no penalty if you choose
not to respond, although maximum participation is encouraged so the data will be complete and representative.
OMB NO.: 0720-0031
EXPIRATION DATE: XX/XX/XXXX
Q1. Does [Insert Provider Name]
provide treatment or counseling to patients through
private practice? (Is he/she working in a setting where
providers, individually or as a group, decide or influence
which health insurance to accept?)
Q6. If you answered “no” to Q5 below, why is
[Insert Provider Name]
not accepting new TRICARE Standard patients?
Please list all the reasons. If you need additional space,
please include a separate sheet of paper.
Yes (Go to Q2)
No, does not provide treatment or counseling, or has
retired (Thank you, please return the questionnaire)
No, not in private practice
(Go to Q1a)
Q1a. What type of practice is [Insert Provider Name]
in? (Please choose one)
Government: Federal, State or other municipality
School, University or other academic institution
Hospital staff
Contractor providing services exclusively to
government clients
Rehab Facility, Nursing Home, or Home Health
Provider
Closed Panel HMO
Other ______________
Q2. What type of health care provider is
[Insert Provider Name]?
MARK ALL THAT APPLY.
Certified Clinical Social Worker
Certified Psychiatric Nurse Specialist
Clinical Psychologist
Certified Marriage and Family Therapist
Pastoral Counselor
Mental Health Counselor
Other _____________
Q3. Is [Insert Provider Name]
aware of the TRICARE health care program?
Yes
No
I Don't Know
Q4. As of today, is [Insert Provider Name]
a contracted member of the TRICARE network of
health care providers?
Yes
No
I Don't Know
Q5. As of today, is [Insert Provider Name] accepting
new TRICARE Standard patients?
No
(Go to Q6)
Yes, on a claim by claim basis only (Go to Q7)
Yes, for all claims
(Go to Q7)
I Don't know
(Go to Q7)
Q7. What percentage of patients seen by
[Insert Provider Name]
use any form of TRICARE? If unsure, please
write down your best guess.
None: [Insert Provider Name]
has no TRICARE patients
___________ percent use some form of TRICARE
I Don’t Know
Q8. Does [Insert Provider Name]
accept Medicare patients?
Yes
No
I Don't Know
Q9. As of today, is [Insert Provider Name] accepting
new Medicare patients?
Yes
Thank you, please return
the questionnaire
No
I Don't Know
(Go to Q10)
(Go to Q11)
Q10. If you answered “no” to Q9 above, why is
[Insert Provider Name]
not accepting new Medicare patients?
Please list all the reasons. If you need additional space,
please include a separate sheet of paper.
Q11. Does [Insert Provider Name]
accept payment from government or private
health insurance plans?
Yes
No
Q12. As of today, is [Insert Provider Name] accepting
new patients?
Yes
No
I Don't Know
Thank you for taking the time to complete this survey. Please put this in the enclosed postage-paid envelope and return it to
the Survey Processing Center or fax the survey to Ipsos at 1-800-409-7681. If you have any questions about TRICARE, its
specific health plans, or the benefits it provides, please visit the TRICARE web site at www.tricare.mil for assistance.
OMB Number 0720-0031
Expiration Date: XX/XX/XXXX
Continuing Viability Survey 2015 – Physician Version
TELEPHONE SCRIPT DRAFT
[FOR REVIEWERS: MD/DO CATI follow-up]
INTRO Hi, my name is ____ and I’m calling on behalf of the Department of Defense TRICARE health
benefits Program. May I speak with the person who is most familiar with billing and insurance
for [Insert Provider Name], [Insert Credentials]?
(INTERVIEWER NOTE: I'm calling from Ipsos, a healthcare survey firm and would like to speak
with the billing manager or the person most familiar with billing and insurance for [Insert Provider
Name], [Insert Credentials]? We have a few questions regarding how your office works with the
TRICARE program. REINTRODUCE AS NECESSARY.)
(IF UNAVAILABLE: Do you know when the (billing manager or the person most familiar with
billing and insurance) will be available?" ARRANGE CALLBACK IF POSSIBLE.)
Respondent on phone
Not available
Go to SMS
[Insert Provider], [Insert Credentials] no longer works at this office
Already returned survey
Alternate phone number
Respondent refuses
Refused – already returned survey
Medical school
Only receives messages
Billing contact unavailable permanently
Moved practice
No Billing – accepts walk-ins
Outsource billing
Military (unspecified)
Not at this address
ER (Emergency Room) doctor
Out of area address change
Left practice
Retired
Not practicing
Military leave
Resident/Doctor in training
Radiologist
Anesthesiologist
Fellow
Military – only sees TRICARE patients
Pathologist
Hospitalist
Pediatrician
Interservist
Hospital accreditation surveyor
Covering provider only
No office practice
Healthplan/Network provider (Kaiser)
Veterans Medical System employee (VA)
State hospital employee
University/student physicians
No private practice
Deceased
[IF INTRO=’RESPONDENT ON PHONE’, GO TO QB1]
[IF INTRO=’ALREADY RETURNED SURVEY’, GO TO QB2]
[IF INTRO=’NOT AVAILABLE’, INTERVIEWER SHOULD ASK ‘Do you know when the person familiar
with billing and insurance for this provider will be available?’] SET CALLBACK.
[IF INTRO=ANY OTHER RESPONSE NOT LISTED ABOVE, RESCREEN FOR NEXT AVAILABLE
PROVIDER. IF NO ADDITIONAL PROVIDERS, THANK AND END.]
QB1.
[PROGRAMMING NOTE: DISPLAY THE FOLLOWING TEXT: Congress has directed the TRICARE
program to survey civilian providers across the U.S. to determine the adequacy of private health care
access for its military beneficiaries. The Department of Defense has contracted Ipsos to conduct this very
short survey. [Insert Provider Name], [Insert Credentials] was randomly selected to participate in this very
important survey.]
[GO TO QB3]
QB2.
[PROGRAMMING NOTE: DISPLAY THE FOLLOWING TEXT: Thank you for returning the survey. For
verification purposes we would like to ask a few questions.]
(INTERVIEWER NOTE: READ IF NEEDED: On behalf of the Department of Defense, I’m calling from
Ipsos, the healthcare survey firm contracted to perform this survey. Congress has directed the TRICARE
program to survey civilian providers across the U.S. [Insert Provider Name], [Insert Credentials] was
randomly selected to participate in this very important survey.)
[GO TO QB3]
QB3.
[PROGRAMMING NOTE: DISPLAY THE FOLLOWING TEXT: Your participation will help the
Department of Defense gain valuable aggregated input to help improve the Military Health System.]
(INTERVIEWER NOTE: READ AGENCY DISCLOSURE STATEMENT IF NEEDED: The public
reporting burden for this collection of information is estimated to average five (5) minutes to complete,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, 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 the burden, to the Department of Defense, Washington Headquarters Services, Executive
Services Directorate, Information Management Division, 4800 Mark Center Drive, East Tower, Suite
02G09, Alexandria, VA 22350-3100 (0720-0031]. Respondents should be aware that notwithstanding any
other provision of law, no person shall be subject to any penalty for failing to comply with a collection of
information if it does not display a currently valid OMB control number.
(INTERVIEWER NOTE: READ IF NEEDED This Official DoD survey may be confirmed at the
TRICARE website http://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/HealthCare-Program-Evaluation/TRICARE-Patient-Satisfaction-Surveys, click on Current Active Surveys, and
find "Survey of Civilian Provider Acceptance of TRICARE Standard.")
[GO TO QB4]
QB4.
PROGRAMMING NOTE: DISPLAY THE FOLLOWING TEXT: INTERVIEWER NOTE: READ PRIVACY
ADVISORY IF NEEDED: Information collected for this Survey will be used to help TRICARE health policy
makers gauge civilian provider awareness and acceptance of the TRICARE Standard health care benefit
option, and provide aggregated input to improve the Military Health System. All information will be deidentified prior to being reported. Completing the Survey is voluntary; you may stop the Survey at any
time and skip any questions you choose. There is no penalty if you choose not to respond, although
maximum participation is encouraged so the data will be complete and representative. Let me assure
you that I am not trying to sell anything. Do you have a few minutes to answer some questions regarding
how your office works with the TRICARE program?)
[GO TO Q1]
Q1.
Does [Insert Provider Name], [Insert Credentials] provide treatment to patients through private practice?
(INTERVIEW NOTE: READ IF NEEDED: Is he/she working in a setting where providers,
individually or as a group, decide or influence which health insurance to accept?)
Yes
No, does not provide treatment or counseling, or has retired
No, not in private practice
DK
REF
[IF Q1=YES, GO TO Q2]
[IF Q1=’NO, DOES NOT PROVIDE TREATMENT OR COUNSELING, OR HAS RETIRED’, GO TO
INSTRUCTIONS AFTER Q11]
[IF Q1=’NO, NOT IN PRIVATE PRACTICE’, DK, OR REF, GO TO Q1A]
Q1a.
What type of practice is [Insert Provider Name], [Insert Credentials] in?
Government: Federal, State or other municipality
School, University or other academic institution
Hospital staff
Contractor providing services exclusively to government clients
Rehab Facility, Nursing Home, or Home Health Provider
Closed Panel HMO
Other (SPECIFY)
DK
REF
Q2.
Is [Insert Provider Name], [Insert Credentials] aware of the TRICARE health care program?
Yes
No
DK
REF
Q3.
As of today, is [Insert Provider Name], [Insert Credentials] a contracted member of the TRICARE network
of health care providers?
Yes
No
DK
REF
Q4.
As of today, is [Insert Provider Name], [Insert Credentials] accepting new TRICARE STANDARD
patients?
No
Yes, on a claim by claim basis only
Yes, for all claims
DK
REF
[IF Q4=NO, GO TO Q5]
[IF Q4=’YES, ON A CLAIM BY CLAIM BASIS ONLY’, ‘YES, FOR ALL CLAIMS’, DK, REF, GO TO Q6]
Q5.
Why is [Insert Provider Name], [Insert Credentials] not accepting new TRICARE STANDARD patients?
(INTERVIEWER NOTE: RECORD ANSWERS VERBATIM. PROBE FOR CLARITY AND ADDITIONAL
INFORMATION. Example: What did you mean by…? Why else does [Insert Provider Name], [Insert
Credentials] not accepting new TRICARE STANDARD patients?)
Q6.
What percentage of patients seen by [Insert Provider Name], [Insert Credentials] use any form of
TRICARE?
(INTERVIEWER NOTE: If necessary, say, “Please give your best guess. Please use a whole number
and not a range”.)
(INTERVIEWER NOTE: IF RESPONSE IS ‘NONE’, ENTER ‘0’)
[PROGRAMMING NOTE: COLLECT DATA AS A NUMERIC VARIABLE, NOT AS AN OPEN-END.
RESERVE ‘998’ FOR DK AND ‘999’ FOR REF]. INTERVIEWER NOTE: IF ‘NONE’, ENTER ‘0’. IF
‘DON’T KNOW’, ENTER ‘998’. IF ‘REFUSED’, ENTER ‘999’.
[0]
[1-100]
[998]
[999]
Q7.
Does [Insert Provider Name], [Insert Credentials] accept Medicare patients?
Yes
No
DK
REF
Q8.
As of today, is [Insert Provider Name], [Insert Credentials] accepting NEW Medicare Patients?
Yes
No
DK
REF
[IF Q8 = YES, SKIP TO INSTRUCTIONS AFTER Q11]
[IF Q8 = NO, DK, OR REF, GO TO Q9]
Q9.
Why is [Insert Provider Name], [Insert Credentials] not accepting new Medicare patients?
(INTERVIEWER NOTE: RECORD ANSWERS VERBATIM. PROBE FOR CLARITY AND ADDITIONAL
INFORMATION. Example: What did you mean by…? Why else does [Insert Provider Name], [Insert
Credentials] not accepting new MEDICARE patients?)
Q10.
Does [Insert Provider Name], [Insert Credentials] accept payment from government or private health
insurance plans?
Yes
No
DK
REF
Q11.
As of today, is [Insert Provider name], [Insert Credentials] accepting new patients?
Yes
No
DK
REF
[ASK Q1-11 FOR NEXT Provider listed for this phone number]
[If NONE] That concludes our survey. Thank you for taking the time to complete this survey.
(INTERVIEWER NOTE: IF RESPONDENT HAS ANY QUESTIONS ABOUT TRICARE, IT’S SPECIFIC
HEALTH PLANS, OR THE BENEFITS IT PROVIDES, PLEASE MENTION THAT THEY CAN VISIT
THE TRICARE WEB SITE AT www.tricare.mil)
OMB Number 0720-0031
Expiration Date: XX/XX/XXXX
Continuing Viability Survey 2015 for Behavioral Health Providers
TELEPHONE SCRIPT DRAFT
[FOR REVIEWERS: BH CATI follow-up]
INTRO Hi, my name is ____ and I’m calling on behalf of the Department of Defense TRICARE health
benefits Program. May I speak with the person who is most familiar with billing and insurance
for [Insert Provider Name]?
(INTERVIEWER NOTE: I'm calling from Ipsos, a healthcare survey firm and would like to speak
with the billing manager or the person most familiar with billing and insurance for [Insert Provider
Name]? We have a few questions regarding how your office works with the TRICARE program.
REINTRODUCE AS NECESSARY.)
(IF UNAVAILABLE: Do you know when the (billing manager or the person most familiar with
billing and insurance) will be available?" ARRANGE CALLBACK IF POSSIBLE.)
Respondent on phone
Not available
Go to SMS
[Insert Provider] no longer works at this office
Already returned survey
Alternate phone number
Respondent refuses
Refused – already returned survey
Medical school
Only receives messages
Billing contact unavailable permanently
Moved practice
No Billing – accepts walk-ins
Outsource billing
Military (unspecified)
Not at this address
ER (Emergency Room) doctor
Out of area address change
Left practice
Retired
Not practicing
Military leave
Resident/Doctor in training
Radiologist
Anesthesiologist
Fellow
Military – only sees TRICARE patients
Pathologist
Hospitalist
Pediatrician
Interservist
Hospital accreditation surveyor
Covering provider only
No office practice
Healthplan/Network provider (Kaiser)
Veterans Medical System employee (VA)
State hospital employee
University/student physicians
No private practice
Deceased
[IF INTRO=’RESPONDENT ON PHONE’, GO TO QB1]
[IF INTRO=’ALREADY RETURNED SURVEY’, GO TO QB2]
[IF INTRO=’NOT AVAILABLE’, INTERVIEWER SHOULD ASK ‘Do you know when the person familiar
with billing and insurance for this provider will be available?’] SET CALLBACK.
[IF INTRO=ANY OTHER RESPONSE NOT LISTED ABOVE, RESCREEN FOR NEXT AVAILABLE
PROVIDER. IF NO ADDITIONAL PROVIDERS, THANK AND END.]
QB1.
[PROGRAMMING NOTE: DISPLAY THE FOLLOWING TEXT: Congress has directed the TRICARE
program to survey civilian providers across the U.S. to determine the adequacy of private health care
access for its military beneficiaries. The Department of Defense has contracted Ipsos to conduct this very
short survey. [Insert Provider Name] was randomly selected to participate in this very important survey.]
[GO TO QB3]
QB2.
[PROGRAMMING NOTE: DISPLAY THE FOLLOWING TEXT: Thank you for returning the survey. For
verification purposes we would like to ask a few questions.]
(INTERVIEWER NOTE: READ IF NEEDED: On behalf of the Department of Defense, I’m calling from
Ipsos, the healthcare survey firm contracted to perform this survey. Congress has directed the TRICARE
program to survey civilian providers across the U.S. [Insert Provider Name] was randomly selected to
participate in this very important survey.)
[GO TO QB3]
QB3.
[PROGRAMMING NOTE: DISPLAY THE FOLLOWING TEXT: Your participation will help the
Department of Defense gain valuable aggregated input to help improve the Military Health System.]
(INTERVIEWER NOTE: READ AGENCY DISCLOSURE STATEMENT IF NEEDED: The public
reporting burden for this collection of information is estimated to average five (5) minutes to complete,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, 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 the burden, to the Department of Defense, Washington Headquarters Services, Executive
Services Directorate, Information Management Division, 4800 Mark Center Drive, East Tower, Suite
02G09, Alexandria, VA 22350-3100 (0720-0031]. Respondents should be aware that notwithstanding any
other provision of law, no person shall be subject to any penalty for failing to comply with a collection of
information if it does not display a currently valid OMB control number.
(INTERVIEWER NOTE: READ IF NEEDED This Official DoD survey may be confirmed at the
TRICARE website http://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/HealthCare-Program-Evaluation/TRICARE-Patient-Satisfaction-Surveys, click on Current Active Surveys, and
find "Survey of Civilian Provider Acceptance of TRICARE Standard.")
[GO TO QB4]
QB4.
[PROGRAMMING NOTE: DISPLAY THE FOLLOWING TEXT: Your participation will help the
Department of Defense gain valuable aggregated input to help improve the Military Health System.]
(INTERVIEWER NOTE: READ PRIVACY ADVISORY IF NEEDED: Information collected for this Survey
will be used to help TRICARE health policy makers gauge civilian provider awareness and acceptance of
the TRICARE Standard health care benefit option, and provide aggregated input to improve the Military
Health System. All information will be de-identified prior to being reported. Completing the Survey is
voluntary; you may stop the Survey at any time and skip any questions you choose. There is no penalty if
you choose not to respond, although maximum participation is encouraged so the data will be complete
and representative. Let me assure you that I am not trying to sell anything. Do you have a few minutes
to answer some questions regarding how your office works with the TRICARE program?)
[GO TO Q1]
Q1.
Does [Insert Provider Name] provide treatment or counseling to patients through private practice?
(INTERVIEW NOTE: READ IF NEEDED: Is he/she working in a setting where providers,
individually or as a group, decide or influence which health insurance to accept?)
Yes
No, does not provide treatment or counseling, or has retired
No, not in private practice
DK
REF
[IF Q1=YES, GO TO Q2]
[IF Q1=’NO, DOES NOT PROVIDE TREATMENT OR COUNSELING, OR HAS RETIRED’, GO TO
INSTRUCTIONS AFTER Q11]
[IF Q1=’NO, NOT IN PRIVATE PRACTICE’, DK, OR REF, GO TO Q1A]
Q1a.
What type of practice is [Insert Provider Name] in?
Government: Federal, State or other municipality
School, University or other academic institution
Hospital staff
Contractor providing services exclusively to government clients
Rehab Facility, Nursing Home, or Home Health Provider
Closed Panel HMO
Other (SPECIFY)
DK
REF
Q1ab. What type of health care provider is [Insert Provider Name]?
[SELECT ALL THAT APPLY]
Certified Clinical Social Worker
Certified Psychiatric Nurse Specialist
Clinical Psychologist
Certified Marriage and Family Therapist
Pastoral Counselor
Mental Health Counselor
Other (SPECIFY)
DK (exclusive)
REF (exclusive)
Q2.
Is [Insert Provider Name] aware of the TRICARE health care program?
Yes
No
DK
REF
Q3.
As of today, is [Insert Provider Name] a contracted member of the TRICARE network of health care
providers?
Yes
No
DK
REF
Q4.
As of today, is [Insert Provider Name] accepting new TRICARE STANDARD patients?
No
Yes, on a claim by claim basis only
Yes, for all claims
DK
REF
[IF Q4=NO, GO TO Q5]
[IF Q4=’YES, ON A CLAIM BY CLAIM BASIS ONLY’, ‘YES, FOR ALL CLAIMS’, DK, REF, GO TO Q6]
Q5.
Why is [Insert Provider Name] not accepting new TRICARE STANDARD patients?
(INTERVIEWER NOTE: RECORD ANSWERS VERBATIM. PROBE FOR CLARITY AND ADDITIONAL
INFORMATION. Example: What did you mean by…? Why else does [Insert Provider Name] not
accepting new TRICARE STANDARD patients?)
Q6.
What percentage of patients seen by [Insert Provider Name] use any form of TRICARE?
(INTERVIEWER NOTE: If necessary, say, “Please give your best guess. Please use a whole number
and not a range”.)
(INTERVIEWER NOTE: IF RESPONSE IS ‘NONE’, ENTER ‘0’)
[PROGRAMMING NOTE: COLLECT DATA AS A NUMERIC VARIABLE, NOT AS AN OPEN-END.
RESERVE ‘998’ FOR DK AND ‘999’ FOR REF].
None/0
1-100 Percent
DK (998)
REF (999)
Q7.
Does [Insert Provider Name] accept Medicare patients?
Yes
No
DK
REF
Q8.
As of today, is [Insert Provider Name] accepting NEW Medicare Patients?
Yes
No
DK
REF
[IF Q8 = YES, SKIP TO INSTRUCTIONS AFTER Q11]
[IF Q8 = NO, DK, OR REF, GO TO Q9]
Q9.
Why is [Insert Provider Name] not accepting new Medicare patients?
(INTERVIEWER NOTE: RECORD ANSWERS VERBATIM. PROBE FOR CLARITY AND ADDITIONAL
INFORMATION. Example: What did you mean by…? Why else does [Insert Provider Name] not
accepting new MEDICARE patients?)
Q10.
Does [Insert Provider Name] accept payment from government or private health insurance plans?
Yes
No
DK
REF
Q11.
As of today, is [Insert Provider name] accepting new patients?
Yes
No
DK
REF
[ASK Q1-11 FOR NEXT Provider listed for this phone number]
[If NONE] That concludes our survey. Thank you for taking the time to complete this survey.
(INTERVIEWER NOTE: IF RESPONDENT HAS ANY QUESTIONS ABOUT TRICARE, IT’S SPECIFIC
HEALTH PLANS, OR THE BENEFITS IT PROVIDES, PLEASE MENTION THAT THEY CAN VISIT
THE TRICARE WEB SITE AT www.tricare.mil)
OMB NO.: 0720-0031
EXPIRATION DATE: XX/XX/XXXX
OFFICE OF THE ASSISTANT SECRETARY OF DEFENSE
HEALTH AFFAIRS
[FOR REVIEWERS: MD/DO Mailing #2]
DEFENSE
HEALTH AGENCY
[Unique Provider ID Number]
FOR: [Insert Provider Name] [Credentials]
Street Address
City, State, and Zip
Month Date, 2015
Dear BILLING MANAGER for [Insert Provider Name] [Credentials],
Hello! [Insert Provider Name] [Credentials] was randomly selected to participate in this very important effort. In support of
the thousands of U.S. military men and women who are currently defending our communities at home and abroad,
Congress is interested in whether family members of active duty military, and military retirees and their families, have
sufficient access to the health care they need. Much of their care is delivered at military facilities; however, a substantial
amount of health care is delivered by private, civilian physicians.
Congress has directed the Department of Defense's health benefits program called TRICARE to survey civilian providers
across the U.S to determine the adequacy of private health care access for its military beneficiaries. The DoD has
contracted Ipsos to conduct this survey. If there is more than one physician in your office, please complete each survey
for the appropriate physician. If you are not the appropriate person to answer these questions, please pass this on to
person in your office most familiar with the doctor’s billing and insurance for completion. If you have already completed
your survey and returned it to Ipsos, thank you and please excuse this reminder.
If you have not yet had a chance to respond, please take a few minutes now to answer the questions on the back of this
letter on behalf of the physician and return it within five days. There are several ways to complete this survey, which
should only take five minutes of your time:
Complete the survey on the reverse side of this letter and return it via postal mail in the enclosed postage paid envelope
Complete the survey on the reverse side of this letter and fax it to 1-800-409-7681
Complete the survey on the internet at the following URL: http://www.dodcv08.com
Your unique login name: xxxxxxxx
Your unique password: xxxxxxxx
We recognize that there may be more than one provider in your office and ask that you complete the survey for the
provider listed above. Since we may survey more than one provider in your office, please complete each survey for the
appropriate provider named above. If you are not the appropriate person to answer these questions, please pass this on
to the person in your office most familiar with [Insert Provider Name] [Credential]’s billing and insurance.
Thank you in advance for your cooperation and help as we examine this important issue that impacts our American
service men and women. If you have questions about this survey, please call Ipsos between the hours of 8AM and 5PM
Eastern Time at 1-800-228-6764.
Sincerely yours,
Capt. Jamie Lindly, MSC, USN Chief, Analytics Division
SURVEY QUESTIONS ON REVERSE SIDE
The public reporting burden for this collection of information is estimated to average five (5) minutes to complete, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, 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 the burden, to the Department of Defense, Washington Headquarters Services, Executive Services
Directorate, Information Management Division, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 (07200031]. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for
failing to comply with a collection of information if it does not display a currently valid OMB control number. This Official DoD survey
may be confirmed at the TRICARE website http://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Health-CareProgram-Evaluation/TRICARE-Patient-Satisfaction-Surveys, click on Current Active Surveys, and find "Survey of Civilian Provider
Acceptance of TRICARE Standard."
PRIVACY ADVISORY STATEMENT
Information collected for this Survey will be used to help TRICARE health policy makers gauge civilian provider awareness and acceptance of the TRICARE
Standard health care benefit option, and provide aggregated input to improve the Military Health System. All information will be de-identified prior to being
reported. Completing the Survey is voluntary; you may stop the Survey at any time and skip any questions you choose. There is no penalty if you choose
not to respond, although maximum participation is encouraged so the data will be complete and representative.
OMB NO.: 0720-0031
EXPIRATION DATE: XX/XX/XXXX
Q1. Does [Insert Provider Name] [Credentials]
provide treatment to patients through private
practice? (Is he/she working in a setting where
providers, individually or as a group, decide or influence
which health insurance to accept?)
Yes
(Go to Q2)
No, does not provide treatment, or has retired
(Thank you, please return the questionnaire)
No, not in private practice (Go to Q1a)
Q1a. What type of practice is [Insert Provider Name]
[Credentials] in? (please choose one)
Government: Federal, State or other municipality
School, University or other academic institution
Hospital staff
Contractor providing services exclusively to
government clients
Rehab Facility, Nursing Home, or Home Health
Provider
Closed Panel HMO
Other ______________
Q2. Is [Insert Provider Name] [Credentials]
aware of the TRICARE health care program?
Yes
No
I Don't Know
No
Yes, on a claim by
claim basis only
Yes, for all claims
I Don't know
None: Dr. [Insert Last Name] [Credentials] has no
TRICARE patients
________ percent use some form of TRICARE
I Don’t Know
Q7. Does [Insert Provider Name] [Credentials]
accept Medicare patients?
Yes
No
I Don't Know
Q8. As of today, is [Insert Provider Name]
[Credentials] accepting new Medicare patients?
Q4. As of today, is [Insert Provider Name]
[Credentials] accepting new TRICARE Standard
patients?
Q6. What percentage of patients seen by
[Insert Provider Name] [Credentials]
use any form of TRICARE? If unsure, please write
down your best guess.
Yes
Yes
No
I Don't Know
Q3. As of today, is [Insert Provider Name]
[Credentials] a contracted member of the
TRICARE network of health care providers?
Q5. If you answered “no” to Q4 below, why is
[Insert Provider Name] [Credentials]
not accepting new TRICARE Standard patients?
Please list all the reasons. If you need additional space,
please include a separate sheet of paper.
(Go to Q5)
(Go to Q6)
(Go to Q6)
(Go to Q6)
No
I Don't Know
Thank you, please return
the questionnaire
(Go to Q9)
(Go to Q10)
Q9. If you answered “no” to Q8 above, why is
[Insert Provider Name] [Credentials]
not accepting new Medicare patients?
Please list all the reasons. If you need additional space,
please include a separate sheet of paper.
Q10. Does [Insert Provider Name] [Credentials]
accept payment from government or private
health insurance plans?
Yes
No
Q11. As of today, is [Insert Provider Name]
[Credentials] accepting new patients?
Yes
No
I Don't Know
Thank you for taking the time to complete this survey. Please put this in the enclosed postage-paid envelope and return it to
the Survey Processing Center or fax the survey to Ipsos at 1-800-409-7681. If you have any questions about TRICARE, its
specific health plans, or the benefits it provides, please visit the TRICARE web site at www.tricare.mil for assistance.
| File Type | application/pdf |
| Author | greenym |
| File Modified | 2015-09-04 |
| File Created | 2015-07-16 |