CMS-10814 CMS-10814. Written Correspondence Instrument

Provider Contact Center - Written Correspondence Survey

* means a response is required to proceed

Introduction text:

We’re looking for ways to improve your experience when you write us.

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

Q1*. What jurisdiction is your feedback about?

• 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/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:

• 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.

• 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 or dissatisfied 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, or clearinghouse

• Consultant or attorney

• Other [open text box] *

Notes:

• If ‘Provider of medical services’ or ‘Staff of a provider of medical services’ is selected, show question 3a

• If any other answer choice is selected, show Question 4

Q3a*. What’s your Medicare enrollment type or your practice or facility’s enrollment type?

• Institutional Provider

• Clinic or Group Practice

• Physician

• Non-Physician Practitioner

• Home Health

• Hospice

• Other [open text box] *

Q4*. How did you contact us?

• Mail

• [MAC Portal]

• Email

• Web form

• Fax

Q5*. What did you write to us about?

• Appeal

• Claim denial

• Claim status

• Billing problem

• Beneficiary eligibility

• Provider enrollment

• EDI

• Other (open text)

Q6*. What did you try before writing us? (select all that apply)

• Called the contact center

• Called the IVR

• Used [MAC Portal]

• Searched our website

• Attended a Provider Outreach and Education event

• Searched CMS.gov

• Searched the internet (Google, etc.)

• Other [open text box]*

• Nothing

Q7-10*

	Yes	No
Did we answer your question?
Was our reply professional?
Was our reply format easy to follow?
Was our reply worded clearly?

Q11

	Yes	No	N/A
Did we include next steps in our reply?

Notes:

• If ‘No’ to Did we answer your question, show Q7a

• If ‘No’ to Was our reply professional, show Q8a

• If ‘No’ to Was our reply format easy to follow, show Q9a

• If ‘No’ to Was our reply worded clearly, show Q10a

• If ‘Yes’ to Did we include next steps in our reply, show Q11a

• If ‘No’ to Did we include next steps in our reply, show Q11b

• If ‘N/A’ to Did we include next steps in our reply, show Q12

Q7a*. What was missing from our answer?

• [Open text box]

Q8a*. What wasn’t professional about our reply?

• [Open text box]

Q9a*. How can we make our reply format easier to understand?

• [Open text box]

Q10a*. How could we make our answer clearer?

• [Open text box]

Q11a*. Were the next steps clear?

• Yes

• No

Notes:

• If ‘Yes’ go to Q12

• If ‘No’ go to Q11c

Q11b*. Did you need next steps?

• Yes

• No

Notes:

• If ‘Yes’ or ‘No’ go to Q12

Q11c*. How could our next steps be clearer?

• [Open text box]

Q12*. What did you do next?

• Took the recommended action

• Called the contact center

• Searched our website

• Used [MAC Portal]

• Searched CMS.gov website

• Searched the internet (Google, etc.)

• Sent another letter

• Nothing

• Other [open text box]*

Q13*. Overall, how satisfied or dissatisfied were you with this contact center experience?

• Extremely satisfied

• Somewhat satisfied

• Neither satisfied nor dissatisfied

• Somewhat dissatisfied

• Extremely dissatisfied

Q14*. What could we do to make your experience better?

This feature won’t provide live support or result in immediate assistance. This is only for feedback and suggestions. Don’t enter Protected Health Information (PHI) or Personally Identifiable Information (PII). Please use our resources such as the portal, IVR or contact center to resolve your questions.

• [Open text box]

• Nothing additional to share

Q15*. If we have questions about your feedback, can we contact you?

• Yes

• No

Notes:

• If ‘Yes’ go to 15a

• If ‘No’ show appropriate End of Survey Message

Q15a*. Please provide the following contact information:

• Name:

• Work email*:

• Work Phone:

• Best time to contact:

• Reference or Correspondence Control number:

• NPI:

Custom End of Survey Messages

• If “Somewhat dissatisfied” or “Extremely dissatisfied” is selected in Question 13 then the following response is provided:

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

• If “Neither satisfied nor dissatisfied” is selected in Question 13 then the following response is provided:

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

• If “Somewhat satisfied” or “Extremely satisfied” is selected in Question 13 then the following response is provided:

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

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

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