Form CMS-10764 Appendix A - RADV Instrument

Appendix A:
Form CMS-10764 - Survey Instrument
Evaluation of Risk Adjustment Data Validation
(RADV) Appeals/Health Insurance Exchange
Outreach Training Sessions

OMB Number: 0938-NEW
Expiration Date: XX/XX/XXX

[TITLE OF TRAINING EVENT]
Please take a few minutes to answer the following questions regarding the [TITLE OF
TRAINING EVENT] training event. Your feedback will assist CMS in determining the
extent to which we achieved the goals of the training and will help make improvements for
future training sessions. Your responses will remain confidential and will be reported in
aggregate form only. Please do not include any personally identifiable information (PII) in
your responses.
1.

Please indicate your level of agreement with the following statements regarding the
[TITLE OF TRAINING EVENT]? (Select one response per statement.)

Content was presented
in an organized
manner.
Information regarding
resources related to the
topic of this session
was provided.
Session met the stated
learning objectives.
Information provided
during this session will
be useful to my
organization.
In general, the session
met my expectations.

Strongly
Agree

Agree

Neither
Agree nor
Disagree

Disagree

Strongly
Disagree

2.

How satisfied were you with each of the following aspects of the [TITLE OF TRAINING
EVENT]? (Select one response for each aspect.)
Neither
Very
Satisfied nor
Very
Satisfied Satisfied Dissatisfied Dissatisfied
Dissatisfied
Webinar log-in
Webinar functionality
Audibility of the
speaker(s)
Questions and Answer
(Q&A) process

3.

If you expressed dissatisfaction with at least one aspect of this training, please provide a
brief description of why you were dissatisfied in the space below.

4.

What did you like most about this training?

5.

What recommendations, if any, do you have for future [TITLE OF TRAINING EVENT]
training event topics?

6.

Do you have any general comments regarding the [TITLE OF TRAINING EVENT] training
event?

[Q7 AND Q8-RADV SURVEY]

7.

Which of the following best describes your organization?
CMS
Cost Plan
Consulting Firm
Employer Group Waiver Plan
MA only
MA-PDP
PACE
SNP
Third Party Submitter
Other (please specify)

8.

Which of the following best describes your role within your organization?
Business Program Analyst
Chief Executive Officer
Claims Processing Staff
CMS Staff
Coder/Data Analyst
Compliance Staff
Consultant
Finance/Revenue Staff
Information Technology Staff
Operations Staff
Program/Project Manager
CMS Contractor
Industry Association Representative
Quality Assurance/Quality Control Staff
Risk Adjustment/Encounter Data Staff
Third Party Submitter
Other (please specify)

[Q7 AND Q8 -EXCHANGE SURVEY]
7.

Which of the following best describes your organization?
CMS
Cost Plan
Consulting Firm
Employer Group Waiver Plan
MA only
MA-PDP
PACE
SNP
Third Party Submitter
SBE Regulator
FFE Regulator
Federal Law Enforcement Agency
State Law Enforcement Agency
Industry Association
National Stakeholder (e.g. AARP, AMA, NAACP)
Insurance Agency or Brokerage
Other (please specify)

8.

Which of the following best describes your role within your organization?
Business Program Analyst
Chief Executive Officer
Claims Processing Staff
CMS Staff
Coder/Data Analyst
Compliance Staff
Consultant
Finance/Revenue Staff
Information Technology Staff
Operations Staff
Program/Project Manager
CMS Contractor
Industry Association Representative
Quality Assurance/Quality Control Staff
Risk Adjustment/Encounter Data Staff
Third Party Submitter
Law Enforcement Agent
Agent/Broker
State Regulator/DOI Staff
Other (please specify)

For onsite attendees, webinar specific items in Question 2 will be replaced with the following items:
Aspect
Helpfulness of onsite staff
Registration check-in process
Session location and accessibility

For CBT participants, webinar specific items in Question 2 will be replaced with the following items:
Aspect
Ease of navigation, functionality
Narration and notes (if applicable)
Screen quality

Thank you for completing the [TITLE OF TRAINING EVENT] Training Event Evaluation Form.

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 collection is 0938-NEW. 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