CMS-10210 Extraordinary Circumstances Form

Centers for Medicare & Medicaid Services (CMS) Quality Reporting Program
Extraordinary Circumstances Exceptions (ECE) Request Form
A facility can request an exception or extension (if applicable) from various Quality Reporting requirements due
to extraordinary circumstances beyond the control of the facility. Such circumstances may include (but are not
limited to) natural disasters (such as a severe hurricane or flood), systemic problems with CMS data collection
systems that directly affected the ability of facilities to submit data, or extreme circumstances preventing
facilities from electronic clinical quality measure (eCQM) or electronic health record (EHR)-based reporting
(e.g., extraordinary infrastructure challenges or vendor issues outside of the facility’s control). To request an
exception or extension, please complete and submit this form. This form must be submitted within 90
calendar days of the extraordinary circumstance for all programs, except the submission of eCQMs
under the Hospital IQR Program, which has an ECE Request deadline of April 1st following the end of the
reporting period, to align with the EHR Incentive Program’s April 1st deadline for submitting hardship exception
requests.
Asterisk (*) indicates required fields. All sections must be complete and specific in order for the CMS
to consider the request.
*Dates
*Date of Request

*Date of Extraordinary Circumstance

*Program(s) for Which Facility Is Requesting Exception/Extension
Hospital
Inpatient

Hospital
Inpatient eCQM

Inpatient
Psychiatric
Facility

PPS-Exempt
Cancer
Hospitals

Hospital
Value-Based
Purchasing

Hospital-Acquired
Condition
Reduction

Hospital
Readmissions
Reduction

Hospital
Outpatient

Ambulatory
Surgical
Centers

ESRD
Quality
Improvement
Program (QIP)

NOTE: Please refer to the Federal Register for program-specific rules on the availability of this
exception/extension.

*Facility Contact Information
*Facility Name
*CMS Certification Number (CCN)
*National Provider Identifier Number (NPI) (ASC only)
(Place additional NPIs in Additional Comments section.)
*CEO/Designee Contact Information
*Last Name

*First Name

*City

*State

*Telephone Number

Ext.

‘

*Address (must include physical street address)

*ZIP Code
*Email Address

Centers for Medicare & Medicaid Services (CMS) Quality Reporting Program
Extraordinary Circumstances Exceptions (ECE) Request Form
Additional Contact Information
Last Name

First Name

Address (must include physical street address)
City

State

Telephone Number

Extension

‘'
ZIP Code
Email Address

Exception or Extension Request Information
*Measure(s) affected (State “None” if not applicable)
*Submission quarter(s)/dates affected (State “None” if not applicable)
*Validation quarter(s)/dates affected (State “None” if not applicable)
*Date facility will restart data submission
*Provide justification for the submission restart date.

*Enter specific reasons for requesting an exception or extension. Please include the specific
requirements or data for which you are seeking an exception or extension. Please indicate how the
extraordinary circumstance negatively impacted performance on the measure(s) for which an
exception or extension is being sought (if applicable). Attach supporting documentation when
necessary.

*Provide evidence of the impact of the extraordinary circumstance including (but not limited to)
photographs, web links, newspaper, and other media articles. Attach supporting documentation when
necessary.

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Centers for Medicare & Medicaid Services (CMS) Quality Reporting Program
Extraordinary Circumstances Exceptions (ECE) Request Form
Additional Comments (Attach additional documentation/comments if necessary):

*CEO/Designee Signature:

*Date:

Extraordinary Circumstances Exceptions Request Form Submission Instructions
Complete and submit this form via the QualityNet Secure Portal, Secure File Transfer “WAIVER EXCEPTION
WITHHOLDING” group. If unable to submit via Secure File Transfer, please submit via e-mail to
[email protected], secure fax to (877) 789-4443, or mail to 3000 Bayport Drive, Suite 300, Tampa, FL
33607. The Support Contractor will forward, as directed, to CMS.
For ESRD QIP only, please complete and submit this form to the ESRD QIP mailbox at
[email protected].
Following receipt of the request form, CMS will: (1) Provide a written acknowledgement using the contact
information provided in the request, to the CEO and any additional designated facility personnel, notifying them
that the facility’s request has been received and (2) provide a formal response to the CEO and any additional
designated facility personnel using the contact information provided in the request notifying them of our
decision. CMS will strive to complete its review of each ECE request within 90 calendar days of receipt of the
request.
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0938-1022.The time required to complete this information collection is
estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have comments concerning the accuracy of the time estimates(s) or suggestions for improving this
form, please write to CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, MD 21244-1650. Please do
not send applications, claims, payments, medical records, or any documents containing sensitive information to the PRA Reports Clearance
Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control
number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your
documents, please contact the Hospital IQR Support Contractor at (844) 472-4477.
Expiration Date: xx-xx-xxxx

March 2017

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