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.
For events affecting the submission of data, this form must be submitted within 90 calendar days of the
extraordinary circumstance, except the submission of eCQMs under the Hospital Inpatient Quality
Reporting Program, which has an ECE Request deadline of April 1 following the end of the reporting
period. At the latest, you should submit your ECE no later than 90 days from the submission deadline for
the quarter requested.
For events affecting the Hospital Value-Based Purchasing, Hospital Acquired-Condition Reduction, and
Hospital Readmissions Reduction Programs, this form must be submitted no later than 90 calendar days
of the extraordinary circumstance. At the latest, you should submit your ECE no later than 90 days from
the last date of the quarter requested.
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
December 2022

*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.
Program
Ambulatory
Surgical
Center Quality
Reporting
(ASCQR)
Program

Measure and/or Program Requirement

Quarter(s)

☐ Web-based measure(s)
☐ COVID-19 Vaccination Among Healthcare Personnel (HCP) measure via National
Healthcare Safety Network (NHSN)
☐ Other (Please specify):

_______________________________________________________________________
End-Stage
Renal
Disease
Quality
Incentive
Program
(ESRD QIP)

☐ In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems
(ICH CAHPS) Survey
☐ National Healthcare Safety Network (NHSN)
☐ ESRD Quality Reporting System (EQRS)
☐ Validation

☐ Other (Please specify):

_______________________________________________________________________
HospitalAcquired
Condition
(HAC)
Reduction
Program

☐ NHSN Healthcare-associated infection (HAI) measure(s)

Hospital
Inpatient
Quality
Reporting
(IQR)
Program

☐ Chart-abstracted measure(s)

☐ Validation

☐ Other (Please specify):

_______________________________________________________________________
☐ Electronic Clinical Quality Measures (eCQMs)
☐ Hybrid 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
☐ Web-based measure(s)
☐ Structural measure(s)

☐ Population and Sampling
☐ Validation

☐ Other (Please specify):

_______________________________________________________________________
Hospital
December 2022

☐ Chart-abstracted measure(s)
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Program
Outpatient
Quality
Reporting
(OQR)
Program

Centers for Medicare & Medicaid Services (CMS) Quality Program
Extraordinary Circumstances Exceptions (ECE) Request Form
Measure and/or Program Requirement

Quarter(s)

☐ Web-based measure(s)

☐ COVID-19 Vaccination Among Healthcare Personnel (HCP) measure National
Healthcare Safety Network (NHSN)
☐ Validation

☐ Other (Please specify):

_______________________________________________________________________
Hospital
Readmissions
Reduction
Program
(HRRP)

☐ Other (Please specify):

Hospital
Value-Based
Purchasing
(VBP)
Program

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

_______________________________________________________________________

☐ NHSN Healthcare-associated infection (HAI) measure(s)
☐ Other (Please specify):
_______________________________________________________________________

Inpatient
Psychiatric
Facility
Quality
Reporting
(IPFQR)
Program

☐ Chart-abstracted measure(s)

PPS-Exempt
Cancer
Hospital
Quality
Reporting
(PCHQR)
Program

☐ Web-based measure(s)

☐ COVID-19 Vaccination Among Healthcare Personnel (HCP) measure
☐ Other (Please specify):

_______________________________________________________________________

☐ 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)
☐ Other (Please specify):

_______________________________________________________________________

Exception or Extension Request Information
*Date ECE relief would end

December 2022

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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 prevented
your facility from submitting accurate data for the measure(s) for which an exception is being sought
(if applicable). Attach supporting documentation when necessary.

December 2022

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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
QRFormsSubmission@hsag.com. You may instead submit via email to QRFormsSubmission@hsag.com or
secure fax to (877) 789-4443.
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.

December 2022

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