Appealing a denial of Part A coverage from a change in status during a hospital stay

You can appeal past hospital stays back to January 2009

Starting January 1, 2025: If you’re a Medicare patient who was admitted to the hospital as an inpatient, and the hospital changed your status to “outpatient getting observation services,” you may be able to appeal the denial of Part A (Hospital Insurance) inpatient coverage that came from the change in your status.

If your appeal is approved, Part A may cover the hospital and skilled nursing facility (SNF) services (if appealed) you got. In certain situations, you may also get a refund for payments you or a family member made for services that weren’t covered. Learn more about situations where you might get a refund.

Who’s eligible for a retrospective appeal?

You can appeal the denial of Part A (Hospital Insurance) inpatient coverage that came from your hospital change in status if you meet all these requirements:

• You were admitted to the hospital as an inpatient on or after January 1, 2009, and the hospital changed your status to outpatient during your stay.
• You got observation services in the hospital after the hospital changed your status to outpatient.
• You got a Medicare Summary Notice (MSN) for outpatient services for your hospital stay OR a Medicare Outpatient Observation Notice (MOON) for observation services during your hospital stay.
• This is the first time you’re appealing for Medicare to cover services related to this hospital stay OR if you did appeal, you got a final decision AFTER September 4, 2011.

AND one of these statements also applies to you:

• You didn’t have Medicare Part B (Medical Insurance) while you were in the hospital.

OR

• You stayed in the hospital for 3 or more consecutive days, but were an inpatient for less than 3 days, and you were admitted to a skilled nursing facility within 30 days after you left the hospital.

If you or a family member paid out-of-pocket for skilled nursing facility (SNF) services because you didn’t have a qualifying inpatient hospital stay, you may also be eligible to file an appeal for those services.

If the care you got in a skilled nursing facility was covered by Medicare or another insurance company or third-party payer, you can’t appeal those services under this new process.

How do I file a retrospective appeal?

If you think you meet the eligibility requirements, there are 2 ways to file a retrospective appeal:

1. Fill out a “Request Form for Retrospective Appeal of Medicare Part A Coverage” and mail or fax it to the address on the form.

2. Submit your written appeal to:

   Q2 Administrators 
   CMS 4204-F Appeals 
   300 Arbor Lake Drive, Suite 1350 
   Columbia, SC 29223-4582

We must get your retrospective appeal request by January 2, 2026. 
What happens if you don’t get my request by January 2, 2026? 

If you’re submitting a written appeal (not using the form), include:

• Your name and address
• Your Medicare Number
• The name and location of the hospital where you were admitted
• Dates you were in the hospital

If you’re also appealing skilled nursing facility (SNF) services, include:

• The name and location of the SNF
• The dates you were staying at the SNF
• A signed statement that you or a family member paid out-of-pocket for the services you got in the SNF, and the amount of the payment
• Documentation showing the payments made to the SNF, like a copy of a credit card statement or an invoice from the SNF that shows how much you paid for their services

With either your form or your written appeal, it’s also helpful to include:

• Why you believe you qualified for Part A inpatient coverage for your hospital stay. You can also include why you believe you should have remained a hospital inpatient and not had your status changed to outpatient.
• All medical records from your hospital stay. You can ask the hospital for these records. If you can’t send the records with your form or written request, we’ll try to get them from the hospital. If we have to ask the hospital for the records, they have 120 days to respond (which will delay your appeal decision).
• The Medicare Summary Notice (MSN) from your hospital stay. You can log into (or create) your secure Medicare account to view and download your MSNs.
• The Medicare Outpatient Observation Notice (MOON) from your hospital stay (if you got one). You get this notice from the hospital if you get observation services as an outpatient for more than 24 hours.
• Any bills or itemized statements from the hospital.
• If you’re also appealing skilled nursing facility (SNF) services, include:
  • Your medical records from the SNF.
  • The MSN from your SNF stay (if you got one).
  • Any itemized bills or statements from the SNF.

Can I get help with my appeal?

State Health Insurance Assistance Program (SHIP): Visit shiphelp.org to get the phone number for your local SHIP and get free, personalized health insurance counseling. SHIPs are state programs that get money from the federal government to give free local health insurance counseling to people with Medicare.

Representative: If you have a trusted family member or friend helping you with your appeal, you can appoint them as a representative. How do I appoint a representative?

• A family member or person authorized to act for someone who’s deceased may be able to file an appeal on their behalf. You should submit proof of your authority to act on behalf of the deceased person (for example, proof that you’re the executor of their estate, or information about the state law that authorizes you to handle this person’s affairs).
• The hospital or skilled nursing facility that provided the services you’re appealing can’t be your representative.

You can also call 1-800-MEDICARE (1-800-633-4227) if you have questions about the process, but the only way to find out if you’re eligible is to file an appeal.

What happens after I file my appeal?

• We’ll review the documents you submit and any information we can get from your provider(s) to determine if you’re eligible to appeal. We may contact you by mail if we need more information from you.
• We’ll notify you of our decision about your eligibility for an appeal by mail, usually no later than 60 days after we gather all the records.
• If we determine that you’re eligible for an appeal, your information will automatically be sent to the Medicare Administrative Contractor to decide on your appeal. They’ll mail you a letter letting you know how your appeal is decided.
• If we determine you aren’t eligible for an appeal, you’ll get a letter telling you why. You can ask for a review of the denial within 60 days of getting the letter. Your letter will tell you how to ask for a review of the denial.

What happens if the appeal is decided in my favor? 

You’ll be notified if we determine that your hospital stay met the coverage requirements for a Part A (Hospital Insurance) inpatient hospital stay. The hospital will also be notified of the decision. The hospital may choose to submit a Part A claim to Medicare for payment. 

• If the hospital submits a Part A claim: You (or the company that paid the hospital) will get a refund of any payments for the outpatient services (including any coinsurance and deductibles they collected). You’ll still have to pay your Part A hospital inpatient coinsurance and/or deductible (if you have one).
• If the hospital doesn’t submit a Part A claim: 
  • If you had Medicare Part B (Medical Insurance) when you were hospitalized for the services in the appeal, the hospital may decide not to submit a Part A claim. In that case, the hospital may keep the payment it collected for the outpatient services, and won’t refund any payments, including your coinsurance and/or deductible (if you had one). You won’t need to pay anything else to the hospital.
  • If you didn’t have Medicare Part B when you were hospitalized for the services in the appeal, the hospital must refund any payments collected from you (or the company that paid them). In this situation the hospital must refund your payments, even if they don’t submit a Part A claim.
• If you included skilled nursing facility (SNF) services in your appeal: If we decide some or all of the services you appealed are covered, we’ll notify the SNF that they must refund payments they collected from you or your family member for the covered services. You should get a refund from the SNF within 60 days of the skilled nursing facility getting the decision.

What happens if the appeal isn’t decided in my favor?

You’ll be notified if we determine that your hospital services didn’t meet the coverage requirements for a Part A inpatient hospital stay. You’ll be able to file a second level appeal with the Qualified Independent Contractor. Your decision letter will provide detailed information about how to file a second level appeal.