The Retrospective Appeals Process

Appeal requests may be submitted in writing to the EC either by mail or secure facsimile (fax) using the form Request for Retrospective Appeal Medicare Part A Form on CMS.gov or a letter which includes the following elements:

1. Beneficiary’s name and address
2. Beneficiary’s Medicare number
3. Name and location of the hospital and the date(s) of the hospitalization 
4. If the appeal includes Skilled Nursing Facility (SNF) services paid for out-of-pocket by a beneficiary or family member (and not covered by Medicare or a third-party insurer (such as a supplementary or secondary insurer)), the written request must include:

• Name and location of the Skilled Nursing Facility (SNF)
• The dates of the stay
• An attestation to the out-of-pocket payment(s) made by the beneficiary or family member for the SNF services. The request must also include documentation of these payments (for example, a copy of a canceled check, a credit card statement showing payment to the SNF for the services, or an invoice or bill from the SNF showing the payment made).

In addition to these required elements, the written request may include a statement explaining why the beneficiary believes their hospital services qualified for Part A inpatient coverage, and why the patient should have remained a hospital inpatient and not had their status changed to outpatient receiving observation services. We encourage eligible parties to include copies of medical records from the hospital stay and SNF stay (as applicable) in order to assist with the eligibility decision. If you cannot send the records with your form or request, we will try to get them from your providers. If we have to ask your providers for the records, they have 120 days to respond (which will delay your decision).

Beneficiaries, their authorized or appointed representatives, or the successors in interest in the case of a deceased beneficiary may send their appeal request and any additional information to the EC at the mailing address or via secure fax provided below.

Mailing Address and Fax:    

Q2Administrators – CMS 4204--F Appeals

300 Arbor Lake Dr

Suite 1350

Columbia, SC 29223-4582

Fax: 803-278-9541

Links

Request form CMS-10885: Request Form for Retrospsective Appeal of Medicare Part A Coverage  (The form is available now, however the ability to request an review will not be available until Jan. 1, 2025)

(Large Print) Request form CMS-10885

CMS Eligibility Page

Frequently Asked Questions (FAQs) 

The process for determining an appellant's eligibility is broken down into three steps, plus an addendum should an appellant request a review of a denial notice. Click on each step below to see a process description.

Step 1: Validity Review

Step 2:  Making an Eligibility Decision

Step 3: Issuing Eligibility Decisions

Requests for Review of a Denial Notice

Step 1: Validity Review

The EC will review the request to determine whether it was submitted timely and whether it includes the required elements.

Incomplete Requests: If the request is incomplete, the EC will send an acknowledgment letter to the requestor, noting the missing information which is needed to continue with our review. The EC will send the acknowledgement letter no later than 21 calendar days after the receipt of the appeal request. If additional information is requested, it must be sent to the EC within 14 calendar days of the date of receipt of the acknowledgement letter. The date of receipt of the letter is presumed to be five (5) calendar days from the date printed on the letter unless there’s evidence to show it was received later.

Untimely Filed Requests: If the appeal request is not received by the filing deadline, January 2, 2026, and does not include an explanation of why the request was filed late, the EC will notify the requestor and ask for an explanation that shows good cause for the late filing. Good cause includes things like a serious illness, a death in your immediate family, or you were impacted by an emergency disaster. More information on what is considered good cause for an untimely request is available on the CMS Website. The EC will send this letter no later than 21 calendar days after the receipt of the appeal request. The requestor must respond to the EC in writing and provide an explanation showing good cause for the late filing within 14 calendar days of the date of receipt of the letter. The date of receipt of the letter is presumed to be five (5) calendar days from the date printed on the letter unless there’s evidence to show it was received later.

Valid Appeal Requests: When a request includes the required elements and is received timely, the EC will issue an acknowledgement letter to the requestor. The acknowledgement letter will be sent no later than 21 calendar days after receipt of the appeal request.

• Complete Supporting Information: If the request includes all information needed to make an eligibility decision (for example, medical records for the hospital stay and, as applicable, the SNF stay and proof of payment for the SNF services, the EC will make a decision and send notice within 60 calendar days of receipt of the appeal request. More information on the eligibility decision process is available on the Patient Status page on Medicare.gov
• Incomplete Supporting Information: If the request does not include all of the information needed to make an eligibility decision, the EC will work with the Medicare Administrative Contractor (MAC) to try to get this information. For example, if the request does not include medical records for the hospital stay, the EC will work with the MAC to get these records from the hospital. If the MAC asks a provider for records, the provider will have 120 calendar days to submit the records. The 60-calendar day timeframe for the EC to issue a decision will be paused until the contractor receives the requested records, or the 120-calendar day period expires.

Step 2:  Making an Eligibility Decision

For valid appeal requests, the EC will review all information sent with the request and any additional information the EC obtains to determine whether the beneficiary is eligible for an appeal under this new process.

If the beneficiary was enrolled in Original Medicare, they may be eligible for this new appeal if they met all these requirements:

• Were admitted to a hospital as an inpatient on or after January 1, 2009, and the hospital changed their status to outpatient during their stay.
• Got observation services in the hospital after the hospital changed their status to outpatient.
• Got a Medicare Summary Notice (MSN) for outpatient services for the the hospital stay OR a Medicare Outpatient Observation Notice (MOON) for observation services during the hospital stay. For more information on the MOON, go to the on the FFS & MA MOON page on the CMS website.
• This is the first time an appeal was sent for Medicare to cover services related to this hospital stay OR if previously appealed, there was a final decision after September 4, 2011

And one of these statements also applies:

• The beneficairy did not have Medicare Part B (Medical insurance) while they were in the hospital

OR

• The beneficiary stayed in the hospital for three or more consecutive days, but were an inpatient for less than three days, and was admitted to a skilled nursing facility within 30 days after they left the hospital.

The EC will send its decision to the requestor no later than 60 calendar days after the receipt of the appeal request, plus any days where the period was paused while additional research was being conducting or medical documentation was being requested from a provider on the beneficiary’s behalf.

Step 3: Issuing Eligibility Decisions

Approved requests: If the EC determines the beneficiary meets all eligibility criteria, the EC will send a notice to the requestor explaining that the appeal has been accepted for processing and will be automatically sent to the MAC to conduct the Level 1 appeal.

Denial notices: If the EC determines the request is either not valid, was not filed on time (absent good cause), does not meet all eligibility criteria, or the services previously furnished are not otherwise eligible for an appeal, the EC will send a denial notice to the requestor. The requestor has the right to ask the EC to review its denial.

Requests for Review of a Denial Notice

 Requests for review of the EC’s denial must be received by the EC no later than 60 calendar days after the date the requestor receives the denial notice. The date of receipt of the denial notice is presumed to be five calendar days from the date printed on the letter unless there’s evidence to show it was received later. An individual at the EC not involved in the eligibility denial will perform this review. The EC will issue a decision affirming or reversing the initial eligibility denial. If the request for review of the EC’s denial is not filed timely, the EC will dismiss the request. The decisions made when reviewing a denial are binding and not subject to further review. If the denial is reversed, the request will continue to either an eligibility decision by the EC or it will be sent to the MAC for the Level 1 appeal.

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