Form CMS-10393 Attachment A: Beneficiary Experience Survey

CMS 10393 Supporting Statement – Attachment A

Beneficiary and Family Centered Data Collection

Beneficiary Experience Survey
(Combined Appeals/Complaints/Immediate Advocacy)

This survey will be conducted by telephone interviewers with three groups of beneficiaries/ representatives: 1) a sample of beneficiaries/representatives who filed an appeal; 2) all beneficiaries/representatives who filed a complaint that was addressed using Immediate Advocacy; and; 3) all beneficiaries/representatives who filed a complaint and received their determination (medical records review).

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 0938-1177.  The Expiration Date is XX/XX/XXXX. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the CMS BFCC ORC subject matter expert <insert name> at xxx-xxx-xxxx.

Sample Verification

I would like to talk with you today about your recent experience with the Medicare program and {QIO Name}, the Quality Improvement Organization in your state which handled your recent {appeal/ Immediate Advocacy/complaint} process. I am going to start by checking some information, then ask a few yes/no type questions, and finally I would like to get your suggestions about how to make the process better. This should take no more than 15 minutes.

1. Our records show that on {DATE} you filed {an appeal/a complaint about care or services {you/beneficiary name} received under the Medicare program/ a complaint} about {your/beneficiary name’s Medicare benefits/the quality of care you/beneficiary name received under the Medicare program}. Is that right?

• Yes

• No (interviewer prompt with provider/facility name to promote recall. If still no, skip to end, thank you and close)

Filing Your {Appeal/Complaint} – The Intake Process

{QIO Name} is the Quality Improvement Organization, or QIO, in your state that assisted you with your {appeal/complaint}. The QIO is responsible for collecting information, coordinating the process and determining the outcome of your {appeal/complaint}. We would like to know about your experience with the QIO. The first questions are about the way they handled the first stage your {appeal/complaint}, or the intake process.

2. Did you call {QIO Name} to file your {appeal/complaint}?

• Yes

• No (skip to Q4)

3. When you called {QIO Name} to file your {appeal/complaint}, did you reach a QIO representative or did you leave a message?

• QIO representative (skip to Q5)

• Voicemail

4. When you were filing your {appeal/complaint}, did you ever speak to a QIO representative?

• Yes

• No (skip to Q8)

5. When you were filing your {appeal/complaint}, did the QIO representative listen carefully to you?

• Yes, definitely

• Yes, somewhat

• No

6. When you were filing your {appeal/complaint}, did the QIO representative explain the steps in the {appeal/complaint} process?

• Yes, definitely

• Yes, somewhat

• No

7. When you were filing your {appeal/complaint}, did the QIO representative spend enough time with you?

• Yes, definitely

• Yes, somewhat

• No

If appeal, skip to Question 12

If Immediate Advocacy, skip to Question 10

8. (Only Medical Records Review)
   When you were filing your {appeal/complaint}, did you need help from the QIO to fill out any forms?

• Yes

• No (skip to Q10)

9. (Only Medical Records Review)
   Did you get the help you needed from the QIO to fill out the forms about your complaint?

• Yes, definitely

• Yes, somewhat

• No

Processing and Addressing Your Complaint

10. (Only Immediate Advocacy and Medical Records Review)

Did the QIO keep you informed about the status of your complaint throughout the process?

• Yes, definitely

• Yes, somewhat

• No

11. (Only Immediate Advocacy)

Has the complaint process been completed?

• Yes

• No

If Immediate Advocacy, skip to Question 17

Processing and Getting Your Final Determination

Now I would like to ask you about the outcome or determination of your {appeal/complaint}.

12. (Only Appeal and Medical Records Review)

Have you received your {appeal/complaint} determination?

(Appeal: If needed: have you been told about the outcome or result of your appeal?

(Medical Records Review: If needed: have you received a letter with the outcome or result of your complaint?)

• Yes

• No (skip to Q17)

If Medical Records Review, skip to Question 17

13. (Only Appeal)

How were you notified about the result of your {appeal/complaint}? (Mark all that apply)

• Mail

• Phone

• Voicemail/Answering machine

• Other (Specify)

(If responses don’t include Phone, skip to Q17)

14. (Only Appeal)

Did the QIO representative explain the results of your appeal?

• Yes

• No (skip to Q17)

15. (Only Appeal)

When the QIO representative was explaining the results of your appeal, was the explanation clear?

• Yes, definitely

• Yes, somewhat

• No

16. (Only Appeal)

When explaining the results of your appeal, did the QIO representative spend enough time with you?

• Yes, definitely

• Yes, somewhat

• No

Overall Feedback and Suggestions

17. Thinking about your overall experience with {QIO Name} regarding {your {DATE} appeal/your complaint on {DATE}/the complaint you filed on {DATE}, did the QIO representative treat you with courtesy and respect?

• Yes, definitely

• Yes, somewhat

• No

18. Again, thinking about your overall experience with {QIO Name} regarding your recent {appeal/ complaint}, did the QIO representative involve you and your family as much as you wanted in the {appeal/complaint} process?

• Yes, definitely

• Yes, somewhat

• No

19. Using any number from 0 to 10 where 0 is the worst {appeal/complaint} process possible, and 10 is the best {appeal/complaint} process possible, what number would you use to rate the overall {appeal/complaint} process?

20. (Only Immediate Advocacy)

Have you or are you planning to follow-up on your complaint with other steps?

• Yes, definitely

• Yes, somewhat

• No

21. What did {QIO Name} do well during your recent {appeal/complaint}?

22. What suggestions do you have for {QIO Name} to improve the process that they use in working with Medicare beneficiaries and their families during the {appeal/complaint} process?

CMS 10393 11^th SOW Supporting Statement Attachment A

4/4/2017 7