Click on a particular question below to see an answer.
When does the appeal period open and how long do I have to file?
What happens if you do not get my request for a retrospective appeal by January 2, 2026?
Is there a form I can use to submit a request and, if so, how do I submit the form?
Is there another way I can file an appeal request?
Is there other information I should include with my appeal request?
What is the role of the Eligibility Contractor?
My request pertains to a service provided ten years ago. Can I request a review of my case?
Does the EC perform expedited appeals?
What are the timelines and when can I expect correspondence or need to take action?
When does the appeal period open and how long do I have to file?
Appeal requests may be filed with the EC starting on January 1, 2025 and must be received by the EC no later than January 2, 2026.
What happens if you do not get my request for a retrospective appeal by January 2, 2026?
If we do not get your request for a retrospective appeal before the deadline, you can ask for more time fi you have "good cause." Good cause includes things like:
- A serious illness prevented you from contacting the appeals reviewer
- You had a death or serious illness in your immediate family
- Important records were destroyed or damaged by fire or other event such as a hurricane, earthquake, or flood
- You did not understand how to file an appeal or you were given the wrong information on how to appeal
If we get your request for a retrospective appeal after January 2, 2026 and it does not include a reason for being late, it will not be accepted.
We will send you a letter telling you why your appeal was not accepted. You will be able to ask for a review of our decision. Detailed information about how to ask for a review wil lbe included in the letter.
Is there a form I can use to submit a request and, if so, how do I submit the form?
Yes, there is a form you may use to submit an appeal request. This form is available at medicare.gov/statuschange and may be filled out online and printed. Forms with any additional information (such as proof of payment if SNF services are included, or medical records from the hospital) must be mailed to the EC at the mailing address below, or securely faxed to the EC at 803-278-9541. Keep a copy of everything you send.
Mailing Address:
Q2 Administrators – CMS 4204-F Appeals
300 Arbor Lake Dr
Suite 1350
Columbia, SC 29223-4582
Is there another way I can file an appeal request?
If you decide not to use the form, you may request an appeal by sending us a letter at the address listed above. Your request must include the following information:
- 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 SNF services, include:
- The name and location of the SNF
- The dates you stayed in 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
Is there other information I should include with my appeal request?
It’s also helpful to include with your appeal:
- Why you believe you qualified for Part A inpatient coverage for your hospital stay. You can also include an explanation of 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 calendar 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 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.
What is the role of the Eligibility Contractor?
The Eligibility Contractor (EC) serves as a single point of contact for incoming retrospective appeal requests submitted by beneficiaries, their authorized or appointed representative, or as applicable, the successors filing on behalf of a deceased beneficiary. The EC reviews the appeal request to determine if it contains the required information and requests additional information when necessary from the beneficiary, the representative, or the provider(s) who furnished services to the beneficiary.
Does the Eligibility Contractor (EC) decide my appeal?
No, the EC reviews information to see if you are eligible for this new appeal. If the EC determines your request is valid and that you meet the eligibility requirements it will automatically forward your request to the Medicare Administrative Contractor (MAC) to decide your appeal. The MAC will issue a decision that explains the reason for the decision and provides detailed information about the next steps based on the decision.
My request pertains to a service provided ten years ago. Can I request a review of my case?
Yes. The new appeal process applies to hospitalizations for eligible parties that began on or after January 1, 2009, through the implementation date of the expedited process (February 14, 2025). For those cases, beneficiaries, authorized representatives, or the successor in interest for a deceased beneficiary may file their request starting January 1, 2025. The request must be received by the EC no later than January 2, 2026. However, if you previously filed an appeal for these services and received a final decision before September 4, 2011, you are not eligible for this new appeal.
Does the EC perform expedited appeals?
No. The appeals handled by the EC are for hospitalizations for eligible parties that began on or after January 1, 2009 through the implementation date of the expedited process (February 14, 2025). These appeals related to past hospitalizations are not processed under expedited timeframes. The EC has 60 calendar days from the date of receipt of an appeal request to issue a decision if all information needed to make an eligibility decision is included with the appeal request. If the EC needs to request additional information from hospitals or SNFs to make an eligibility decision, then the timeframe to make a decision is paused up to 120 additional calendar days while the EC waits for the information.
What are the timelines and when can I expect correspondence or need to take action?
|
Action
|
Timeline
|
|
EC sends acknowledgment letter
|
No later than 21 calendar days after receipt of request for review
|
|
If additional information is requested by EC
|
Requestor has 14 calendar days to cure the invalid request
|
|
Eligibility determination letter sent by EC
|
No later than 60 calendar days after receipt of the request for review, plus up to 120 additional calendar days for receipt of missing information requested from a provider
|
Patient Status Appeal Rights Background
The Centers for Medicare & Medicaid Services (CMS) issued a final rule titled Medicare Program: Appeal Rights for Certain Changes in Patient Status-CMS-4204-F on October 15, 2024[[1]]. This rule creates new appeals procedures to implement the court order in the class action lawsuit Alexander v. Azar, 613 F. Supp. 3d 559 (D. Conn. 2020), aff’d sub nom., Barrows v. Becerra, 24 F.4th 116 (2d Cir. 2022). The court order required CMS to “… permit all members of the modified class to appeal the denial of Part A Coverage” if admitted to a hospital as an inpatient and had their status changed by the hospital during the stay to outpatient receiving observation services, denying Part A coverage for the hospital stay. In some cases, denial of Part A coverage of the hospital stay also affected coverage of a beneficiary’s post-hospital extended care services furnished in a skilled nursing facility (SNF). If the beneficiary or a family member made out-of-pocket payments for the SNF services, then those services may also be included in the appeal request.
In this rule, CMS has established new temporary retrospective appeal procedures that will allow eligible beneficiaries to appeal the denial of Part A coverage for hospital stays that started on or after January 1, 2009. Beginning January 1, 2025, beneficiaries who believe they meet the required conditions for eligibility may submit a written request for retrospective appeal to the Eligibility Contractor (EC). The request must be received by the EC no later than January 2, 2026, unless good cause for late requests is submitted and accepted. The EC serves as the starting point for beneficiaries for this new appeal right, and will determine if the beneficiary meets the eligibility requirements for an appeal. Q2 Administrators has been selected to perform the functions of the EC.
[1] Federal Register :: Medicare Program: Appeal Rights for Certain Changes in Patient Status
Copyright 2010-24 by Q2 Administrators. LLC. All Rights reserved
Privacy Statement Terms Of Use