Medicare Advantage and Prescription Drug Plan CAHPS® Survey

Event Report
     

MA & PDP CAHPS 
Event Report

Event Report Process

On occasion, a survey vendor may identify deviations from MA & PDP CAHPS Survey protocols that require corrections to procedures and/or electronic processing to realign the activity to comply with MA & PDP CAHPS Survey protocols. Survey vendors are required to notify CMS of these events immediately upon discovery. In its oversight role, the MA & PDP CAHPS Survey Project Team may also identify issues that require correction.

  • To formally notify CMS of events such as these, survey vendors must submit an event report to document any and all field events that result in any deviation from the timeline, procedures or specifications detailed in the MA & PDP CAHPS QAP&TS or any lapse in the CMS procedures for transmitting, using or storing PII and PHI. Tmely submission of an event report will help CMS to implement changes in the survey timeline or protocol if required.

 

This form must be submitted using the form provided below. All required sections are indicated with an asterisk (*). Information not known at the time the initial event report is completed should be recorded on the form as "Pending." Any information reported as “Pending” must be provided in an updated report within 7 days of submitting the Initial report of the event. More than one updated event report may be required.

Date Submitted: 11/24/2017


Indicate whether this report is an Initial Event Report or an Updated Event Report.

Initial Report (Must be submitted within one business day of discovery that a reportable field event has occurred.)

Updated Report (Must be submitted within 7 days of the Initial Event Report; more than one update may be required.)

Date of original report submission: Original Report Form ID:

I. GENERAL INFORMATION

1. Survey Vendor Organization Information
* Organization Name:
* Mailing Address 1:
  Mailing Address 2:
* City: * State: * ZIP Code:


2. Survey Vendor Contact Person
* First Name, Last Name:
  Title:
* (Area Code) Telephone Number: (Area Code) Fax Number:
* Email Address:


3. Date Event Was First Discovered
* Date:


II. LIST THE NAMES AND NUMBERS OF EACH CONTRACT THAT EXPERIENCED THE EVENT BEING REPORTED

Enter Contract Name and CMS Contract Number, then click “Add Contract Name and Number“

* Contract Name:      * CMS Contract Number:


Contract Name CMS Contract Number
{{plan.grpPracticeName}} {{plan.grpPracticeID}}

III. EVENT INFORMATION

Please complete items 1 through 4 below in detail. If any information is not known at time of initial report, enter “Pending.” Any information reported as “Pending” must be completed in an updated event report within 7 days of submitting the initial report of the event. More than one updated event report may be required.
1. * Description of event and how it was discovered


2. *For each contract identified in Section II, list the date(s) associated with the event being reported (e.g., mm/dd/yyyy - mm/dd/yyyy)


3. * For each contract identified in Section II, provide:
  1. CMS Contract Number
  2. Total sample size
  3. Number of sampled beneficiaries affected by the event


4. * Description of corrective action your organization proposes to take to address the event, along with proposed timeline


5. * Additional information not provided above which may help the MA & PDP CAHPS project team understand what occurred


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