CMS-10393 Beneficiary Appeals Survey

CMS M
MEDICA
ARE BEN
NEFICIA
ARY AND
D 
FAM
MILY CEENTEREED SATISFACTION SUR
RVEY 

The CMS Medicare Beneficiiary and Faamily Centeered Satisffaction Survey is bein
ng 
e Centers for Medicare & Mediccaid Servicces. 
conduccted by the

SURVEY
Y INSTRUCTIONS 

Please ccomplete this survey aand return it in the enclosed, posstage‐paid e
envelope to
o: 

1600
 Research
 Blvd
 RC
 B16

Rockville,
 MD
 20850-­‐3129

black or blu
ue pen to ccomplete this survey..  
 Pleaase use a b
 Your answers are imporrtant. 
ng uppercaase, block leetters (for example, “WEEKLY”)). 
 Please print cclearly usin
ou want to
o change yo
our answer, shade in the wrongg answer.
 If yo

If you h
have any q
questions aabout this survey or how to filll it out, ple
ease call  
1-888-518-2690, or send an e-mail to [email protected]

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 0938-1177, and it expires September 30, 2015. 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, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

4.

Your Medicare Appeal
1.

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

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

Yes
No

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
[Complaint DATE] as "your appeal".
2.

Have you received the results or
findings in response to your appeal?
Yes
No

3.

Appeal Process
The next questions are about the way your
appeal was handled and the process that
[QIO NAME - (60 character max)], the
Quality Improvement Organization (QIO) in
your state, used to get information and
coordinate the steps in the appeal process.

If No, go to #4

How satisfied are you with the results
or findings in response to your appeal?
Very satisfied
Satisfied

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.

Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied

5.

Did you speak to a QIO representative
about your appeal?
Yes
No

If No, go to #14

Continued on next page.

51326

2

6.

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

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

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

Very satisfied
Satisfied
Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied
7.

Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree

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

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

Very satisfied
Satisfied

Strongly agree
Agree

Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied
8.

Neither agree nor disagree
Disagree
Strongly disagree

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

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.

Very satisfied
Satisfied

Strongly agree
Agree

Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied
9.

Neither agree nor disagree
Disagree
Strongly disagree

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

Letter(s) about your Appeal

Very satisfied
Satisfied

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

Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied

Yes
No

If No, go to #19

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

Continued on next page.

51326

3

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

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?

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

0 - Worst process possible
1
2
3
4
5
6
7
8
9
10 - Best process possible

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

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.

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

Thank you for your participation.

51326

4