CMS-10763 CMS-10763.Medical Review Survey - English final

Medical Review Survey

* means a response is required to proceed

Introduction text:

We are always looking for ways to improve your Targeted Probe and Educate experience.

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

Q1*. Please select your Medicare Contract:

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

• Jurisdiction D Durable Medical Equipment Supplier (DME 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 Providers from KY, OH) 

• Jurisdiction 15 (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 Provider 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 respondent is providing feedback.

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

Q2*. 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

Q3*. 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 3a

2. If any other answer choice is selected, show Question 4

Q3a*. What’s 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] *

Note:

This question only shows if ‘Provider of medical services’ or ‘Staff of a provider of medical services’ is selected in Question 3

Header text above question: Regarding our initial notification letter:

Q4*. Did our initial notification letter give you a clear understanding of the Targeted Probe and Educate (TPE) process?

• Yes

• No

Q4a*. What would make our initial notification letter clearer to understand?

• Open text field

Notes:

This question only shows if ‘No’ is selected in Question 4

Q5*. What service type was identified for your TPE audit?

• Open text Field

Header text above question: Regarding our Medical Review staff:

Q6*. How professional was our Medical Review staff during your TPE review process?

• Extremely professional

• Somewhat professional

• Neither professional nor unprofessional

• Somewhat unprofessional

• Extremely unprofessional

Q6a*. What was unprofessional about our Medical Review staff?

• Open text Field

Notes:

This question only shows if ‘Somewhat unprofessional or ‘Extremely unprofessional’ is selected in Question 6

Header text above question: Regarding our Medical Review staff:

Q7*. How knowledgeable was our Medical Review staff during your TPE review process?

• Extremely knowledgeable

• Very knowledgeable

• Moderately knowledgeable

• Slightly knowledgeable

• Not knowledgeable at all

Q7a*. What specifically didn’t our Medical Review staff know?

• Open text Field

Notes:

This question only shows if ‘Not knowledgeable at all’ is selected in Question 7

Header text above question: Regarding our educational materials:

Q8*. How useful were the educational materials we provided during your TPE review process?

• Extremely useful

• Very useful

• Moderately useful

• Slightly useful

• Not useful at all

Q8a*. How could we improve these educational materials for you?

• Open text Field

Notes:

This question only shows if ‘Not useful at all’ is selected in Question 8

Header text above question: Regarding the TPE Results Letter:

Q9*. Did you, without needing help from [MAC name], understand the TPE Results Letter that explained the outcome of the completed review?

• Yes

• No

Q9a*. What would make our TPE Results Letter easier to understand?

• Open text Field

Notes:

This question only shows if ‘’No’ is selected in Question 9

Q10*. Which round of the TPE process did you just complete for this claim review?

• First

• Second

• Third

Q11*. How satisfied or dissatisfied are you with your overall experience during the TPE review process?

• Extremely satisfied

• Somewhat satisfied

• Neither satisfied nor dissatisfied

• Somewhat dissatisfied

• Extremely dissatisfied

Q12. How can we improve your experience during the TPE review process?

• Open text Field

Q13*. Would it be okay if we followed-up with you about your feedback?

• Yes

• No

Q13a*. Please provide the following contact information:

Name:

Reference/Case number:

Work email:

Notes:

1. This question only shows if ‘Yes’ is selected in Q13

2. Reference/Case number will only display if the MAC uses an identification number for their TPE process

3. Only the Work email will be a required field; respondents don’t need to leave their name or Reference/Case number

Custom End of Survey Messages

• If “Somewhat dissatisfied” or “Extremely dissatisfied” is selected in Question 11 then the following response is provided:

Thank you for taking our survey. We’re sorry you didn’t have a positive experience during the TPE process, and we appreciate the time you took to share your feedback with us. We’ll work to address your concerns.

• If “Neither satisfied nor dissatisfied” is selected in Question 11 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 11 then the following response is provided:

Thank you for taking our survey. We're happy you had a positive experience during the TPE process, 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