Medicare Beneficiary and Family-Centered Satisfaction Survey

CMS 10393 Supporting Statement – Attachment H

Beneficiary and Family Centered Data Collection

General Feedback Web Survey Instructions
(Combined Appeals/Complaints/Immediate Advocacy)

A URL will be printed on all final letters sent to beneficiaries/representatives. Individual URLs will be established for each service area to track/report responses and to establish appropriate survey skips/fills.

Invitation Letter inclusion

The following text will be included on determination letters that each QIO sends to beneficiaries with their final appeal/complaint 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.xxxxxx.xxx.

Instructions Included on the Web Survey Web 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.