Extraordinary Circumstances Exceptions (ECE) Policy

Hospital Inpatient Quality Reporting Program

The Centers for Medicare & Medicaid Services (CMS) offers a process for hospitals to request and for CMS to grant extensions or exceptions with respect to the reporting of required quality data—including electronic Clinical Quality Measure (eCQM) data—when there are extraordinary circumstances beyond the control of the hospital.

Non-eCQM Related ECEs

Hospitals may request an extension of or exception from various quality reporting 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) or systemic problems with CMS data collection systems that directly affected the ability of facilities to submit data.

For non-eCQM related ECEs, hospitals must submit an Extraordinary Circumstances Exceptions (ECE) Request Form (PDF-416 KB), with all required sections completed within 90 calendar days of the extraordinary circumstance. The hospital may request consideration for an extension or exception of the requirement to submit quality data for one or more quarters. If the hospital requests an exception for validation, the hospital will only have the requested quarter included in validation if all requested medical records are submitted for the quarter.

eCQM Related ECEs

Hospitals may utilize the ECE form to request an exception from the Hospital Inpatient Quality Reporting (IQR) Program’s eCQM reporting requirement for the applicable program year, based on hardships preventing hospitals from electronically reporting. Such circumstances could include, but are not limited to, infrastructure challenges (a hospital is in an area without sufficient Internet access) or unforeseen circumstances, such as vendor issues outside of the hospital’s control (including a vendor product losing certification). For further information, reference the ECE Policy Clarification Questions and Answers (PDF-51 KB).

In the event of such circumstances, hospitals must submit an Extraordinary Circumstances Exceptions (ECE) Request Form (PDF-416 KB) with all required sections completed, by April 1 following the end of the reporting period calendar year (CY)*. As an example, for data collection for the CY 2017 reporting period (through December 31, 2017), hospitals would have until April 1, 2018, to submit an ECE request.

ECE Request Form Submission Instructions

The form must be signed by the hospital’s chief executive officer (CEO) or designee, and submitted via one of the following methods:

  • the QualityNet Secure Portal, Secure File Transfer to: WAIVER EXCEPTION WITHHOLDING group
  • secure fax to: (877) 789-4443
  • email to: QRSupport@hcqis.org
  • conventional mail to:

    HSAG
    ATTN: Hospital Inpatient Quality Reporting Program Support Contractor
    3000 Bayport Drive, Suite 300
    Tampa, FL 33607

The support contractor will forward, as directed, to CMS.

Note: This process does not preclude CMS from granting extensions or exceptions to hospitals when it is determined that an extraordinary circumstance, such as an act of nature, affects an entire region or locale. CMS may also grant an extension or exception if it is determined that a systemic problem with one of its data collection systems directly affected the ability of the hospitals to submit data. If CMS makes the determination to grant a blanket extension or exception, CMS will communicate this decision to hospitals, vendors, and Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs) through routine communication channels, including memos, emails, and notices on QualityNet.

* Hardship Exceptions for the EHR Incentive Program follow a different process. For additional information on this process, refer to CMS’ Payment Adjustments & Hardship Information web page.

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