QHP Secret Shopper Surveys That Meet CMS Appointment Wait Time Standards

PRIME® runs your CMS appointment wait time survey from sample to final report, with validated scripts and CMS-ready results.

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90%

Required compliance threshold

Third-party execution

Required for medical QHP issuers in FFEs

Jan 1 to May 31

CMS survey window

<span>QHP Secret Shopper Surveys </span>That Meet CMS Appointment Wait Time Standards

Pass the QHP Secret Shopper Survey with PRIME®: Meet CMS Wait Time Standards

What CMS Expects From FFE Issuers Each Plan Year

A Survey Your Team Cannot Run Internally

CMS requires medical QHP issuers in the FFEs to use a third party separate from the issuer, so affiliates and sister subsidiaries cannot run the survey.

Three Standards, Two Surveyed Today

CMS sets standards for behavioral health, routine primary care, and non-urgent specialty care. Secret shopper surveys cover the first two today, with specialty care expected in future plan years.

A Fixed Window Every Plan Year

Secret shopper calls run January 1 to May 31, with results due by the second Friday of June. Issuers that miss the survey or fall below 90% must add contracted providers.

CMS Appointment Wait Time Standards for QHPs

Issuers in the FFEs must meet these standards at least 90% of the time. CMS confirmed in the 2027 Letter to Issuers that the approach is unchanged from 2025.

PRIME® Runs Your Secret Shopper Survey, Fully Managed

Over two decades of provider outreach for health plans, applied to the CMS secret shopper methodology.

[01] Survey Design

Tailored Scripts and Outreach Protocols

New-patient scripts for primary care and behavioral health, with specialty scripts ready
In-person and telehealth availability, as CMS requires
Separate protocols for QHP and voluntary access surveys
Scripts validated against CMS requirements before launch

[02] Independent Outreach

Third-Party Execution for Medical QHP Issuers

A separate entity with no corporate ties to your plan
Verifies network status, new-patient acceptance, and wait times
Calls January 1 to May 31, in each provider’s local business hours
Every attempt logged with outcome and timestamp

[03] Wait Time Measurement

How Your Wait Times Are Measured

Business days from request to first available appointment
Primary care at 15 business days, behavioral health at 10
Ineligible providers replaced from the same-specialty reserve
Results tracked by provider type and geography

Primary Care, Behavioral Health, and Specialists-1

[04] Analysis and Reporting

CMS-Ready Results and Documentation

Statistical analysis that meets CMS sampling requirements
Results in CMS reporting fields, with compliance rates by provider type
Methodology, outreach evidence, and contract documentation for CMS
Delivered with review time before the June deadline

What Your Survey Reveals About Your Network

Every secret shopper call also tests your provider data. These are the gaps the survey surfaces most often.

And the findings are sent straight into provider directory data validation and continuous provider data monitoring

Providers listed as accepting new patients who are not
Wrong phone numbers, locations, or departed providers
No in-network appointment available within the standard

FAQs

Why can't we conduct this survey in-house?

CMS requires medical QHP issuers in the FFEs to use a third party for secret shopper calls. Your team prepares the provider sample and acts on the findings.

Does the CMS secret shopper survey include specialists?

Not yet. Specialty care has a 30-business-day standard, but CMS currently surveys only primary care and behavioral health.

Which product lines does the survey need to cover?

The CMS requirement applies to medical QHP issuers in the FFEs. States will contract Medicaid managed care surveys from rating periods on or after July 10, 2028, and PRIME® runs voluntary access surveys for other lines of business.

When should we contract our survey partner?

Calls start on or shortly after January 1, so contracting in Q4 leaves time to finalize your sample and approve scripts.

What happens if a provider does not respond to outreach attempts?

Every attempt is logged with date, time, and outcome. Unreachable or ineligible providers are replaced from the same-specialty reserve, as CMS guidance requires.