Appendix J 2021 Extreme and Uncontrollable Circumstances Applicatio

Centers for Medicare and Medicaid Services
2020 Extreme and Uncontrollable Circumstances Reweighting Application
Row
1

Field Label
“Add New Exception”

Req’d
Yes

Screen Guidance
Select Exception Type

Data Form
Select One

Possible Values
Exception Type
1. Promoting Interoperability Hardship
Exception
MIPS eligible clinicians, group, and virtual
groups may submit Promoting
Interoperability Hardship Exception
Application citing one of the following
specified reasons:
• Your’re a small practice
• You have a decertified EHR
technology
• You have sufficient internet
capability
• You face extreme and
uncontrollable circumstances
such as disaster, practice closure,
severe financial distress, or
vendor issues
• You lack control over the
availability of CEHRT
2. Extreme and Uncontrollable
Circumstances Exception
The Extreme and Uncontrollable
Circumstances application is reserved for
instances where there is indeed an
Extreme and Uncontrollable
Circumstance, such as a natural disaster,
public health emergency or other
significant event, that prevents collecting
data for an extended period of time, or

Row

Field Label

Req’d

Screen Guidance

Data Form

2

“Add New Extreme
and Uncontrollable
Circumstances
Application

Yes

Select Application Type

Select One

3

“Submission
Information”

Yes

Individual Application
Type Details

Select One

4

“Submitter Details”

Yes

Contact Information

Free Text

5

“Submitter Details”

Yes

Contact Information

Select One

6

“Additional Access”

No

Additional Staff Access
Email(s)

Free Text

Possible Values
that could impact performance on cost
measures.
All other events such as vendor issues,
decertification of EHR, etc. should be
filed as a Promoting Interoperability
Hardship Exception.
Application Type
1. Individual
If selected, include Clinician NPI#
2. Group
If selected, include Group TIN#
3. Virtual Group
If selected, include Virtual Group ID#
Group Practice Name
• Select group practice name from drop
down
Contact Information for further information as
needed
1. Phone number
2. Email address
Submitter/Third Party Intermediary Relationship
Select relationship to the party you are
submitting the exception application for
• Other: describe relationship if not listed
Additional Staff Access Email(s)
Enter email address(es) for additional staff you
would like to include for the management of the
form and to receive program announcements.

Row
7

Field Label
“Event Type”

Req’d
Yes

Screen Guidance
Indicate the type of
Extreme and
Uncontrollable
Circumstance

Data Form
Select One

8

“Event Date Range”

Yes

Start Date to End Date

Calendar Select

9

“Event Description”

Yes

Free Text

10

“Performance
Category(ies)
Affected”

Yes

Description of the
Extreme and
Uncontrollable
Circumstance
Performance
Category(ies) Impacted
by the Extreme and
Uncontrollable
Circumstance

Multi Select

Possible Values
Event Type
1. COVID-19
2. Natural Disaster
• Hurricane
• Tropical Storm
• Fire
• Flood
• Tornado
• Earthquake
• Other
3. Ransomware/Malware
4. Medical Issue
5. Other
Event Date Range
Indicate the start and end dates for the period of
time for which the clinician(s) were unable to
collect or submit data.
Event Description
Describe the event that impacted the clinician(s)
ability to collect or submit data.
Performance Category(ies) Affected
1. Quality
2. Promoting Interoperability
3. Improvement Activities
4. Cost

Row
11

Field Label
“Submit for Review”

Req’d
Yes

Screen Guidance
Certify and Submit for
Review

Data Form
Select One

Possible Values
Review Submission Summary and Certification
Information, Certify & Submit
1. Review submission information selected
or included
• Individual, Group, or Virtual
Group application details
• Submitter details
• Additional Access
2. Review Extreme and Uncontrollable
Circumstances Details
• Event type
• Event date range
• Event Description
• Performance Category(ies)
Affected
3. Review General Application Notice
• Disclosures, notices and
certification of the clinician(s) or
submitter working on behalf of
the clinician(s)
• By submitting this Extreme and
Uncontrollable Circumstances
Exception Application, I am
certifying that the details entered
are correct to the best of my
knowledge. Furthermore, I am
submitting this request as if a
physically signed and submitted a
hard copy of this form.

12

“Application
Submitted”

N/A

“Application Submitted
Successfully and Pending
Review”

N/A

Automatic notification indicating application was
submitted successfully and is now pending
review.

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 0938-1314 (Expiration date: 01/31/2025). The time required to complete this
information collection is estimated to average 0.25 hours 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 QPP at [email protected]