CMS-10393 Beneficiary Complaint Survey

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

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

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Y INSTRUCTIONS 

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o: 

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respond to, a collection of information unless it displays a currently valid OMB control number. The OMB
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Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

4.

Your Medicare Quality of Care Complaint
1.

Our records show that on [Complaint
DATE] you filed a complaint about the
quality of care you or another person
received under Medicare. Is that
right?

Please give us your comments on the
results or findings in response to your
quality of care complaint and concerns.

Yes
No

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

The questions in this survey refer to the
Medicare quality of care complaint that you
filed on [Complaint DATE] as "your quality
of care complaint".
2.

Have you received the results or
findings in response to your quality of
care complaint?
Yes
No

3.

Quality of Care Complaint Process
The next questions are about the way your
quality of care complaint was handled and
the process that [QIO NAME (Max length 60
characters)], the Quality Improvement
Organization (QIO) in your state, used to
get information and coordinate the steps in
the process.

If No, go to #4

How satisfied are you with the results
or findings in response to your quality
of care complaint?

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.

Very satisfied
Satisfied
Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied

5.

Did you speak to a QIO representative
about your quality of care complaint?
Yes
No

If No, go to #14

Continued on next page.

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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 quality of care
complaint 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 quality of
care complaint.

Very satisfied
Satisfied
Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied
8.

Strongly agree
Agree
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
Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied
9.

Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree

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

Letter(s) about your Quality of Care
Complaint

Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied

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

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

Yes
No

If No, go to #19

Very satisfied
Satisfied
Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied

Continued on next page.

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

Overall Quality of Care Complaint Process
19. 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 worst 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?

Very satisfied
Satisfied
Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied
16. How satisfied were you that the forms
or letters you got about your quality of
care complaint had all the information
you needed?
Very satisfied
Satisfied
Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied

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

17. How satisfied were you that the forms
or letters you got about your quality of
care complaint 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 quality of care complaint. 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 quality of
care complaint 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.
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