CMS-10813 Web Chat Survey

Library of Questions for Palmetto’s Webchat Survey

Palmetto’s Edited Questions:

1. What’s your Medicare enrollment type or your practice or facility’s enrollment type?

• Institutional provider

• Clinic or group practice

• Physician

• Non-physician practitioner

• Staff of a provider of medical services

• Staff of a billing service, credentialing agency, or clearinghouse

• Consultant or attorney

• Other [open text box] *

Notes:

• CMS required question: asked on every survey

2. Based on your interaction with our representative, how satisfied or dissatisfied are you with the service you got?

• Extremely satisfied

• Somewhat satisfied

• Neither satisfied nor dissatisfied

• Somewhat dissatisfied

• Extremely dissatisfied

Notes:

• CMS required question: asked on every survey

3. How professional was our representative?

• Extremely professional

• Somewhat professional

• Neither professional nor unprofessional

• Somewhat unprofessional

• Extremely unprofessional

3a*. How can we be more professional?

• [Open text box]

Notes:

• Displays if “Somewhat unprofessional” or “Extremely unprofessional” is selected for “How professional was our representative?”

4. How knowledgeable was our representative about the topic you discussed?

• Extremely knowledgeable

• Somewhat knowledgeable

• Neither knowledgeable nor unknowledgeable

• Somewhat unknowledgeable

• Extremely unknowledgeable

4a*. What didn’t our representative know?

• [open text box]

Notes:

• Displays if “Somewhat unknowledgeable” or “Extremely unknowledgeable” is selected for “How knowledgeable was our representative about the topic you discussed?”

5. Did our representative clearly explain the answer?

• Yes

• No

5a*. How could our representative better explain the answer?

Notes:

• Displays if “No” is selected for “Did our representative clearly explain the answer”

6. Is there anything you would like to share that could make your experience better?

• [open text box]

7. If we have questions about your feedback, can we contact you?

• Yes

• No

7a*. Please provide the following contact information:

• Name

• Work email (required):

• Work phone:

• Reference number:

• NPI:

• PTAN:

Notes:

• Displays if “Yes” is selected for “If we have questions about your feedback, can we contact you?”

Additional Questions:

Before using webchat, did you try another way to get the information you needed?

• Yes

• No

What did you try before webchat?

• Called Provider Contact Center

• Called IVR

• Searched your website

• Searched CMS.gov

• Searched the internet (Google, etc.)

• Used the MAC portal

• Wrote to the MAC (letter, email, fax)

• Something else (open text)

Notes:

• Displays if “Yes” is selected for “Before using webchat, did you try another way to get the information you needed?”

How satisfied are you with how long it took to start the webchat?

• Extremely satisfied

• Somewhat satisfied

• Neither satisfied nor dissatisfied

• Somewhat dissatisfied

• Extremely dissatisfied

How satisfied are you with how long the webchat took?

• Extremely satisfied

• Somewhat satisfied

• Neither satisfied nor dissatisfied

• Somewhat dissatisfied

• Extremely dissatisfied

What was your webchat about?

• Appeal

• Claim denial

• Claim status

• Billing issue

• Other [open text box]

How many times have you contacted us about this exact issue?

• 1

• 2

• 3

• 4+

Did you get the information you needed?

• Yes

• No

Why did you choose to use webchat over our other services?

• [open text box]

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

PRA Disclosure Statement

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-XXXX (Expires XX/XX/XXXX).  This is a [mandatory/voluntary/required to retain or obtain a benefit (please select one)] information collection. The time required to complete this information collection is estimated to average [Insert Time (hours or 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. ****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 [List Program Specific Contact].