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

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 between January 1, 2009 and February 13, 2025, 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 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

   This address is only for retrospective appeals of your hospital status. If you have Original Medicare and you want to appeal a coverage or payment decision for items or services listed on your Medicare Summary Notice (MSN), send it to the address listed on your MSN. The address is on the last page of your MSN, under step 7. Learn more about filing Original Medicare appeals. 

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.

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.

• 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.