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.
The HCAHPS Project Team (HPT) has identified acceptable variations from established methodologies. Requested exceptions may fall into categories such as:
- Disproportionate Stratified Random Sampling - Include the following information in the Exception Request:
- Name of each stratum
- Estimated number of total inpatient discharges for each stratum
- Estimated number of eligible patients for each stratum
- Estimated 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 current HCAHPS Quality Assurance Guidelines manual.
- If hospitals/survey vendors are requesting Determination of Service Line, additional documentation is required:
- Current electronic or written confirmation from the hospital that they are unable to provide MS-DRG codes or other preferred means of establishing the HCAHPS Service Line Category
- Current electronic or written confirmation from the hospital delineating which patient populations are served (Medical, Surgical or Maternity)
- Participating in Another CMS or CMS-sponsored Inpatient Initiative - If a hospital accepts an offer to participate in another CMS or CMS-sponsored project that includes an inpatient survey which may contravene HCAHPS protocols, the HPT requests that hospitals file an Exception Request to alert and inform the HCAHPS Project Team of its participation.
- Survey Materials - An Exception Request must be filed for the use of survey materials that do not align with the examples provided in the current HCAHPS Quality Assurance Guidelines 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 mode).
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 may only be implemented at the beginning of a quarter and are limited to a two-year approval timeframe, unless otherwise specified.
If the Exception Request is not approved:
- The HCAHPS Project Team will notify the hospital/survey vendor with information and reasoning for the denial unless otherwise specified.
- 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 (01/19/22)