Health Care Providers and Suppliers

Appendix B3.
Appellant Climate Survey-Mail

(English)

Instructions

Mark your response to each question by checking the related box or circling your answer choice. If you do not have an answer, you may leave it blank.

In the questions that follow, “OMHA” refers to the Office of Medicare Hearings and Appeals.

Section I. Hearings History

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

 0

 1

 2 to 10

 More than 10

Please respond to the survey questions based on your most recent hearing experience with OMHA.

2a. Approximately, when was your most recent hearing? Month_______ Year _______

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

o Albuquerque

o Arlington

o Atlanta

o Cleveland

o Denver

o Irvine

o Kansas City

o Miami

o New Orleans

o Phoenix

o Seattle

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

o The appellant

o Employee of the appellant

_{o Appellant’s authorized or appointed representative}

o 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?

 Very great extent

 Great extent

 Some extent

 Very little extent

 Not heard and considered at all

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 xxxx-xxxx. 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. SW, Suite 537-H, Washington DC 20201, Attention: PRA Reports Clearance Officer.

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?

 Very satisfied

 Satisfied

 Neither satisfied nor dissatisfied

 Dissatisfied

 Very dissatisfied

6. How satisfied were you with the professionalism of OMHA staff when they assisted you with the

hearing process (from requesting a hearing up to receiving a final decision?

 Very satisfied

 Satisfied

 Neither satisfied nor dissatisfied

 Dissatisfied

 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?

 Mail

 OMHA e-Appeal Portal or website

 Phone (if “phone” selected, skip to Question 9)

 Fax

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

 Yes

 No (if “no” selected, skip to Question 9)

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

 Very satisfied

 Satisfied

 Neither satisfied nor dissatisfied

 Dissatisfied

 Very dissatisfied

 Didn’t use

9. How satisfied were you with your experience using either Mail, OMHA e-Appeal Portal or

website, Phone, or Fax to request a hearing?

 Very satisfied

 Satisfied

 Neither satisfied nor dissatisfied

Please explain why you were dissatisfied in the lines provided below.

 Dissatisfied

 Very dissatisfied

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Section IV. Communications and Web Tools

10. 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?”

 Yes

 No

 Don’t know

11. [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?”

 Very satisfied

 Satisfied

 Neither satisfied nor dissatisfied

 Dissatisfied

 Very dissatisfied

 Didn’t receive

 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?

 Yes

 No (if “no” selected, skip to Question 17)

13. Which took did you use to check the status of your appeal?

 AASIS (if “AASIS” selected, skip to Question 17)

 OMHA e-appeal portal

 Both

14. How satisfied are you with OMHA E-Appeal Portal’s capability to provide updates on your appeal?

 Very satisfied

 Satisfied

 Neither satisfied nor dissatisfied

Please explain why you were dissatisfied in the lines provided below.

 Dissatisfied

 Very dissatisfied

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

15. Did you use the OMHA e-Appeal Portal to upload documents after the appeal was assigned to a

Judge?

 Yes

 No (if “no” selected, skip to Question 17)

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

 Very satisfied

 Satisfied

 Neither satisfied nor dissatisfied

Please explain why you were dissatisfied in the lines provided below.

 Dissatisfied

 Very dissatisfied

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

17. Have you ever accessed OMHA’s website?

 No, I did not try

 No, I did not have access to a computer and/or the Internet

 No, I tired to but could not find it

 Yes (If “yes” selected, answer Question 18)

18. Do you have any suggestions for improving the OMHA website? Please provide your suggestions in

the lines below.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

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

 Yes (Answer Question 20)

 No (Skip to Question 21)

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

 Very satisfied

 Satisfied

 Neither satisfied nor dissatisfied

 Dissatisfied

 Very dissatisfied

Section V. Experience Scheduling Your Hearing

21. There were four different phases of the scheduling process (listed below), starting with your initial request for a hearing, up to when you actually participated in the hearing and received the Judge’s decision. Please rate your level of satisfaction with each phase.

Phases of the Scheduling Process	Very Satisfied	Satisfied	Neither Satisfied nor Dissatisfied	Dissatisfied	Very Dissatisfied
The timeframe between filing your request for a hearing and when you were notified that your case had been assigned to a Judge					
The amount of time you waited after the appeal was assigned until your hearing was scheduled					
The timeframe after the hearing was scheduled but before it was held					
The timeframe between the hearing and receiving a decision					

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

 Very satisfied

 Satisfied

 Neither satisfied nor dissatisfied

Please explain why you were dissatisfied in the lines provided below.

 Dissatisfied

 Very dissatisfied

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

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

 Yes (Answer Questions 24A and 24B)

 No (Skip to Question 25)

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

 You requested a rescheduling of the hearing.

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

 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?

 Very satisfied

 Satisfied

 Neither satisfied nor dissatisfied

 Dissatisfied

 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?

 Yes

 No (Skip to Question 28)

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?

 Very satisfied

 Satisfied

 Neither satisfied nor dissatisfied

Please explain why you were dissatisfied in the lines provided below.

 Dissatisfied

 Very dissatisfied

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

_{Section V}II. Telephone Hearing

Next are questions about your telephone hearing.

28. What type of hearing did you have?

 Telephone

 Video

29. Overall, how satisfied were you with the use of the telephone or the use of video to conduct your hearing(s)?

 Very satisfied

 Satisfied

 Neither satisfied nor dissatisfied

Please explain why you were dissatisfied in the lines below.

 Dissatisfied

 Very dissatisfied

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

30. If you had a telephone hearing, were you offered the option of a video hearing?

 Yes (Skip to Question 32)

 No (Answer Question 31)

 Don’t Remember (Answer Question 31)

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

 Yes

 No

Section VIII. Final Questions

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

 Very satisfied

 Satisfied

 Neither satisfied nor dissatisfied

 Dissatisfied

 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?

 Very satisfied

 Satisfied

 Neither satisfied nor dissatisfied

 Dissatisfied

 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
a. The Judge clearly understood the issue(s) in my case(s).				
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?

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Thank you for taking the time to respond to this survey. 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.

Use the postage-paid return envelope to return this survey or mail it to:

2M Research

ATTN: OMHA Survey

1521 N. Cooper St., Suite 600

Arlington, TX 76011