Form CMS-10450 Appendix F: Vendor Form

The Consumer Assessment of Healthcare
Providers and Systems (CAHPS) for the Meritbased Incentive Payment System (MIPS) Survey
Participation Form for Survey Vendors
The following items are required for your organization to be a Centers for Medicare & Medicaid
Services (CMS) survey vendor of the CAHPS for MIPS Survey:
1. Meet all of the Minimum Survey Vendor Business Requirements at the time of the submission
of this form; and
2. Fill out the participation form below. Please note sections indicated with an asterisk ("*") are
required.

DRAFT

Note: Organizations must also adhere to the Rules of Participation

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*
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1.1.b. MAILING ADDRESS 1*
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1.1.c. MAILING ADDRESS 2
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1.1.d. CITY*

1.1.e. STATE*

1.1.f. ZIP CODE*

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1.1.g. TELEPHONE AND FAX (area code, number and
extension)

Date TBD

1.1.h. WEB SITE*

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TEL*

EXT

FAX

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1.2 APPLICANT CONTACT PERSON
1.2.a. PRIMARY CONTACT PERSON
FIRST NAME*

MIDDLE INITIAL*

LAST NAME*

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1.2.b. TITLE*

1.2.c. DEGREE (e.g., RN, MD, PhD)

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DRAFT

1.2.d. MAILING ADDRESS 1*
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1.2.e. MAILING ADDRESS 2
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1.2.f. CITY*

1.2.g. STATE*

1.2.h. ZIP CODE*

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1.2.i. TELEPHONE AND FAX (area code, number and
extension)
TEL*

EXT

FAX

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Date TBD

1.2.j. EMAIL ADDRESS*
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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

*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.

DRAFT

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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.

Date TBD

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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

DRAFT

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?

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*What was the average sample size in the data collection
period?

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*When did your organization collect data? (month/year of
start and end dates)

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*How many clients did your organization administer this
survey for?
*In which mode(s) did you administer the survey? (MixedMode, mail only, telephone only, etc.)
*What language(s) did you administer the survey in?

Date TBD

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#2

*What was the survey name?
*What was the average sample size in the data collection
period?

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*When did your organization collect data? (month/year of
start and end dates)

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*How many clients did your organization administer this
survey for?

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*In which mode(s) did you administer the survey? (MixedMode, mail only, telephone only, etc.)

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*What language(s) did you administer the survey in?

#3

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DRAFT
*What was the survey name?

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*What was the average sample size in the data collection
period?

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*When did your organization collect data? (month/year of
start and end dates)

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*How many clients did your organization administer this
survey for?

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*In which mode(s) did you administer the survey? (MixedMode, mail only, telephone only, etc.)

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*What language(s) did you administer the survey in?

Date TBD

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#4

*What was the survey name?
*What was the average sample size in the data collection
period?

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*When did your organization collect data? (month/year of
start and end dates)

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*How many clients did your organization administer this
survey for?

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*In which mode(s) did you administer the survey? (MixedMode, mail only, telephone only, etc.)

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*What language(s) did you administer the survey in?

#5

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DRAFT
*What was the survey name?

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*What was the average sample size in the data collection
period?

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*When did your organization collect data? (month/year of
start and end dates)

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*How many clients did your organization administer this
survey for?

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*In which mode(s) did you administer the survey? (MixedMode, mail only, telephone only, etc.)

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*What language(s) did you administer the survey in?

*2.1.c. Number of years in business: Have you been in business at
least 4 years?

Date TBD

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Yes

No

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*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.
*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

Yes

No

No

(Please check the
languages you have
administered surveys in)
Spanish

DRAFT
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. Designate key CAHPS for MIPS Survey Personnel: Does
your organization have a:
•
•
•
•

Yes

No

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.

Date TBD

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*2.2.b. System resources: Does your organization have a secure
commercial workplace 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. Mixed-Mode of survey administration: Your organization
will be given the 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.

Yes

No

You acknowledge that telephone interviews are not to be conducted
from a residence, or from a virtual office?

Yes

No

*2.2.d. Data submission:
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. Confidentiality: Can your organization meet all HIPAA rules
and regulations 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

DRAFT

Date TBD

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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?

Yes

No

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

DRAFT

2.4 EXPLANATION

Please explain why you replied “NO” to any of the questions above.
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Date TBD

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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

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2. Click to enter text.

Mail Survey Supervisor

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3. Click to enter text.

Telephone Survey
Supervisor

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Programmer/Developer

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DRAFT

4. Click to enter text.

Date TBD

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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:
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What will subcontractor do in administering the
2018 CAHPS for MIPS Survey?
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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.

DRAFT

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?
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What general survey experience does the subcontractor have?
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Subcontractor 2 name:
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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?
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Include additional subcontractor information in a separate document.

Date TBD

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Part 5. Curriculum Vitae (CV)
5.1. Please email CVs for all of your key project staff listed in Table 3.1.a. List of Key Project 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:
1. 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).
2. Take part in and successfully complete the CAHPS for MIPS Survey Training(s). In addition to
the Project Manager, we require the following staff to attend training, as applicable: Mail
Survey Supervisor; Telephone Survey Supervisor; Information Systems Specialist and
Computer Programmer/Developer; Data Administrator; and Back-up Data Administrator. Your
organization’s subcontractors that have key roles in administering the CAHPS for MIPS
Survey are also required to attend training.

DRAFT

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

4. 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.
5. 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.
6. Participate and cooperate (including subcontractors) in all oversight activities conducted by
the CAHPS for MIPS Survey Project Team.
7. Send in an interim and final CAHPS for MIPS Survey data file to CMS.
8. 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.

.

Date TBD

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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: ___________________________________

DRAFT

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 (Expiration date: XX/XX/XXXX). 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. ****CMS Disclosure**** 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 [email protected]

Date TBD

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