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 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), issues 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., vendor issues
outside of the facility’s control). To request an exception, 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 1
following the end of the reporting period.
An 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
Ambulatory Surgical Centers Quality
Reporting (ASCQR) Program
End-Stage Renal Disease Quality
Incentive Program (ESRD QIP)
Hospital-Acquired Condition (HAC)
Reduction Program
Hospital Inpatient Quality Reporting (IQR)
Program (includes eCQMs)
Hospital Outpatient Quality Reporting (OQR)
Program

Hospital Readmissions Reduction
Program (HRRP)
Hospital Value-Based Purchasing
(VBP) Program
Inpatient Psychiatric Facility Quality
Reporting (IPFQR) Program
PPS-Exempt Cancer Hospital Quality
Reporting (PCHQR) Program
Skilled Nursing Facility Value-Based
Purchasing (SNF VBP) Program

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

*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 ____________________________________ *State _________________ *Zip Code ________
*Telephone Number _____________________________ *Extension _________________________
*Email Address ___________________________________________________________________
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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 _____ ZIP Code_______________________
Telephone Number _________________________________ Extension __________________________
Email Address ________________________________________________________________________

Exception or Extension Request Information
*Data Submission Requirement(s) Affected – Please indicate which requirement(s) were affected by the
extraordinary circumstance.
Influenza Vaccination Among Healthcare
Chart-abstracted measure(s)
Personnel (HCP) measure
Claims-based measure(s)
Web-based measure(s)
CrownWeb
Electronic clinical quality measures (eCQMs)
NHSN healthcare-associated infection (HAI)
measure(s)
Consumer Assessment of Healthcare Providers
and Systems (CAHPS) Survey data

Structural measure(s)
Non-measure related requirement(s)
(Please specify below)
________________________________

*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.

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Centers for Medicare & Medicaid Services (CMS) Quality Program
Extraordinary Circumstances Exceptions (ECE) Request Form
*Enter specific reasons for requesting an exception. Please include the specific requirements or data for
which you are seeking an exception. Please indicate how the extraordinary circumstance negatively
impacted performance on the measure(s) for which an exception 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.

Additional Comments (Attach additional documentation/comments if necessary.)

*CEO/Designee Signature:

April 2019

*Date:

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

April 2019

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