Medicare Beneficiary and Family-Centered Satisfaction Survey

CMS 10393 Supporting Statement – Attachment E

Beneficiary and Family Centered Data Collection

Beneficiary Experience Survey Telephone Instructions
(Combined Appeals/Complaints/Immediate Advocacy)

This survey will be conducted by telephone interviewers with three groups of beneficiaries/ representatives: 1) a sample of beneficiaries/representatives who filed an appeal; 2) all beneficiaries/representatives who filed a complaint that was addressed using Immediate Advocacy; and; 3) all beneficiaries/representatives who filed a complaint and received their determination (medical records review).

Screener:

Hello may I please speak with {Name of beneficiary/representative}?

This is {Name of interviewer} and I am calling on behalf of the Centers for Medicare & Medicare services. I wanted to ask you about the help you recently received from {QIO name}. Do you have a few minutes to speak with me?

Thank you.

Introduction:

I would like to talk with you today about your recent experience with the Medicare program and {QIO Name}, the Quality Improvement Organization in your state which handled your recent {appeal/ Immediate Advocacy/complaint} process. I am going to start by checking some information, then ask a few yes/no type questions, and finally I would like to get your suggestions about how to make the process better. This should take no more than 15 minutes. If you would prefer to take the survey by mail, we can accommodate that request.

Elect Telephone - Instructions:

I am going to start by checking some information, then ask a few yes/no type questions, and finally I would like to get your suggestions about how to make the process better.

Elect Mail - Instructions:

Let me verify the address we have on record for you. Thank you. You will receive a survey packet in the mail within the next 7-10 days. If you have any questions when you receive your survey, you can call the Survey HelpLine at 1-xxx-xxx-xxxx, or send an email to xxx@xxxxxx.xxx and we will be happy to assist you.