CMS-10393 Attachment A: Beneficiary Experience Survey

CMS 10393 Supporting Statement – Attachment B
Beneficiary and Family Centered Information Collection
Beneficiary Experience Survey Script
Submitted for the Centers for Medicare & Medicaid Services
June 25, 2020
Telephone Introduction
Hello, may I please speak with {Beneficiary/Representative Name}?
I would like to ask you some questions about your interactions with {QIO Name}. My questions
should take about 15 minutes and your participation is completely voluntary. Any feedback you
provide will be treated as confidential.
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 (Expires XX/XX/XXXX). This is a
voluntary information collection. 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. ****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 the CMS BFCC ORC subject matter expert Kaysha Meredith at
410-786-2449.

CMS 10393 Beneficiary Experience Survey Script Attachment B
June 25, 2020

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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)

CMS 10393 Beneficiary Experience Survey Script Attachment B
June 25, 2020

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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

CMS 10393 Beneficiary Experience Survey Script Attachment B
June 25, 2020

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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)

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June 25, 2020

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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?

CMS 10393 Beneficiary Experience Survey Script Attachment B
June 25, 2020

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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 Beneficiary Experience Survey Script Attachment B
June 25, 2020

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Text of covering letter provided to beneficiary/representative receiving survey by mail:

/

,

Agree to be surveyed
Thank you for telling , the Quality Improvement Organization (QIO) in your
state, that you’d be willing to be surveyed on your or another person’s experience with
. This survey is regarding your experience with and the
process. According to our records, you or another person filed a
with Medicare about your experience on the date and about the provider
below:
•
•
How you can help
We need your help to improve the Medicare services you and other people with Medicare get by
filling out and returning the survey. Any information you provide will be kept private and will
not affect your or others Medicare benefits.
Your responses will help Medicare:
• Identify areas of strength and growth for the QIO program
• Support QIO improvement
• Identify best practices in resolving concerns
Get help & more information
For help with or questions about this survey, call Avar Consulting, Inc. at 1-888-810-8833 or
send an email to [email protected]. We are working with Avar on this
important activity.
Your time to give feedback to Medicare is appreciated and helpful.
Sincerely,

Steven C. Rubio, MGA, BSN, RN
Director, Beneficiary Health Improvement & Safety

Por favor vea el otro lado de esta hoja para la versión en español.
CMS 10393 Beneficiary Experience Survey Script Attachment B
June 25, 2020

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