CMS-10393 Attachment B: Direct Follow-up

CMS 10393 Supporting Statement – Attachment C
Beneficiary and Family Centered Information Collection
Direct Follow-up Script
Submitted for the Centers for Medicare & Medicaid Services
June 25, 2020
Introduction
Hello may I please speak with {Name of beneficiary/representative}?
This is {Name of interviewer} and I am calling on behalf of the Centers for Medicare &
Medicare services. I wanted to ask you about the call you recently made to {QIO name}. Do you
have a few minutes to speak with me?
I would like to ask you some questions about your call to {QIO name}. My questions should
take about 5 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 Direct Follow-up Script Attachment C
June 25, 2020

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{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 Direct Follow-up Script Attachment C
June 25, 2020

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