CMS-10393 Attachment C: General Feedback Web Survey

CMS 10393 Supporting Statement – Attachment C

Beneficiary and Family Centered Data Collection

General Feedback Web survey
(Combined Appeals/Complaints/Immediate Advocacy)

A URL will be printed on all final letters sent to beneficiaries/representatives. Individual URLs will be established for each service area to track/report responses and to establish appropriate survey skips/fills.

Included on the web survey web page

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 2 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 collecting information, coordinating the process and determining the result or outcome of your {appeal/complaint}. We would like to know about your experience with the QIO.

Filing your appeal – the intake process

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

• Yes

• No (skip to Q3)

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

• Yes, definitely

• Yes, somewhat

• No

Processing your {appeal/complaint}

If Complaint or Immediate Advocacy, skip to Question 6

3. (Appeal only)

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

• Mail

• Phone

• Voicemail/Answering machine

• Other (Specify)

4. (Appeal only)

Did the QIO representative explain the results of your appeal?

• Yes

• No (skip to Q6)

5. (Appeal only)

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

• Yes, definitely

• Yes, somewhat

• No

6. (Complaint/Immediate Advocacy only)

Did the QIO representative involve you and your family as much as you wanted in the process?

• Yes, definitely

• Yes, somewhat

• No

Overall feedback and suggestions

7. 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?

8. 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 C

4/4/2017 3