CMS-10210 Extraordinary Circumstances Form

Centers for Medicare & Medicaid Services (CMS) Quality Program
Extraordinary Circumstances Exceptions (ECE) Request Form
A facility may request an exception, as specified by CMS, for quality reporting and value-based purchasing
programs 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 that prevent facilities from electronic clinical quality measure (eCQM) or electronic health
record (EHR)-based reporting. Please refer to the Federal Register and Code of Federal Regulations for
program-specific rules on availability of this exception. 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.
____________________________________________________________________________________
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 ___________________________________________________________________
Additional Contact Information
Name _________________________________________ Title _________________________________
Address (must include physical street address)_______________________________________________
City_______________________________________ State _____ ZIP Code_______________________
Telephone Number________________________ Extension____________________________________
Email Address_________________________________________________________________________

*Dates
*Date of Request

March 2021

*Date of Extraordinary Circumstance ______________________

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Centers for Medicare & Medicaid Services (CMS) Quality Program
Extraordinary Circumstances Exceptions (ECE) Request Form
*Program(s) and Program Requirement(s) for Which Facility is Requesting Exception
Please indicate which program requirement(s) and quarter(s) were affected by the extraordinary circumstance
and if you are requesting the requirement to be excepted from public reporting.
Program
Ambulatory Surgical
Center Quality
Reporting (ASCQR)
Program
End-Stage Renal
Disease Quality
Incentive Program
(ESRD QIP)

Measure and/or Program Requirement

Quarter(s)

☐ Web-based measure(s)
☐ Claims-based measure(s)
☐ Clinical Depression Screening and Follow-up Plan
☐ Clinical Measure(s)

☐ Consumer Assessment of Healthcare Providers and Systems (CAHPS)
Survey
☐ CAHPS Attestation

☐ National Healthcare Safety Network (NHSN)
☐ ESRD Quality Reporting System (EQRS)
☐ Claims-based measure(s)
☐ Validation

Hospital-Acquired
Condition (HAC)
Reduction Program

☐ Claims-based measure(s)

☐ NHSN Healthcare-associated infection (HAI) measure(s) data use
☐ NHSN HAI measure(s) data submission requirements
☐ Validation

Hospital Inpatient
Quality Reporting
(IQR) Program

☐ Chart-abstracted measure(s)
☐ Claims-based measure(s)

☐ Electronic Clinical Quality Measures (eCQMs)

☐ Hospital Consumer Assessment of Healthcare Providers and Systems
(HCAHPS) Survey
☐ Influenza Vaccination Among Healthcare Personnel (HCP) measure

☐ COVID-19 Vaccination Among Healthcare Personnel (HCP) measure
☐ Web-based measure(s)
☐ Structural measure(s)

☐ Population and Sampling
☐ Validation

☐ Non-measure related requirement(s) (Please specify below)

Hospital Outpatient
Quality Reporting

March 2021

☐ Chart-abstracted measure(s)
☐ Web-based measure(s)

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

Measure and/or Program Requirement

Quarter(s)

☐Claims-based measure(s)
☐ Validation

☐ Non-measure related requirement(s) (Please specify below)

Hospital
Readmissions
Reduction Program
(HRRP)
Hospital ValueBased Purchasing
(VBP) Program

☐ Claims-based measure(s)

☐ Claims-based measure(s)

☐ Hospital Consumer Assessment of Healthcare Providers and Systems
(HCAHPS) Survey
☐ NHSN Healthcare-associated infection (HAI) measure(s)

Inpatient Psychiatric
Facility Quality
Reporting (IPFQR)
Program

☐ Chart-abstracted measure(s)

☐ COVID-19 Vaccination Among Healthcare Personnel (HCP) measure
☐ Claims-based measure(s)

☐ Non-measure related requirement(s) (Please specify below)

PPS-Exempt Cancer
Hospital Quality
Reporting (PCHQR)
Program

☐ Web-based measure(s)

☐ Claims-based measure(s)

☐ Hospital Consumer Assessment of Healthcare Providers and Systems
(HCAHPS) Survey
☐ Influenza Vaccination Among Healthcare Personnel (HCP) measure

☐ COVID-19 Vaccination Among Healthcare Personnel (HCP) measure
☐ NHSN Healthcare-associated infection (HAI) measure(s)

☐ Non-measure related requirement(s) (Please specify below)
Skilled Nursing
Facility Value-Based
Purchasing (SNF
VBP) Program

☐ Claims-based measure(s)

Exception or Extension Request Information
*Date ECE relief would end

March 2021

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Centers for Medicare & Medicaid Services (CMS) Quality Program
Extraordinary Circumstances Exceptions (ECE) Request Form
*Provide justification for the ECE end date.

*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 or how the extraordinary circumstance prevented your facility from meeting the
program requirement for the measure(s) for which an exception is being sought (if applicable). Attach
supporting documentation when necessary.

March 2021

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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 Hospital Quality Reporting Secure Portal, Managed File Transfer to
[email protected]. If unable to submit via Managed File Transfer, please submit via email to
[email protected] or secure fax to (877) 789-4443.
For SNF VBP only requests, 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 Inpatient Value, Incentives, and Quality Reporting Outreach and Education Support
Contractor at (844) 472-4477.

March 2021

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