Exception Request Overview

Summary:

A Hospital Performance/Small Hospital Incentive Program (HPIP/SHIP) exception process has been put in place to allow hospitals a mechanism to formally request a review of measurement targets not achieved during the HPIP/SHIP contracted measurement period. For an exception to be considered, certain requirements must be met and demonstrate a situation which is out of the control of the facility. There is no guarantee that submitting a request will result in an exception being granted.

Criteria for consideration:

System wide technical issue resulting in extreme unforeseeable barriers
- Unexpected dissolution of vendor agreement
- Software viruses
Achievement of performance target was beyond the control of the hospital
- Natural disaster including, but not limited to, floods, blizzards, or epidemics
- Unforeseeable occurrence including, but not limited to, unexpected building construction or fire

Criteria exclusions:

Staffing
EMR optimization

Exception Request Requirements:

For each exception to be considered and reviewed, specific requirements must be met.

An exception form must be completed in full for each measure an exception is requested.
Provision of the most current data to allow for continual trending. Inclusion of numerators, denominators, rate, and timeframes is required to be submitted as evidence.
Exception requests require supporting evidence to validate the request and must be submitted with the exception form. Supporting evidence must demonstrate timely process improvement interventions to circumvent the hindrances or correct the unexpected issues. Examples of evidence include:
- New/improved processes
- Policies
- Action plans
All exception request forms, and related evidence documents must be received at the same time as the final data submission due date to be considered by the exception review committee. Evidence can be sent via email to the Clinical Consultant assigned to your facility.

Actions:

Health Plan exception review committee will review all exception requests and evidence submitted.
The Health Plan review committee determination will be final.
Results of final determination will be communicated by email to the hospital quality contact.

Hospital Performance Incentive Program (HPIP)
Small Hospital Incentive Program (SHIP)

Date:

Exception Request Form

This form is required to submit a request for a point’s exception from the Hospital Performance Incentive Program (HPIP)/Small Hospital Incentive Program (SHIP). Please fill out the form completely for each measure and provide information requested for each measure.

The document is pre-formatted to submit your response directly on this form and reply by email.

Hospital Name:	{{ $data['hospital_name'] }}
Hospital Quality Lead Name:	{{ $data['facility_name'] }}		Email: {{ $data['contact'] }}	Phone: {{ $data['phone'] }}
Measure Name:	{{ $data['measure_short_name'] }}
Measure AIM Statement: describe WHAT the project is and its goal. Describe the data elements of the project in writing including baseline numerator & denominator definition** and final target numerator & denominator definition.	{{ $data['aim_statement'] }}
Final Data	Baseline Rate {{ $data['baseline_rate'] }}	Target Rate: {{ $data['target_rate'] }}	Actual Rate: {{ $data['actual_rate'] }}	Numerator {{ $data['numerator'] }}	Denominator {{ $data['denominator'] }}
	Measurement Period: {{ $data['measure_period'] }}
Data for Trending:** include any other supporting evidence that substantiates your claim		Current Rate: {{ $data['current_rate'] }}	Numerator {{ $data['current_numerator'] }}	Denominator {{ $data['current_denominator'] }}
		Timeframe:{{ $data['timeframe'] }}
Describe the facts and circumstances that led to not meeting the target. Present all the related facts clearly and concisely.	{{ $data['describe_facts'] }}
Describe in detail all actions and interventions you have taken to rectify the issue and attempts to meet the target. Please list each item separately.	{{ $data['interventions'] }}
Payor determination	{{ !empty($data['determination']) ? $data['determination'] : 'N/A' }}

Exception Request Overview

Hospital Performance Incentive Program (HPIP)Small Hospital Incentive Program (SHIP)

Date:

Exception Request Form

Hospital Performance Incentive Program (HPIP)
Small Hospital Incentive Program (SHIP)