CMS-10393 Attachment C: General Feedback Web Survey

CMS 10393 Supporting Statement – Attachment D
Beneficiary and Family Centered Information Collection
General Feedback Web Survey Script
Submitted for the Centers for Medicare & Medicaid Services
June 25, 2020
Invitation Letter inclusion
The following text will be included on letters that each QIO sends to beneficiaries with their final
determination.
We would like to hear about your experience with the {appeal/complaint} process. Please take 2
minutes to tell us about your experience at www.URLXYXY.com.
Included on the web survey page
Thank you for taking the time to tell us about your experiences with filing {a complaint/an
appeal}. Please respond to the following 8 questions.
The questions should take you about 2 minutes to complete. 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 General Feedback Web Survey Script Attachment D
June 25, 2020

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{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

CMS 10393 General Feedback Web Survey Script Attachment D
June 25, 2020

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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 General Feedback Web Survey Script Attachment D
June 25, 2020

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