Exception Request

New HCAHPS Technical Assistance Email Address (hcahps@hsag.com)

 Exception Request Process:

The Exception 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 Exception Request Form (see the current HCAHPS Quality Assurance Guidelines) that must be submitted online www.hcahpsonline.org, or to access the Exception Request Form online see below. 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 complete and submit all Exception Request Forms on behalf of their client hospitals

  • Survey vendors may submit one Exception Request Form on behalf of multiple hospitals with the same Exception Request. Survey vendors must include a list of contracted hospitals on whose behalf they are submitting the Exception Request.

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). 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 Exception Request to alert and inform the HCAHPS Project Team of its participation

No alternative modes of survey administration will be permitted other than those prescribed for the survey (Mail Only, Telephone Only, Mixed Mode, and IVR mode).

Review Process

The Exception 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 additional information.

If the Exception Request is approved:

  • The HCAHPS Project Team will notify hospitals/survey vendors. All approved Exception Requests will be limited to a two-year approval timeframe. The two-year period will begin from date of approval.

If the Exception Request is not approved:

  • 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 Exception 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.

This page was last modified on (1/10/20)

I. Exception request
Please complete items 1 and 2 for each requested exception.
1. Exception Request For (Check one in each box)

Please select an option above
Date of initial Exception Request submission is required.
The Initial Exception Request ID is required.

Please Provide your Exception Type

{{2000 - model.OtherExceptionType.length}} characters remaining Please select an option above Please Provide your Exception Type

2. List of hospitals applicable to this Exception Request This section is to be completed by survey vendors or hospitals administering the survey for multiple sites.
You must enter at least one Hospital if 'Yes'
Name of Hospital is required.
CCN required. Invalid CCN for Hospital type.
(click on a row in the grid to edit it)
II. General Information
1. Organization
The Name of the Organization is required.
The Medical Provider Number is required. Invalid CCN for selected Hospital type.
The Address is required.
The City is required.
The State is required.
The Zip Code is required.
Telephone is required.

2. Contact Person
First Name is required.
Last Name is required.
Title is required.
Mailing Address 1 is required.
City is required.
State is required.
Zip Code is required.
Telephone is required.
Email is required.

3. Survey Vendor Organization This section is to be completed for hospitals using a survey vendor to conduct the survey.

The Zip Code must be 5 digits.
Please enter a valid Email

4. Description of Exception Request
Purpose of Proposed Exception is required. {{2000 - model.PurposeOfRequest.length}} characters remaining
Rationale for Proposed Exception is required. {{2000 - model.RationaleOfRequest.length}} characters remaining
Explanation of Implementation is required. {{2000 - model.ExplanationofImplementation.length}} characters remaining
Evidence that Exception Will Not Affect Results is required. {{2000 - model.EvidenceWhyWillNotAffectResults.length}} characters remaining

Enter answer to equation on left.
Note: Please print completed Exception Report form before submitting.