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 Minimum Business Requirements. 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 off-site or remotely, 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 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

Ø Exception Requests must be submitted in a timely manner to allow sufficent time for review

No alternative modes of survey administration will be permitted other than that prescribed for the survey (Web-Mail-Phone 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 compliance with maintaining all aspects of data integrity, including the potential for introducing bias or violating enrollee 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 their exception has been approved. Vendors must not implement any changes to operations prior to CMS approval.

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.

New Exception

Submission Date 12/21/2024

2.Survey Operation* (Please select which operation(s) your organization is requesting an exception from on-site requirements)

Web survey administration (programming, processing completed surveys, etc.)

Mail Production

Mail Receipt

Telephone Interviewing

Telephone Monitoring

Scanning/key Entry

Other Exception (specify)

{{2000 - model.OtherExceptionType.length}} characters remaining

Please select an option above.

II. General Information

1. Organization (Survey vendor)

1a. Organization Name * The Name of the Organization is required.

1b. Mailing Address 1 * The Address is required.

1c. Mailing Address 2

1d. City * The City is required.

1e. State * The State is required.

1f. Zip Code * The Zip Code is required.

1g. Telephone * Telephone is required.

1h. EXT:

1i. Website

2. Contact Person for this Exception Request (Confirmation email will be sent to the Contact Person)

2a. First Name * First Name is required.

2b. Middle Initial

2c. Last Name * Last Name is required.

2d. Title * Title is required.

2e. Degree (e.g. RN, MD, PhD)

2f. Mailing Address 1 * Mailing Address 1 is required.

2g. Mailing Address 2

2h. City * City is required.

2i. State * State is required.

2j. Zip Code * Zip Code is required.

2k. Telephone * Telephone is required.

2l. Fax Number

2m. Email Address * Email is required.

3. Description of Exception Request

3a.Survey Administration Activity/Location/Timeframe of Requested Off-site Operations: * {{AssociatedActivitiesErrorMessage}}

Activity * Activity is required.

Location * Location is required.

Time Frame * TimeFrame is required.

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3b. Purpose of Proposed Exception Requested: * Purpose of Proposed Exception is required. {{4000 - model.PurposeOfRequest.length}} characters remaining

3c. Rationale for Proposed Exception Requested: * Rationale for Proposed Exception is required. {{4000 - model.RationaleOfRequest.length}} characters remaining

3d. Explanation of Implementation of Proposed Exception Requested (key personnel involved; system resources; data security and enrollee confidentiality procedures; remote access procedures; data transmittal procedures; risk mitigation procedures; and quality control, staff oversight and training procedures): * Explanation of Implementation is required. {{4000 - model.ExplanationofImplementation.length}} characters remaining

3e. Evidence that Exception Will Not Affect Results: * 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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Medicare Advantage and Prescription Drug Plan CAHPS® Survey

This site is hosted and maintained by Health Services Advisory Group. It is sponsored by the Centers for Medicare & Medicaid Services.

Medicare Advantage and Prescription Drug Plan CAHPS^® Survey

This site is hosted and maintained by Health Services Advisory Group.
It is sponsored by the Centers for Medicare & Medicaid Services.