Form CMS-10450 Appendix F: Vendor Form

Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey for the Merit-Based Incentive Payment System (MIPS) (CMS-10450)

Appendix F 2018 CAHPS for MIPS Vendor Participation Form 2017.07.12

CAHPS for MIPS Survey Vendor Application

OMB: 0938-1222

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1222 can be found here:

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DRAFT

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for the Merit- based Incentive Payment System (MIPS) Survey

Participation Form for Survey Vendors

^{The
following two items are required for your organization to be a
Centers for Medicare & Medicaid Services (CMS) survey vendor of
the CAHPS for MIPS Survey:}

Meet all of the Minimum Survey Vendor Business Requirements at the time of the submission of this form; and
Fill out the participation form below. Please note sections indicated with an asterisk ("*") are required.

^{If
your organization is approved to be a survey vendor for the CAHPS for
MIPS Survey, all staff and all of your subcontractors must conduct
all of your business activities in the United States.}

^{All
vendor applications and materials are due by [TBD] at 5:00 pm (EDT).}

Part 1. General Information

^{Fill
this part in with your organization’s basic information.}

^{1.1
APPLICANT ORGANIZATION}

^{1.1.a.
ORGANIZATION
NAME*}

Click here to enter text.

^{1.1.b.
MAILING ADDRESS 1*}

Click here to enter text.

^{1.1.c.
Mailing
address 2}

Click here to enter text.

^{1.1.d.
City*}

Click here to enter text.

^{1.1.e.
State*}

Click to enter text.

^{1.1.f.
Zip code*}

^{Click
here to enter text.}

^{1.1.g.
Telephone
and fax (area
code, number and extension)}

^{1.1.h.
Web site*}

^{Click
here to enter text.}

^Tel*

^{Click
here to enter text.}

^Ext

^Click.

^Fax

^{Click
here to enter fax.}

^{1.2
Applicant Contact Person}

^{1.2.a.
Primary
contact person}

^{FIRST
NAME*}

Click here to enter text.

^{MIDDLE
INITIAL*}

Click to enter text.

^{LAST
NAME*}

Click here to enter text.

^{1.2.b.
Title*}

Click here to enter text.

^{1.2.c.
Degree (e.g., RN,
MD, PhD)}

^{Click
here to enter text.}

^{1.2.d.
Mailing address 1*}

Click here to enter text.

^{1.2.e.
Mailing
address 2}

Click here to enter text.

^{1.2.f.
City*}

Click here to enter text.

^{1.2.g.
State*}

^{Click
to enter text.}

^{1.2.h.
ZIP CODE*}

^{Click
to enter text.}

^{1.2.i.
Telephone
and fax (area
code, number and extension)}

^{1.2.j.
Email address*}

^{Click
here to enter text.}

^Tel*

^{Click
here to enter text.}

^Ext

^Click.

^Fax

^{Click
here to enter fax.}

^{1.3 CMS-Sponsored and CAHPS Survey Experience}
^{*1.3.a. Have you been approved as a vendor to implement other CMS or CAHPS surveys in the past five years?}	^{Yes No}
^{If Yes, please provide the name of the survey(s) for which you have been approved as a vendor in the table 2.1.b below.} ^{Click to enter text.}
^{*1.3.b. Have you been a subcontractor to an approved vendor for other CMS or CAHPS surveys in the past five years?}	^{Yes No}
^{If Yes, please provide the name of the survey vendor(s) and the survey(s) for which you have been a subcontractor.} ^{Click to enter text.}
^{CMS will consider prior experience, as either a survey vendor or subcontractor, on CMS or CAHPS surveys when reviewing your organization’s CAHPS for MIPS Survey Participation Form.}

Part 2. CAHPS for MIPS

Minimum Survey Vendor Business Requirements

^{If
you want to be a survey vendor for the CAHPS for MIPS Survey, you
must meet the following minimum business requirements. Please read
each minimum business requirement below and check Yes or No
to show if you do or do not meet each one. Please provide
supporting information in the chart below where asked.}

^{2.1. Relevant organizational survey experience} ^{Recent experience (at least 3 years) in fielding surveys via Mixed-Mode (mail survey administration followed by survey administration via Computer Assisted Telephone Interviewing [CATI] of non-respondents).}
^{*2.1.a. Survey experience: Since 2013, do you have at least 3 years of experience conducting surveys with the Medicare population and administering CAHPS surveys?}		^{Yes No}
^{2.1.b. Experience details: Fill out the chart with the five (5) most recent CAHPS and Medicare population survey projects in which your organization administered surveys:}
^#1	^{*What was the survey name?}	^{Click to enter text.}
	*What was the average sample size in the data collection period?	^{Click to enter text.}
	*When did your organization collect data? (month/year of start and end dates)	^{Click to enter text.}
	^{*How many clients did your organization administer this survey for?}	^{Click to enter text.}
	*In which mode(s) did you administer the survey? (Mixed-Mode, mail only, telephone only, etc.)	^{Click to enter text.}
	*What language(s) did you administer the survey in?	^{Click to enter text.}

#2	*What was the survey name?	^{Click to enter text.}
	*What was the average sample size in the data collection period?	^{Click to enter text.}
	*When did your organization collect data? (month/year of start and end dates)	^{Click to enter text.}
	*How many clients did your organization administer this survey for?	^{Click to enter text.}
	*In which mode(s) did you administer the survey? (Mixed-Mode, mail only, telephone only, etc.)	^{Click to enter text.}
	*What language(s) did you administer the survey in?	^{Click to enter text.}
#3	*What was the survey name?	^{Click to enter text.}
	*What was the average sample size in the data collection period?	^{Click to enter text.}
	*When did your organization collect data? (month/year of start and end dates)	^{Click to enter text.}
	*How many clients did your organization administer this survey for?	^{Click to enter text.}
	*In which mode(s) did you administer the survey? (Mixed-Mode, mail only, telephone only, etc.)	^{Click to enter text.}
	*What language(s) did you administer the survey in?	^{Click to enter text.}

#4	*What was the survey name?	^{Click to enter text.}
	*What was the average sample size in the data collection period?	^{Click to enter text.}
	*When did your organization collect data? (month/year of start and end dates)	^{Click to enter text.}
	*How many clients did your organization administer this survey for?	^{Click to enter text.}
	*In which mode(s) did you administer the survey? (Mixed-Mode, mail only, telephone only, etc.)	^{Click to enter text.}
	*What language(s) did you administer the survey in?	^{Click to enter text.}
#5	*What was the survey name?	^{Click to enter text.}
	*What was the average sample size in the data collection period?	^{Click to enter text.}
	*When did your organization collect data? (month/year of start and end dates)	^{Click to enter text.}
	*How many clients did your organization administer this survey for?	^{Click to enter text.}
	*In which mode(s) did you administer the survey? (Mixed-Mode, mail only, telephone only, etc.)	^{Click to enter text.}
	*What language(s) did you administer the survey in?	^{Click to enter text.}
^{*2.1.c. Number of years in business: Have you been in business at least 4 years?}		^{Yes No}
^{*2.1.d. Number of years conducting surveys: Have you administered surveys (for at least 3 years) in a Mixed-Mode methodology (mail survey administration followed by survey administration via Computer Assisted Telephone Interviewing [CATI] of non-respondents) in the past 5 years?} ^{Note: The 3 years of Mixed-Mode experience must be fulfilled by the applicant vendor and not its subcontractor.}		^{Yes No}
^{*2.1.e. Experience with multiple survey languages: Do you have experience administering surveys in English and at least one other language from the list at right?}		^{Yes No (Please check the languages you have administered surveys in)} ^Spanish ^Cantonese ^Mandarin ^Korean ^Russian ^Vietnamese

^{2.2. Organizational survey capacity} ^{Capability and capacity to handle a required volume of mail questionnaires and conduct standardized telephone interviewing in a specified time frame.}
^*²^.2^.^a^.^D^e^sigⁿ^a^te k^e^y^C^AH^PS^f^or^M^I^P^S^S^u^rv^e^y P^e^r^s^o^nne^l^:^D^o^e^s^y^o^u^rorganization have a: Project Manager who has administered Mixed-Mode surveys for at least 3 years; and Programmer/Developer with survey experience; and Call Center/Mail Center supervisor (with minimum 1 year of prior experience in role); and Organizational back-up staff to cover key staff? ^{Note: Volunteers are not permitted to be involved in any aspect of the CAHPS for MIPS Survey administration process.}	^{Yes No}
^*²^.2.b.^S^y^s^t^e^m^resour^c^e^s^:^D^o^e^s^y^o^u^r^o^r^g^aⁿⁱ^z^a^t^ion^h^ave a^s^e^c^u^r^e^c^om^m^e^r^cialworkplace with the physical plant resources to handle the volume of surveys being administered, including: Computer and technical equipment; and An electronic survey management system to track fielded surveys through the entire protocol? ^{Note: All system resources are subject to oversight activities, including site visits to physical locations.}	^{Yes No}
^*²^.2.c.^Mix^e^d^-^M^ode^of^sur^ve^y^a^d^mⁱⁿ^is^t^r^a^tioⁿ^:^Yo^u^r^o^r^g^aⁿⁱ^z^a^t^ion^wⁱ^l^l^b^e^gⁱ^v^eⁿthe mail and telephone versions of the CAHPS for MIPS Survey in electronic form and text for cover letters. Can you print and copy the survey materials in accordance with specifications and timeline provided and use commercial software/resources to make sure that the addresses and telephone numbers are up to date for all the sample beneficiaries? You will keep the information that identifies the people taking part in the survey confidential. You acknowledge that telephone interviews are not to be conducted from a residence, or from a virtual office?	^{Yes No}
^*²^.2.d.^D^a^t^a^s^u^b^mⁱ^s^sⁱ^oⁿ^: ^{Can your organization encrypt data files for transmission in accordance with required specifications?}	^{Yes No}
^{Does your organization have previous experience with a flat ASCII file format and submitting encrypted data to an external data warehouse?}	^{Yes No}
^{Will authorizations and business associate agreements be established between your organization and the group practices?}	^{Yes No}
^{*2.2.e. Data security: Can your organization register with the [TBD] and follow data specifications and procedures in order to send and receive encrypted data from the Internet?}	^{Yes No}
^*²^.2^.^f^. Coⁿ^fⁱ^den^ti^a^lit^y^:^Can^y^o^u^r^or^g^aⁿⁱ^z^a^t^ion^m^e^e^t^a^l^l HIP^A^A^r^u^les^aⁿ^dregulations and store CAHPS for MIPS Survey data files securely and confidentially?	^{Yes No}
^{*2.2.g. Technical assistance/customer support: Can your organization provide toll-free customer telephone support and respond to all languages you are administering the survey in?}	^{Yes No}

^{2.3
Quality control procedures}

^{Personnel
training and quality control mechanisms used to collect valid,
reliable survey data.}

^{*2.3.a.
Demonstrated Quality Control Procedures: Can your organization
set-up and document quality control procedures for all phases of
survey implementation including: training; printing, mailing and
recording receipt of surveys; telephone administration of survey
(electronic telephone interviewing system); coding, editing, or
keying in survey data; preparing final person-level data files for
submission and all other functions and processes that affect the
administration of the CAHPS for MIPS Survey?}

^{Can
you provide documentation as requested for site visits and
conference calls, including but not limited to staff training
records, telephone interviewer monitoring records, and file
construction documentation?}

^{Yes No}

^{2.4
Explanation}

^{Please
explain why you replied “NO” to any of the questions
above.}

^{Click
to enter text.}

Part 3. Key Project Staff

^{3.1.a. List of key project staff}
^{*Project staff name}	^Role	^Email	^Telephone
^{1. Click to enter text.}	^{Project Manager}	^{Click to enter email.}	^{Click to enter text.}
^{2. Click to enter text.}	^{Mail Survey Supervisor}	^{Click to enter email.}	^{Click to enter text.}
^{3. Click to enter text.}	^{Telephone Survey Supervisor}	^{Click to enter email.}	^{Click to enter text.}
^{4. Click to enter text.}	^{Programmer/Developer}	^{Click to enter email.}	^{Click to enter text.}

Part 4. List of Subcontractors

^{4.1.a. Check here if your organization does not plan to use subcontractors for the 2018 CAHPS for MIPS Survey administration and skip to Part 5. If your organization will use subcontractors, fill out the following about your organization’s subcontractors.}
^{4.1.b. Subcontractor name and experience}
^{Subcontractor 1 name: Click to enter text.}	^{What will subcontractor do in administering the 2018 CAHPS for MIPS Survey? Click to enter text.}
^{How many years has your organization worked with the subcontractor? Click to enter text.}
^{How many years has the subcontractor administered surveys? Click to enter text.}
^{How many years has the subcontractor been in business? Click to enter text.}
^{What experience does the subcontractor have related to how it will administer the CAHPS for MIPS Survey?} ^{Click to enter text.} ^{What general survey experience does the subcontractor have?} ^{Click to enter text.}
^{Subcontractor 2 name: Click to enter text.}	^{What will subcontractor do in administering the 2018 CAHPS for MIPS Survey? Click to enter text.}
^{How many years has your organization worked with the subcontractor? Click to enter text.}
^{How many years has the subcontractor administered surveys? Click to enter text.}
^{How many years has the subcontractor been in business? Click to enter text.}
^{What experience does the subcontractor have related to how it will administer the CAHPS for MIPS Survey?} ^{Click to enter text.} ^{What general survey experience does the subcontractor have?} ^{Click to enter text.}

^{☐ Check
here to add up to 3 more subcontractors}

^{Include
additional subcontractor information in a separate document.}

Part 5. Curriculum Vitae (CV)

^{5.1.
Please email CVs for all of your key project staff and key
subcontractor’s staff via the CAHPS for MIPS Survey
Technical Assistance email at [TBD].}

Part 6. Rules of Participation

^{Any
organization participating in the CAHPS for MIPS Survey must
adhere to the following Rules of Participation. To be eligible,
the organization must:}

Take part in a teleconference with the CAHPS for MIPS Survey Project Team to talk about your organization’s relevant survey experience, organizational survey capability and capacity, quality control procedures, and role of subcontractors (if applicable).

Take part in and successfully complete the CAHPS for MIPS Survey Training(s). Your organization’s Project Manager, Mail Survey Supervisor and Telephone Survey Supervisor must attend training for your organization. Your organization’s Programmer/Developer or the Programmer/Developer’s Supervisor is strongly encouraged to attend training. Your organization’s subcontractors that have key roles in administering the CAHPS for MIPS Survey are required to attend training.

Review and follow the CAHPS for MIPS Survey Quality Assurance Guidelines and policy updates.

Attest to the accuracy of your organization’s data collection (as determined by CMS), following guidelines in the most current version of the CAHPS for MIPS Survey Quality

Assurance Guidelines.

Write and send a CAHPS for MIPS Survey Quality Assurance Plan (QAP) by due date. Also, send in materials relevant to the survey administration (as determined by CMS), including mailing materials (e.g., cover letters, envelopes, and questionnaires) and telephone scripts.

Participate and cooperate (including subcontractors) in all oversight activities conducted by the CAHPS for MIPS Survey Project Team.

Send in an interim CAHPS for MIPS Survey data file to CMS.

Acknowledge that review of and agreement with the Rules of Participation is necessary for participation and public reporting of results by CMS’ Medicare Compare Website.

Part 7: Applicant organization qualification and acceptance

I certify that:

I have reviewed and agree to meet the Rules of Participation for participating in the CAHPS for MIPS Survey.
The statements herein are true, complete and accurate to the best of my knowledge, and I accept the obligation to comply with the CAHPS for MIPS Survey Minimum Survey Vendor Business Requirements.

*AUTHORIZED REPRESENTATIVE:

Name:

Title:

Organization:

Date:

^{If
you need help completing this application, please contact the CAHPS
for MIPS Survey Project Team by email at [TBD].}

^{When
you complete the form, send it as an attachment to [TBD].}

^{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 0938-1222. The time required to complete this
information collection is estimated to average 10 hours 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.}

OMB No. 0938-1222

Expiration Date: XX/XX/XXXX

July 2017

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