CMS-10393 Attachment B: Direct Follow-up

CMS 10393 Supporting Statement – Attachment B

Beneficiary and Family Centered Data Collection

Direct Follow-up

(Beneficiary Experience with QIO: help desk call)

Direct follow-up will be conducted by telephone with a sample of beneficiaries/representatives who spoke with the BFCC QIO. This call may not have resulted in the initiation of an appeal or complaint case.

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 5 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.

{QIO Name} is the Quality Improvement Organization or QIO in your state. The QIO is responsible for addressing beneficiary quality of care complaints and appeals. We would like to know about your recent experience with the QIO.

1. Our records show that on {DATE} you spoke with a representative from {QIO Name}, your QIO. Is that right?

• Yes

• No (interviewer prompt with available information about the call. If still no, skip to end, thank you and close)

2. When you spoke with a QIO representative on {DATE}, did the representative listen carefully to you?

• Yes, definitely

• Yes, somewhat

• No

3. When you spoke with a QIO representative on {DATE}, did the representative treat you with courtesy and respect?

• Yes, definitely

• Yes, somewhat

• No

4. Using any number from 0 to 10 where 0 is the worst, and 10 is the best, what number would you use to rate the help you got from the QIO?

5. What suggestions do you have for {QIO Name} to improve how they support Medicare beneficiaries and their families?

CMS 10393 11^th SOW Supporting Statement Attachment B

4/4/2017 2