CMS-10761 Final Overall Mobile Feedback Survey-final

Overall Mobile Application Experience Survey:

* denotes a response is required

     

Survey Invitation Message: 

We are always looking for ways to improve your experience.

Please take a few minutes to share your thoughts with us.

[Share now button]

Please select your Medicare Contract:

• Jurisdiction A Durable Medical Equipment Supplier (DME Providers Suppliers from CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT)

• Jurisdiction D Durable Medical Equipment Supplier (DME Providers Suppliers from AK, AS, AZ, CA, GU, HI, ID, IA, KS, MO, MT, ND, NE, NV, N. Mariana Islands, OR, SD, UT, WA, WY)

• Jurisdiction E (A/B Providers from AS, CA, GU, HI, NV, N. Mariana Islands) 

• Jurisdiction F (A/B Providers from AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY) 

• Jurisdiction 15 (A/B Providers from KY, OH) 

• Jurisdiction 15 (HH+H Providers from CO, DC, DE, IA, KS, MD, MO, MT, ND, NE, PA, SD, UT, VA, WV, WY) 

• Jurisdiction B Durable Medical Equipment Supplier (DME Suppliers from IL, IN, KY, MI, MN, OH, WI)

• Jurisdiction C Durable Medical Equipment Supplier (DME Suppliers from AL, AR, CO, FL, GA, LA, MS, NC, NM, OK, PR, SC, TN, TX, VA, VI, WV)

• Jurisdiction 5 (A/B Providers from IA, KS, MO, NE) 

• Jurisdiction 8 (A/B Providers from IN, MI) 

• Jurisdiction L (A/B Providers from DC, DE, MD, NJ, PA) 

• Jurisdiction H (A/B Providers from AR, CO, LA, MS, NM, OK, TX) 

• Jurisdiction RRB (Part B Nationwide) 

• Jurisdiction J (A/B Providers from AL, GA, TN) 

• Jurisdiction M (A/B Providers from NC, SC, VA, WV) 

• Jurisdiction M (HH+H Providers from AL, AK, FL, GA, IL, IN, KY, LA, MS, NC, NM, OH, OK, SC, TN, TX) 

• Jurisdiction K (A/B Providers from CT, MA, ME, NH, NY, RI, VT) 

• Jurisdiction K (HH+H Providers from CT, MA, ME, NH, RI, VT) 

• Jurisdiction K (FQHC Providers from CT, ME, MA, NH, RI, VT)

• Jurisdiction 6 (A/B Providers from IL, MN, WI) 

• Jurisdiction 6 (HH+H Providers from AK, AS, AZ, CA, GU, HI, ID, MI, MN, NJ, NV, NY, N. Mariana Islands, OR, PR, VI, WA, WI)

• Jurisdiction 6 (FQHC Providers from AL, AK, AS, AR, CA, CO, DE, FL, GA, GU, HA, ID, IL, IN, IA, KS, KY, LA, MD, MI, MN, MS, MO, NE, NV, NJ, NM, NC, MP, OH, OK, OR, PA, PR, SC, TN, TX, VI, WA, DC, WV, WI, CT, ME, MA, NH, NY, RI, VT)

• Jurisdiction N (A/B Providers from FL, PR, VI)

Notes:

1. This question is only presented to a survey respondent when a Medicare Administrative Contractor (MAC) is not able to pass embedded data to Qualtrics identifying the jurisdiction for which the survey respondent is providing feedback.

2. The answer choices represent the universe of MAC jurisdictions. However, the list will be filtered based on the contracts and the services offered by a particular MAC. For example, a survey respondent will only see the choices Jurisdiction K or Jurisdiction 6 if they are visiting the NGS website.

Q1*. Considering all services provided by [MAC Name], overall, how satisfied are you with us? 

• Extremely satisfied

• Somewhat satisfied

• Neither satisfied nor dissatisfied

• Somewhat dissatisfied

• Extremely dissatisfied

Q2*. Which best describes you?

• Provider of medical services

• Supplier of medical equipment or supplies

• Staff of a provider of medical services

• Staff of a supplier of medical equipment or supplies

• Staff of a billing service/credentialing agency/clearinghouse

• Consultant or attorney

• Other [open text box]*

Notes:

1. If ‘Provider of medical services’ or ‘Staff of a provider of medical services’ is selected, show question 2a

2. If any other answer choice is selected, show Question 3

Q2a.* What is your Medicare enrollment type or the enrollment type of your practice or facility?

• Institutional Provider

• Clinic/Group Practice

• Physician

• Non-Physician Practitioner

• Home Health

• Hospice

• Other [open text box]*

{Notes: This question only shows if ‘Provider of medical services’ or ‘Staff of a provider of medical services’ is selected in Question 2

Q3*. What was the primary purpose of your visit to our mobile app today?

• Register to attend an educational event

• Find provider (Medicare) enrollment information

• Find contact information

• Download forms

• Read news, publications, or general information about the Medicare program

• Look up fee schedules

• Find policy (LCDs) or billing guidance

• Use self-service tools

• Other [open text box]*

     

Q4*. Were you able to {pipe response selection from Q3. If other is selected, pipe in “accomplish your task”}?

• Yes

• No

Notes:

1. If “Yes” is selected, show Question 7.

2. If “No” is selected, show Question 5 and Question 6

     

Q5*. We’re sorry to hear you weren’t able to {pipe response selection from Q3. If other is selected, pipe in “accomplish your task”} during your visit. Please tell us what happened.

[Open text box]

Q6*. What step will you take next?

• Call the contact center

• Continue to search this mobile app

• Search the [MAC] website

• Search the CMS.gov website

• Search the internet (Google, etc.)

• Send a written inquiry

• Other [open text box]*

Notes: Show Question 9 after any selection

Q7*. How easy or difficult was it to {pipe response selection from Q3. If other is selected, pipe in “accomplish your task”}?

• Extremely easy

• Somewhat easy

• Neither easy nor difficult

• Somewhat difficult

• Extremely difficult

Notes:

1. If “Extremely easy,” “Somewhat easy,” or “Neither easy nor difficult” is selected, show Question 9}

2. If “Somewhat difficult” or “Extremely difficult” is selected, show Question 8.

Q8*. Please tell us what made it difficult:

[Open text box]

Q9*. Overall, how satisfied or dissatisfied are you with today’s mobile app experience?

• Extremely satisfied

• Somewhat satisfied

• Neither satisfied nor dissatisfied

• Somewhat dissatisfied

• Extremely dissatisfied

Q10*. Which contributed most to your mobile app experience today?

• Navigation (ability to get to what you were looking for easily)

• Speed or responsiveness of the app

• Visual appeal (overall look of the app)

• Content (pictures, descriptions, etc.)

• Relevance of products and/or services

• Other [open text box]*  

  

Q11. What improvements would you like to see on our mobile app?

[Open text box]

Q12*. Can we follow up with you about your feedback?

• Yes

• No

Notes:

1. If “No” is selected, end survey and show appropriate End of Survey message below

2. If “Yes” is selected, show Question 13

Q.13* Please provide the following contact information:

Name: 

Work Email: 

Custom End of Survey Messages

• If “Somewhat dissatisfied” or “Extremely dissatisfied” is selected in Question 9 then the following response is provided:

Thank you for taking our survey. We’re sorry you didn’t have a positive experience on our mobile app, and we appreciate the time you took to share your feedback with us. We’ll be working to address your concerns.

• If “Neither satisfied nor dissatisfied” is selected in Question 9 then the following response is provided:

Thank you for taking our survey. We appreciate the time you took to share your experience with us.

• If “Somewhat satisfied” or “Extremely satisfied” is selected in Question 9 then the following response is provided:

Thank you for taking our survey. We're happy you had a positive experience on our mobile app, and we appreciate the time you took to share your feedback with us.

PRA Disclosure Statement will be added as a link to the bottom of the survey

https://www.cms.gov/files/document/pra-disclosure-statement