CMS-10450 Appendix F: Vendor Form

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for the Merit- based 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.

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 March 20, 2018 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*
1.1.b. MAILING ADDRESS 1*
1.1.c. MAILING ADDRESS 2
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)				1.1.h. WEB SITE*
TEL*	EXT	FAX
1.2 APPLICANT CONTACT PERSON
1.2.a. PRIMARY CONTACT PERSON
FIRST NAME*		MIDDLE INITIAL*		LAST NAME*
1.2.b. TITLE*			1.2.c. DEGREE (e.g., RN, MD, PhD)
1.2.d. MAILING ADDRESS 1*
1.2.e. MAILING ADDRESS 2
1.2.f. CITY*		1.2.g. STATE*		1.2.h. ZIP CODE*
1.2.i. TELEPHONE AND FAX (area code, number and extension)				1.2.j. EMAIL ADDRESS*
TEL*	EXT	FAX

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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.
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.

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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
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?
	*What was the average sample size in the data collection period?
	*When did your organization collect data? (month/year of start and end dates)
	*How many clients did your organization administer this survey for?
	*In which mode(s) did you administer the survey? (Mixed-Mode, mail only, telephone only, etc.)
	*What language(s) did you administer the survey in?

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#2	*What was the survey name?
	*What was the average sample size in the data collection period?
	*When did your organization collect data? (month/year of start and end dates)
	*How many clients did your organization administer this survey for?
	*In which mode(s) did you administer the survey? (Mixed-Mode, mail only, telephone only, etc.)
	*What language(s) did you administer the survey in?
#3	*What was the survey name?
	*What was the average sample size in the data collection period?
	*When did your organization collect data? (month/year of start and end dates)
	*How many clients did your organization administer this survey for?
	*In which mode(s) did you administer the survey? (Mixed-Mode, mail only, telephone only, etc.)
	*What language(s) did you administer the survey in?

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#4	*What was the survey name?
	*What was the average sample size in the data collection period?
	*When did your organization collect data? (month/year of start and end dates)
	*How many clients did your organization administer this survey for?
	*In which mode(s) did you administer the survey? (Mixed-Mode, mail only, telephone only, etc.)
	*What language(s) did you administer the survey in?
#5	*What was the survey name?
	*What was the average sample size in the data collection period?
	*When did your organization collect data? (month/year of start and end dates)
	*How many clients did your organization administer this survey for?
	*In which mode(s) did you administer the survey? (Mixed-Mode, mail only, telephone only, etc.)
	*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?		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.	Yes No
*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 No (Please check the languages you have administered surveys in) Spanish 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: 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.	Yes No

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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 CMS CAHPS for MIPS Survey Contractor 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

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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? 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 Yes No

2.4 EXPLANATION

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

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Part 3. Key Project Staff

3.1.A. LIST OF KEY PROJECT STAFF
*Project staff name	Role	Email	Telephone
1.	Project Manager
2.	Mail Survey Supervisor
3.	Telephone Survey Supervisor
4.	Programmer/Developer

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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:	What will subcontractor do in administering the 2018 CAHPS for MIPS Survey?
How many years has your organization worked with the subcontractor?
How many years has the subcontractor administered surveys?
How many years has the subcontractor been in business?
What experience does the subcontractor have related to how it will administer the CAHPS for MIPS Survey? What general survey experience does the subcontractor have?
Subcontractor 2 name:	What will subcontractor do in administering the 2018 CAHPS for MIPS Survey?
How many years has your organization worked with the subcontractor?
How many years has the subcontractor administered surveys?
How many years has the subcontractor been in business?
What experience does the subcontractor have related to how it will administer the CAHPS for MIPS Survey? What general survey experience does the subcontractor have?

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Include additional subcontractor information in a separate document.

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 [email protected].

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.

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.

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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: _____________________________________________________

If you need help completing this application, please contact the CAHPS for MIPS Survey Project Team by email at [email protected].

When you complete the form, send it as an attachment to [email protected].

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].

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