Updated Versions of Protocols and Guidelines Manual, Website User and Data Submission Manual, and XML File Layouts have been Posted
folder_openSurvey Materialscalendar_todayPosted November 10, 2025

Version 10.0 of the OAS CAHPS Protocols and Guidelines Manual, Version 9.0 of the OAS CAHPS Website User and Data Submission Manual, and the XML Data File Layouts have been updated and posted on the OAS CAHPS website. The OAS CAHPS Protocols and Guidelines Manual, Version 10.0 is available on the Survey Materials page. The OAS CAHPS Website User and Data Submission Manual, Version 9.0 and XML Data File Layouts are available on the Data Submission Resources page.

The following is a summary of the main differences between Version 9.0 and Version 10.0 of the OAS CAHPS Protocols and Guidelines Manual.

Throughout: Updated the start date for monthly sampling. Data collection can start after the sample month ends and as soon as the sample is ready (Ch. IV, Ch. V, Ch. VI, Ch. VII, Ch. VIII, IX, Appendix M). Clarified that zero-sampled files should not be submitted when a facility with eligible patients does not send the monthly file to the vendor at all or submits the file after the sampling date has passed. In these cases, the vendor should submit a DNR. Vendors should only submit a zero-sampled file if the facility reports they did not serve any eligible patients in the sample month (Ch. IV, Ch. XIII, Ch. XVII, Appendix L). Added a new protocol for folding letters and questionnaires. When folding a 2-sided document that includes English on one side and a translation on the other, the patients preferred language must be visible first. If the preferred language is unknown, English should be visible (Ch. V, Ch. VII, Ch. VIII, Ch. IX).

Chapter II: Updated facility-level eligibility for HOPDs and ASCs in U.S. Territories. HOPDs in U.S. Territories are all exempt from participation, there are no exceptions. ASCs located in U.S. Territories are not automatically exempt from participation and should reach out to the Outpatient Program Support Team to confirm eligibility requirements and clarify their participation status in the Outpatient Quality Reporting Program. ASCs that are eligible to participate in the Outpatient Quality Reporting Program would be expected to participate in OAS CAHPS. Added a new facility-level exclusion for HOPDs, hospitals that are part of the Indian Health Service.

Chapter III: Added the recommendation that facilities and vendors avoid lengthy or sensitive questions (e.g., Sexual Orientation or Gender Identity [SOGI] questions) because they could reduce response rates.

Chapters IV, VI, and IX: Included guidance on what to do if a facility provides two telephone numbers for a sample patient. Prior to sampling, the vendor should work with the facility to determine the primary number. If the facility is not sure which is the primary number, the vendor should use the first number listed. If the first number is found to be not working or not accurate the vendor can switch to the secondary number with call attempts starting over with the secondary number.

Chapters VIII and IX: Clarified that for the web with mail follow-up mode, the individual web survey must remain open after the mail questionnaire has been sent and should close if a survey is final coded for the mail mode. For the web with telephone follow-up mode, the individual web survey must remain open after CATI follow-up begins and should close if a survey is final coded in CATI.

Chapter XI: Added guidance on when to code cases as 350 (No Response after Maximum Attempts) or 320 (Refusal) when a web survey is submitted blank in the web with mail follow-up mode and web with telephone follow-up mode.

Chapter XVI: Updated public reporting table. Clarified which CMS websites HOPD and ASC data is reported on and what data is reported on the Care Compare and PDC websites. Explained requirements that need to be met before a facility's data can be publicly reported and that footnotes are applied when a facility has fewer than the expected number of completed surveys or a shorter time period than expected. Updated text to clarify that Composite 3 is not being publicly reported for voluntary data.

Appendix J and K: Added a new "Email Status" variable to the Standard and DSRS XML layout files to indicate whether a valid patient email address was provided. Provided additional details about this new variable in Chapter XIII.

Appendix M: Added requirement that if vendors are using a commercially available off-the-shelf (COTS) software for their web platform they must document how the COTS is tailored for OAS CAHPS, describe the development and testing processes used before data collection begins, and document all quality control checks that are being implementing in their Quality Assurance Plan (QAP).

Appendix P: Added CPT codes 20560, 20561, 19082, 19084, and 19086 to the list of excluded CPT codes.

Appendix R: Replaced the Participation Exemption Request (PER) Worksheet for the Annual Payment Update for Calendar Year 2027 with the PER for Calendar Year 2028.

If you have questions, you can contact the OAS CAHPS Survey Coordination Team via e-mail at oascahps@rti.org or call 1-866-590-7468.