Minimum Survey Vendor Business Requirements CAHPS for Physician Quality Reporting System (PQRS) Survey 

Applicant Organizations (vendor and subcontractors) must currently possess all required facilities and systems to implement the CAHPS for PQRS Survey. Subcontractors will be subject to the same requirements as the applicant vendor. Organizations that are approved to administer the CAHPS for PQRS Survey must conduct all their CAHPS for PQRS business operations within the United States. This requirement applies to all staff and subcontractors.

Purpose: any interested survey vendor is required to possess the following minimum business requirements to ensure that all participating survey vendors are capable of administering the CAHPS for PQRS Survey in a consistent, unbiased and competent manner.  At a minimum, this includes basic quality assurance and control systems and activities to prevent sloppy, biased, or illegal data collection. 


Relevant Organizational Survey Experience

Relevant Survey Experience

  • Demonstrated experience (minimum of 3 years) in Mixed-Mode survey administration that includes mail survey administration followed by survey administration via Computer Assisted Telephone Interviewing (CATI) with non-respondents
  • Demonstrated experience (minimum of 3 years) with patient experience of care surveys, surveying vulnerable populations, and experience in a health care setting
  • Demonstrated experience (minimum of 3 years) conducting surveys of the Medicare population
  • Demonstrated experience in implementing a statistical sampling process
  • Demonstrated experience with formatting a flat ASCII file utilizing a standardized data layout and submitting encrypted data to an external data warehouse
  • Demonstrated experience in implementing HIPAA and other data security requirements

Note: All applicant vendors must fulfill the above requirements independent of a subcontractor’s experience.

Number of Years in Business

  • Minimum of 4 years

Number of Years Conducting CAHPS Surveys

  • Minimum of 3 years experience conducting CAHPS surveys of individuals; all experience is within the last 5 years
Survey Capability and Capacity


  • Project Manager with 3 years of relevant Mixed-Mode (mail survey administration followed by CATI administration with non-respondents)  survey experience
  • Information Systems Specialist(s) and Computer Programmer(s)/Developer(s) with experience receiving large encrypted data files in different formats/software packages electronically from an external organization; processing survey data needed for survey administration and survey response data; preparing data files for electronic submission; and submitting data files to an external organization
  • Call Center and Mail Center Supervisor (subcontractor designee, if applicable) with minimum 1 year prior experience in role 
  • Have organizational back-up schedule in place for coverage of key staff
  • Do not use volunteers to conduct any aspect of the CAHPS for PQRS Survey administration process

Facilities and Systems (all administration modes)

  • Physical facilities and electronic equipment and software to collect, process and report data securely
  • A secure commercial office/facility in which all survey activities are conducted
  • Facilities and processes to protect the confidentiality of personally identifiable information and patient response data (e.g., hardcopy documents must be stored in a locked file cabinet, room, or building)
  • Systems needed to protect the confidentiality of personally identifiable information and survey data received from patients (e.g., password protections, firewalls, data encryption software, personnel access limitation procedures, and virus and spyware protection)
  • Computers and other equipment needed for survey implementation 
  • Systems and ability to receive electronic sample files containing patient-level data (the sample) needed to administer the survey
  • Electronic survey management system to track fielded surveys
  • All system resources are subject to oversight activities, including site visits to physical locations

Experience with Multiple Survey Languages

Prior experience required in conducting survey administration in both English AND at least one of the following languages:

    • Spanish
    • Cantonese
    • Mandarin
    • Korean
    • Russian
    • Vietnamese 

Mixed-Mode Survey Administration

Must have capability to adhere to the following Mixed-Mode survey administration requirements:
  • Mail 
    • Must have capability to:
      • Verify addresses of sampled patients
      • Print professional-quality survey instruments and materials according to formatting guidelines
      • Merge and print sample name and address on personalized mail survey cover letters and print corresponding unique sample identification number and group practice provider name associated with each sampled beneficiary on the mail surveys
      • Receive and process (key entry or scanning) returned mail surveys
      • Track and identify non-respondents for follow-up mailing
      • Assign disposition codes to identify the outcome of data collection for each sampled case
  • Telephone
    • Must have the equipment, software and facilities to conduct interviews using CATI, and to monitor interviewers
    • Must have capability to:
      • Verify telephone numbers
      • Develop computer programs for electronically administering the survey 
      • Schedule call backs to non-respondents at varying times of the day/week
  • Assign final disposition codes to reflect the outcome of data collection for each sampled case
  • Track cases from mail survey through telephone follow-up activities
  • Mail survey administration and telephone interviews must be conducted from the physical place of business, not from a residence or virtual office

Data Processing and File Submission

Must have capability to:
  • Scan or key data from completed mail surveys
  • Develop data files and edit the data according to standard protocols
  • Follow all data reporting and data submission requirements, including verifying that data files are de-identified and contain no duplicate cases
  • Export data from the electronic data collection system into the specified ASCII format. Conduct quality checks to confirm that the data are exported correctly and that the ASCII files are formatted correctly and contain the correct data headers and data records
  • Encrypt data files for transmission per specifications
  • Submit data electronically in the specified format (ASCII) to the CAHPS for PQRS Survey secure data warehouse
  • Work with CMS’ data warehouse contractor to resolve issues or problems with data submission or data files

Data Security

  • Execute business associate agreement with group practices and receive annual authorization from group practices to collect data on their behalf and submit to CMS
  • Store returned paper surveys in a secure and environmentally safe location (e.g., locked file cabinet, locked closet or room)
  • Utilize firewalls and/or other mechanisms to protect electronic files 
  • Employ electronic security via implementation of access levels and passwords
  • Implement daily data back-up procedures that safeguard system data
  • Utilize required encryption protocols for transmitting data files
  • Develop procedures for identifying and handling breaches of confidential data
  • Data custodian must be accountable for all data security for data collection as specified in the CMS Data Use Agreement

Data Retention

  • Retain all data files for a minimum of 3 years


  • Include HIPAA compliant content regarding confidentiality and disclosure that is in the Quality Assurance Plan
  • Store CAHPS for PQRS Survey data files (paper or electronic) securely and confidentially in accordance with requirements specified in the Quality Assurance Guidelines

Customer Support

  • Provide toll-free customer support telephone lines with live operator during regular business hours (to be established from the date of the pre-notification letter through the end of data collection)
    • Customer support must be offered in all languages survey vendor is administering surveys
    • Respond to calls within 24-48 hours
Adherence to Quality Assurance Guidelines and Participation in QA Activities

Demonstrated Quality Control Procedures

  • Demonstrated ability to conduct well-documented quality control procedures (as applicable) for:   
    • In-house training of staff involved in survey operations
      • Printing, mailing and recording of receipt of mail surveys
    • Telephone administration of survey (CATI system)
      • Coding and editing of survey data and survey-related materials
    • Scanning or keying in survey data
    • Preparing final record-level data files for submission
    • All other functions and processes that impact the administration of the CAHPS for PQRS Survey
  • Participate in conference calls and site visits as scheduled by the Project Team as part of mandatory quality oversight activities
  • Develop and submit annual Quality Assurance Plans by specified due date
Documentation Requirements

 Maintain Records


Must provide documentation as requested for site visits and conference calls, including but not limited to: staff training records, telephone interviewer monitoring records and file construction documentation. 

Must have capability to:
  • Keep electronic or hard copy files of staff training and dates
  • Maintain electronic or hard copy records of interviewer monitoring activities
  • Maintain electronic or hard copy records of survey mailing dates and dates of returned surveys
  • Maintain other documentation necessary to allow the CAHPS for PQRS Survey Project Team to review survey protocol implementation during site visits
  • Maintain documentation of actions required (and implemented) as a result of site visit findings by the Project Team
Adhere to all Protocols and Specifications, and Agree to Participate in Training Sessions

Survey Training

  • Attend and successfully complete the CAHPS for PQRS Survey Webinar Training Sessions and all CAHPS for PQRS Survey Update Training Sessions
    • The following personnel from vendor and subcontractor organizations must attend (at a minimum):
      • Project Manager
      • Mail Center Supervisor
      • Call Center Supervisor
      • Recommended: Programmer/Developer and/or their supervisor

                           Note: Minimum of one person per subcontractor performing key roles required to attend the training

  • Pass a post-training quiz measuring comprehension of CAHPS for PQRS Survey protocols

Approval Term

  • 1 year subject to annual re-approval
  • Approved survey vendors are required to maintain at least one active CAHPS for PQRS Survey client contract for one of two consecutive survey fielding cycles

Administer the Survey According to All Survey Specifications

  • Must review and follow all procedures described in the CAHPS Survey for PQRS Participating in Medicare Initiatives Quality Assurance Guidelines Version 2
  • Must agree to all conditions in the Vendor Participation Application

Download a PDF version of the 2021 CAHPS for PQRS Survey Minimum Survey Vendor Business Requirements