Medicare Advantage and Prescription Drug Plan CAHPS® Survey

Exception Request Form

MA & PDP CAHPS

Exception Request Instructions and Form

The Exception Request process and Exception Request Form have been established to handle requests for alternatives to on-site operating requirements outlined in the 2021 Minimum Business Requirements during the current COVID-19 public health emergency. The proposed alternative procedures must not be implemented until the submitted Exception Request Form has been approved by CMS.

Exception Request Process

Ø  The Exception Request process has been created to provide survey vendors with increased flexibility to conduct business operations in a manner that might vary from on-site requirements during the public health emergency, while still maintaining the integrity of the data for standardized public reporting. The Exception Request Form must be completed with sufficient detail, including clearly defined security measures and timeframes, for the MA & PDP CAHPS Project Team to make an informed decision.

Ø  Exception Requests will be limited to the duration of the COVID-19 public health emergency

Ø  Approved Exception Requests are for internal survey vendor use only and must not be used for marketing purposes

To request an exception, survey vendors are required to complete and submit an Exception Request Form online (see form below). The form is designed to capture information on the proposed alternative(s) to the standard on-site operating requirements.

Ø  Survey vendors may submit one Exception Request Form for multiple survey administration operations

Ø  Provide the timeframe and location(s) of work for each operation included in the request

Ø  Survey vendors must include details regarding:

o   Key personnel; system resources; remote access procedures, data transmittal procedures; and measures to be implemented to ensure the security and confidentiality of data

o   Quality control measures that will be implemented during the period survey operation(s) will not occur on-site

o   Processes for staff training, oversight and risk mitigation procedures that will be implemented

Ø  Please be sure to include the information in the specified section of the Exception Request Form

Ø  A new Exception Request Form must be submitted for additional operations not included in the original request

No alternative modes of survey administration will be permitted other than that prescribed for the survey (Mixed [Mail with Telephone follow-up] Mode).

Review Process

Exception Requests will be reviewed by the MA & PDP CAHPS Project Team. These reviews will include an assessment of the proposed alternative(s) and the potential for introducing bias or violating beneficiary confidentiality. Depending on the information provided, additional information may be requested and/or a conference call may be required. The MA & PDP CAHPS Project Team will notify survey vendors whether or not their exception has been approved. Updates to survey administration processes for approved Exception Requests must only be implemented upon approval by the project team.

 

Note: Do not use symbols or special characters (^*@#&) of any kind when submitting the Exception Request Form. Items marked with an asterisk (*) are required.

 

I. Exception request
Please complete items 1 and 2 for each requested exception.
03/05/2021
{{2000 - model.OtherExceptionType.length}} characters remaining
Please select an option above.
II. General Information
1. Organization (Survey vendor)
The Name of the Organization is required.
The Address is required.
The City is required.
The State is required.
The Zip Code is required.
Telephone is required.

2. Contact Person for this Exception Request (Confirmation email will be sent to the Contact Person)
First Name is required.
Last Name is required.
Title is required.
Mailing Address 1 is required.
City is required.
State is required.
Zip Code is required.
Telephone is required.
Email is required.

3. Description of Exception Request
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Activity is required.
Location is required.
TimeFrame is required.
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(click on a row in the grid to edit it)
Purpose of Proposed Exception is required. {{4000 - model.PurposeOfRequest.length}} characters remaining
Rationale for Proposed Exception is required. {{4000 - model.RationaleOfRequest.length}} characters remaining
Explanation of Implementation is required. {{4000 - model.ExplanationofImplementation.length}} characters remaining
Evidence that Exception Will Not Affect Results is required. {{4000 - model.EvidenceWhyWillNotAffectResults.length}} characters remaining

Upon submission, a confirmation email will be sent to the email address listed in the Contact Person section. If a confirmation email is not received, please contact MA &PDP CAHPS Technical Assistance at www.ma-pdpcahps.org to verify submission was successful.

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