Form Appendix B1 Appendix B1 Appellant Climate Survey Telephone English

Appendix B1.
Appellant Climate Survey

Telephone Script

(English)

U.S. Department of Health and Human Services

Office of Medicare Hearings and Appeals

_{Medicare Administrative Law Judge Hearings}

_{Telephone Survey}

Form Approved

OMB No.

Exp. Date

I am calling on behalf of the Office of Medicare Hearings and Appeals within the U.S. Department of Health and Human Services. The purpose of my call is to learn more about the level of customer service you received when you experienced the Medicare Administrative Law Judge hearing process.

The Office of Medicare Hearings and Appeals has asked my firm, 2M Research, to administer the survey in order to keep your answers completely anonymous. We will not reveal your name, or other personal identifying information, with your comments to the survey or in any report to the government.

As we go through the survey, when we say “OMHA” I mean the Office of Medicare Hearings and Appeals.

Do you have any questions for me before we begin the survey?

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(to be included in internet version and read upon request for telephone version)

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 0990-0330. The time required to complete this information collection is estimated to average 11 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: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

Section I. Hearings History

1. Approximately how many OMHA hearings have you participated in during the last 12 months?

a. 0

b. 1

c. 2 to 10

d. More than 10

1b. Please respond to the survey questions based on your most recent hearing experience with OMHA over the last 12 months.

When answering these questions, think of the last hearing you participated in, which we show as [date] in the [field office]. Is that correct? [IF NO, THEN ASK]

2a. Approximately when was the last hearing you participated in? Month ______ Year _____

2b. Do you recall the office that heard this case?

Albuquerque

Arlington

Atlanta

Cleveland

Denver

Irvine

Kansas City

Miami

New Orleans

Phoenix

Seattle

For question below, stop reading answer options if the caller picks one before list is finished.

3. Which of the following best describes your relationship to the appellant? Are you. . .

a. The appellant

b. Employee of the appellant

_{c. Appellant’s authorized or appointed representative}

d. Other. Please specify:

Section II – Overall Experience

4. Independent of the Judge’s decision, to what extent do you think you were given the opportunity to have your case fully heard and considered?

a. Very great extent

b. Great extent

c. Some extent

d. Very little extent

e. Not heard and considered at all

5. Next, think about the entire process of working with OMHA, from requesting a hearing up to receiving a final decision. Regardless of the outcome of that decision, how satisfied were you with the process of working with OMHA overall?

a. Very satisfied

b. Satisfied

c. Neither satisfied nor dissatisfied

d. Dissatisfied

e. Very dissatisfied

[If answer to question 5 is d or e, then read only if the respondent begins to offer feedback:] Your feedback is important to us and there is a place later in the survey where I can note it. But first, I have a few more specific questions to ask you.

6. How satisfied were you with the professionalism of OMHA staff when they assisted you with the hearing process [interviewer, remind if needed: from requesting a hearing up to receiving a final decision]?

a. Very satisfied

b. Satisfied

c. Neither satisfied nor dissatisfied

d. Dissatisfied

e. Very dissatisfied

Section III – Request for Hearing

You may have requested a hearing by downloading, printing, and mailing or faxing Form OMHA-100—Request for an Administrative Law Judge Hearing. Or, you may have created an account and requested an appeal using the OMHA e-Appeal portal or website which allows you to fill in the form online. In some cases, you may request an appeal by phone.

7. Which of these methods did you use to request a hearing?

a. Mail [ask question 8]

b. OMHA e-Appeal Portal or website [ask question 8]

c. Phone [Go to question 9]

d. Fax [ask question 8]

8. Did you use form OMHA-100? That form is called a Request for an Administrative Law Judge Hearing.

1. Yes [ask question 8a]

2. No [Go to question 9]

8a. How satisfied were you with the clarity of the form you filled out?

a. Very satisfied

b. Satisfied

c. Neither satisfied nor dissatisfied

d. Dissatisfied

e. Very dissatisfied

f. Didn’t use

9. How satisfied were you with your experience using [display answer from question 7] to request a hearing?

a. Very satisfied

b. Satisfied

c. Neither satisfied nor dissatisfied

d. Dissatisfied

e. Very dissatisfied

10. [If answer to Q9 is d or e] Why were you dissatisfied?

Section IV. Communications and Web Tools

11a. [SKIP IF NON-BENEFICIARY] When you received written notification of your scheduled hearing, it may have included a “Notice of Nondiscrimination”. This document included instructions in a variety of languages on how to obtain free aid and services for people with disabilities and how to obtain free language services. Did you receive this document?”

1. Yes

2. No

3. Don’t know

11b. [Another/A] document you should have received is the Index of the Administrative Record (Form-156) or Exhibit List. How satisfied were you with how clearly it listed all the documents admitted to the administrative record and with its organization?”

1. Very satisfied

2. Satisfied

3. Neither satisfied nor dissatisfied

4. Dissatisfied

5. Very dissatisfied

6. Didn’t receive

7. Don’t know

12. OMHA offers two online tools that allow you to look up the status of the appeals you have filed. The first is the Administrative Law Judge Appeal Status Information System abbreviated as AASIS. The second is the OMHA e-Appeal Portal. Have you used either of these tools to look up the status of your appeal?

a. Yes

b. No [Go to 17]

13. [If answer to prior question is a] Which tool did you use to check the status of your appeal?

a. AASIS [Go to 17]

b. OMHA e-Appeal Portal

c. Both

14A. [If answer to Q13 is B or C] How satisfied are you with [OMHA e-Appeal Portal]’s capability to provide updates on your appeal?

a. Very satisfied

b. Satisfied

c. Neither satisfied nor dissatisfied

d. Dissatisfied

e. Very dissatisfied

14B. [If answer to Q14A is d or e] Why were you dissatisfied?

15. [If answer to Q13 is b or C] Did you use the OMHA e-Appeal Portal to upload documents after the appeal was assigned to a Judge?

a. Yes

b. No [Go to 17]

16. How satisfied are you with using the e-Appeal Portal to electronically upload documents?

a. Very satisfied

b. Satisfied

c. Neither satisfied nor dissatisfied

d. Dissatisfied

e. Very dissatisfied

16A. [If answer to Q16 is d or e] Why were you dissatisfied?

17. Have you accessed OMHA’s website?

a. No, I did not try

b. No, I do not have access to a computer and/or the Internet

c. No, I tried to but could not find it

d. Yes [GO to question 18]

18. [If 17d, then] Do you have any suggestions for improving the OMHA website?

19. Did you ever use the beneficiary or national toll-free helplines to contact OMHA?

a. Yes [Go to 20]

b. No [Go to 21]

20. How satisfied were you with the customer service provided by OMHA through the toll‑free helpline?

a. Very satisfied

b. Satisfied

c. Neither satisfied nor dissatisfied

d. Dissatisfied

e. Very dissatisfied

Section V- Experience Scheduling Your Hearing

_{Next, I will ask you some questions about your satisfaction with scheduling your hearing.}

21. There were four different phases of the scheduling process, starting with your initial request for a hearing up to when you actually participated in the hearing and received the Judge’s decision. The first is ____________. Would you say that you were very satisfied, satisfied, neither satisfied nor dissatisfied, dissatisfied or very dissatisfied with _______________? The next phase was____________? Were you . . .

	Very Satisfied	Satisfied	Neither Sat. nor Dissat.	Dissatisfied	Very Dissatisfied
a. The timeframe between filing your request for hearing and when you were notified that your case had been assigned to a Judge					
b. The amount of time you waited after the appeal was assigned until your hearing was scheduled					
c. The timeframe after the hearing was scheduled but before it was held					
d. The timeframe between the hearing and receiving a decision.					

22. Overall, how satisfied were you with the entire process to schedule the Judge hearing(s)?

a. Very satisfied

b. Satisfied

c. Neither satisfied nor dissatisfied

d. Dissatisfied

e. Very dissatisfied

23. [If answer to prior question is d or e] Please specify:

24. After your hearing was scheduled, was it ever rescheduled?

1. Yes [ask 24A and 24b]

2. No [Go to 25]

24A. Did you request the hearing to be rescheduled or did the Judge change the time and/or

place of the hearing?

1. Respondent requested the hearing be rescheduled.

2. The Judge changed the time and/or place of the originally scheduled hearing.

3. Both parties requested the hearing be rescheduled and/or change in time and/or place at least one time.

24B. How satisfied were you with the rescheduling process?

1. Very satisfied

2. Satisfied

3. Neither satisfied nor dissatisfied

4. Dissatisfied

5. Very dissatisfied

Section VI – Interaction With OMHA Between Scheduling and Hearing

25. Did you have any interaction with OMHA staff after the hearing was scheduled, but before the hearing was conducted?

a. Yes

b. No [GO TO Q29]

26. What was the purpose of the interaction between you and OMHA staff [please check all that apply]?

a. Submit evidence or other documents

b. Request a copy of the administrative record

c. Discuss procedural matters

d. Get general questions about the hearing process answered

e. Other. Please specify:

27. During the period after the hearing was scheduled but before it was held, how satisfied were you with your interaction with OMHA staff overall?

a. Very satisfied

b. Satisfied

c. Neither satisfied nor dissatisfied

d. Dissatisfied

e. Very dissatisfied

28. [If answer to question 27 was d, or e] Please describe why your interaction with OMHA staff was less than helpful.

_{Section VII – Hearing}

_{Next are a few questions about your hearing.}

29. What type of hearing did you have?

a. Telephone

b. Video

30. Overall, how satisfied were you with the [use of telephone/use of video]to conduct your hearing(s)?

a. Very satisfied

b. Satisfied

c. Neither satisfied nor dissatisfied

d. Dissatisfied

e. Very dissatisfied

30A. [If d or e to question 30] Please specify:

31. [Beneficiaries only and question 29 is a] Were you offered the option of a video hearing?

1. Yes [Go To 32]

2. No [ask 31A]

c. Don’t Remember [ask 31A]

31A. If offered, would you have participated in a video hearing?

1. Yes

2. No

Section VIII – Final Questions

32. Regardless of the Judge’s decision, how satisfied were you with the interaction(s) you had with the Judge?

a. Very satisfied

b. Satisfied

c. Neither satisfied nor dissatisfied

d. Dissatisfied

_{e. Very dissatisfied}

33. Regardless of the Judge’s decision, how satisfied were you with how clearly the decision explained the final outcome and reasoning behind the Judge’s decision?

a. Very satisfied

b. Satisfied

c. Neither satisfied nor dissatisfied

d. Dissatisfied

_{e. Very dissatisfied}

34. Regardless of the Judge’s decisions, please respond to the following statements about the Judge during your hearing(s) experience.	Always	Often	Some- times	Never	Don’t Know
a. The Judge clearly stated the relevant issues in my case					
b. The Judge was professional					
c. The Judge was an effective listener					
d. The Judge was prepared					
e. The Judge conducted an orderly hearing(s)					

35. Based on your experience with the OMHA appeals process, do you have any suggestions for improvement?

END, closing statement►

These are all the questions we have for you. Thank you very much for taking the time to speak with us. If you would like to make a comment about this survey or confirm that it meets the necessary requirements as a valid information collection tool under the Paperwork Reduction Act, please contact the OMHA Survey Team at 1-866-207-4466.

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