CMS-10210 Extraordinary Circumstances Form

Centers for Medicare & Medicaid Services (CMS) Quality Program
Extraordinary Circumstances Exceptions (ECE) Request Form
A facility can request an exception or extension (if applicable) from CMS quality reporting and payment program
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.
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
Cancer
Hospital

Inpatient Hospital-Acquired
Condition
Reduction

Hospital
Readmissions
Reduction

Ambulatory

Hospital
Outpatient

Centers

Skilled Nursing Facility ValueBased Purchasing (SNF VBP)

Hospital
Value-Based
Purchasing
End-Stage Renal
Disease
Quality Incentive
Program (ESRD
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
* Name

*Title

*Address (must include physical street address)
*City
*Telephone Number

*State

*ZIP Code
*Email Address

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

Title

Address (must include physical street address)
City

State

Telephone Number

Extension

ZIP Code
Email Address

Exception or Extension Request Information
*Measure(s) Affected – Please indicate which measure(s) were affected by the extraordinary circumstance.
Chart-abstracted

Healthcare-associated Infections

Influenza Vaccination Among Healthcare
Personnel (HCP)

Electronic Clinical Quality Measures
(eCQMs)

Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS) Survey

Structural

Claims-based

Web-based

Not Applicable

CrownWeb

*Submission quarter(s)/dates affected
*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.

Updated April 2018

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Centers for Medicare & Medicaid Services (CMS) Quality Program
Extraordinary Circumstances Exceptions (ECE) Request Form

*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.

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].
For SNF VBP only, please complete and submit this form to the SNF VBP 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 (Expires xx-xx-xxxx).The time required to complete this
information collection is estimated to average 15 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 estimate(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, Maryland 21244-1850. ****CMS Disclosure**** 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 Inpatient Value,
Incentives, and Quality Reporting Outreach and Education Support Contractor at (844) 472-4477.

Updated April 2018

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