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Exception Request & Discrepancy Report Processes
Quick links:
Exception Request | Discrepancy Report
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 Appendix W) that can be submitted online (www.hcahpsonline.org), by mail, fax, or e-mail. The form will collect information on the proposed alternative to the standard protocols.

  • Either the hospital, or survey vendor submitting on behalf of the hospital may submit an exceptions request.

  • 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.
Allowable Exceptions
The HCAHPS Project Team has identified acceptable variations from established methodologies. Requested exceptions may fall into categories

  • Disproportionate Stratified Random Sampling - The file layout must include the following additional data elements:

  1. Name of each stratum

  2. Number of eligible patients for each stratum

  3. Number of sampled patients for each stratum (minimum of 10 sampled discharges)


Determination of Service Line Categories - MS-DRGs are the preferred means to establish the service line category (Maternity Care, Medical, or Surgical). When MS-DRGs are not available (e.g., critical access hospitals), hospitals/survey vendors must submit an Exceptions Request Form for approval to use other means to establish the service line category (e.g., CMS V.24 DRG codes or ICD-9 codes).

  • Other - Hospitals/Survey vendors will need to request an exception for alternative strategies not identified in the Quality Assurance Guidelines V3.0 manual.


No alternative modes of survey administration will be permitted other than those prescribed for the survey (mail only, telephone only, mixed mode, and IVR).

Review Process
The exceptions request will be reviewed by the HCAHPS Project Team, and will include an assessment of 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 a site visit may be required. The HCAHPS Project Team will notify hospitals/survey vendors whether or not their exception has been approved. If it has not been approved, the HCAHPS Project Team will send the hospital/survey vendor an explanation of why the exception was not approved. Hospitals/Survey vendors then have the option of appealing the 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 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 days.

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 Appendix X for the Discrepancy Report Form, which may be submitted online (www.hcahpsonline.org), or by mail, fax, or e-mail. 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.

  • The Discrepancy Report must be completed and submitted immediately upon discovery of the discrepancy from HCAHPS Protocol
Review Process
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 results

Depending on the nature and extent of the discrepancy, a formal review of the hospital's/survey vendor's procedures, and/or an 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.

Click here to begin the Discrepancy Report