Exceptions Request & Discrepancy Report Processes
|Exceptions Request Process:
|The Exceptions Request process is designed to allow for as much flexibility
as possible, while still maintaining the integrity of the data for
standardized public reporting. Hospitals/Survey vendors proposing
a variation from the standard HCAHPS protocol must request
an exception prior to survey administration.
- To request an exception, hospitals/survey vendors are required to
complete and submit an Exceptions Request Form (see the
current HCAHPS Quality Assurance Guidelines,)
that must be submitted online
The form will collect information on the proposed alternative to
the standard protocols. NOTE: This form does not accept
any special characters or symbols in the text boxes. Use
only alphanumeric characters when completing this form.
- Survey vendors must submit an Exceptions Request Form on behalf of
their client hospital(s).
- Survey vendors may submit one Exceptions Request Form on behalf of
multiple hospitals with the same Exceptions Request. Survey
vendors must include a list of contracted hospitals
on whose behalf they are submitting the Exceptions Request.
This list should be updated as hospitals are added or deleted.
The HCAHPS Project Team has identified acceptable variations from
established methodologies. Requested exceptions may fall into categories:
No alternative modes of survey administration will be permitted other
than those prescribed for the survey (mail only, telephone only, mixed
mode, and IVR).
- Disproportionate Stratified Random Sampling - The file layout must
include the following additional data elements:
- Name of each stratum
- Number of eligible patients for each stratum
- Number of sampled patients for each stratum (minimum of 10 sampled
- Determination of Service Line Categories - MS-DRGs are the preferred
means to establish the service line category (Maternity Care,
Medical, or Surgical). Hospitals/Survey vendors will need to request
an exception for alternative strategies not identified in
the HCAHPS Quality Assurance Guidelines manual.
- If a hospital accepts an offer to participate in another CMS or
CMS-sponsored project that includes an inpatient survey which
may contravene HCAHPS, the hospital must file an Exceptions
Request to alert and inform the HCAHPS Project Team of its
The Exceptions Request will be reviewed by the HCAHPS Project Team who will
assess the methodological soundness of the proposed alternative and the
potential for introducing bias. Depending on the type of exception, a
review of procedures and/or conference call or site visit may also be
required. If further clarification or additional information is required
for the HCAHPS Project Team to better assess the exception, the
hospitals/survey vendors will be notified and requested to provide
If the Exceptions Request is approved:
If the Exceptions Request is not approved:
- The HCAHPS Project Team will notify hospitals/survey vendors.
All approved Exceptions Requests will be limited to a two
year approval timeframe. The two-year period will begin from
date of approval.
- The HCAHPS Project Team will notify the hospital/survey vendor with
information and reasoning for the denial.
- Hospitals/Survey vendors have the option of appealing the denial decision.
Hospitals/Survey vendors have five business days to submit an appeal. In
such cases, hospitals/survey vendors will resubmit
the Exceptions Request Form (checking the box marked "Appeal of Exception
the Denial") and update it to provide further information about the nature
of the exception. The appeal is then returned to the HCAHPS Project Team
for re-review. The second review will take approximately 10 business
Click here to begin the Exceptions Process Form
|Discrepancy Report Process:
|From time to time a hospital/survey vendor may identify inadvertent and temporary
discrepancies from HCAHPS protocols that require corrections to procedures and/or
electronic processing to realign the activity to HCAHPS protocols. Hospitals/Survey
vendors are required to notify CMS of these discrepancies. (Examples of temporary
discrepancies may include, but are not limited to, missing eligible discharges from
a particular date, or computer programming that caused an otherwise eligible MS-DRG
to be excluded from the sample frame.)
- To formally notify CMS of discrepancies such as these, hospitals/survey vendors
are required to complete and submit a Discrepancy Report as soon as possible. See the current HCAHPS
Quality Assurance Guidelines for the form that must be submitted online (www.hcahpsonline.org). This report notifies
the HCAHPS Project Team of the nature, timing, cause, and extent of the discrepancy,
as well as the proposed correction and timeline to correct the discrepancy.
- Survey vendor must submit a Discrepancy Report on behalf of their client hospital(s).
- The Discrepancy Report must be completed and submitted immediately upon discovery
of the discrepancy from HCAHPS Protocol
The Discrepancy Report will be reviewed by the HCAHPS Project Team, who will assess
the actual or potential impact of the noted discrepancy on publicly reported HCAHPS
Depending on the nature and extent of the discrepancy, a formal review of the hospital's/survey
vendor's procedures, and/or conference call or on-site visit, may be undertaken. The HCAHPS Project
Team will notify hospitals/survey vendors whether additional information is required
to document and correct the issue.
Directions for Completing the Discrepancy Report Form
NOTE: This form does not accept any special characters or symbols in the text boxes. Use only alphanumeric characters when completing this form.
Please be sure to complete the Discrepancy Report in its entirety.
Section 1: Must contain information for the organization submitting the Discrepancy Report.
Section 2: Must contain the name of the individual to contact regarding the Discrepancy Report.
Section 3: Provide information about the discrepancy, including: a detailed description of the discrepancy;
how it was identified; the corrective actions taken to prevent the identified issue from reoccurring; and
any other information that might assist the HCAHPS team to determine an outcome.
Section 4: Submit information for each hospital that was affected by the discrepancy. All fields
are required and at least one hospital must be listed in order to submit the online Discrepancy Report.
To enter data for a minimum of one hospital: Complete all items in Section 4 and select the “Add Affected Hospital Information” button. Select the “Submit Form” button and the Discrepancy Request will be submitted to the HCAHPS team for review.
To enter data for multiple hospitals: After entering the data for one hospital, select the “Add Affected Hospital Information” button. A notice will appear at the top of the page indicating that the “Affected hospital information has been added successfully.” This action will result in listing the previously entered information in the “onscreen” table and blank out the data fields so that information regarding an additional hospital may be entered. Repeat this process until all hospitals have been entered. Next step is to select the “Submit Form” button and the Discrepancy Request will be submitted to the HCAHPS team for review. A notice will appear at the top of the page indicating that “You have successfully submitted your completed Discrepancy Report Form.”
If the Discrepancy Report affects more than 20 hospitals, download the Discrepancy Report Hospital Information Form, input the information regarding each hospital, and email the completed spreadsheet via HCAHPS Technical Assistance at hcahps@HCQIS.org.
Click here to begin the Discrepancy Report