Hospital Appeals -Change of Inpatient Status (Alexander v Azar)

Appealing a Denial of Part A Coverage for Past Hospital Stay 

Important Notice: End of the Filing Period for Retrospective Patient Status Appeals (Alexander v Azar)

Effective January 2, 2026, the 365-calendar day timeframe for filing new patient status appeal requests for eligible hospital stays (the retrospective appeal process) has ended. Retrospective patient status appeal requests received after January 2, 2026, will be denied as untimely filed unless an eligible party establishes good cause for late filing as explained below (42 CFR 405.932(a)(2)(ii)). 

Please note: this notice does not apply to fast appeals for patients who are currently in the hospital, receive the Medicare Change of Status Notice (CMS-10868), and are eligible for the prospective appeal process.

Late Filing Requests

If we receive your request for a retrospective appeal after January 2, 2026, you must include information to show good cause for late filing. Requests received after this date without a good cause explanation will be denied as untimely filed. We strongly encourage you to submit your request with a good cause explanation by April 1, 2026, to avoid any delays in processing. 

What is Good Cause for Late Filing?

Good Cause exists when circumstances beyond your control prevented you from filing your appeal request on time. 

To establish good cause, you must show that:

1. You had a valid reason for missing the deadline, AND
2. The reason was beyond your control, AND
3. You filed your appeal as soon as possible after the circumstances preventing timely filing were resolved.

Examples of Good Cause

Good Cause may be established in situations including, but not limited to:

• Serious illness or hospitalization that prevented you from filing on time
• Physical or mental incapacity that made it impossible to understand or meet the deadline
• Death or serious illness of an immediate family member
• Natural disaster, fire, or other catastrophic event that prevented timely filing, OR
• Other extraordinary circumstances that were beyond your control and prevented you from filing on time

For more information about what may be considered good cause for late filing, visit: https://www.cms.gov/appeals-late-filing

How to Request Good Cause for Late Filing

If you believe you have good cause for filing a late appeal, you must:

1. Submit your appeal request along with a written explanation of why you are filing late
2. Provide evidence supporting your good cause claim (medical records, documentation of circumstances, etc.)
3. File as soon as possible after the circumstances preventing timely filing are resolved

Your good cause request will be reviewed, and you will receive a written decision on whether good cause has been established.

Appealing a denial of Part A coverage for past hospital stay            

Who’s eligible for a retrospective appeal?

The appeal process is available to certain Medicare beneficiaries who were enrolled in Original Medicare and who were initially admitted as hospital inpatients but were subsequently reclassified as outpatients receiving observation services during their hospital stay and meet other eligibility criteria established in the new rule. 

If you were enrolled in Original Medicare you may be eligible for this new appeal 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. For more information on the MOON, go to: https://www.cms.gov/medicare/forms-notices/beneficiary-notices-initiative/ffs-ma-moon
• 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 services because you didn’t have a qualifying inpatient hospital stay, you may be able to include those services in your appeal. However, if the services you got in a skilled nursing facility were covered by Medicare or another insurance company or third-party payer, you can’t include those services in your appeal under this new process.

How do I file a retrospective appeal?

If you believe you meet the eligibility requirements and you have good cause for filing late, you may choose 1 of the following 2 options to file a retrospective appeal: 

1. Fill out a “Request Form for Retrospective Appeal of Medicare Part A Coverage” (available in “Downloads” below) and mail or fax it to the address on the form with any additional information you have, including an explanation of your good cause for filing late if your request is expected to be received after January 2, 2026. Examples of additional information that may help with your appeal are included on the form and are listed below.
2. If you don’t use the form, you may submit a written request with 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
• An explanation of your good cause for filing late (if your request is expected to be received after January 2, 2026)

If you are also appealing SNF services, include:

• The name and location of the SNF
• The dates you stayed 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

Where to send your request:

               Mail:

                Q2 Administrators

                CMS 4204-F Appeals

                300 Arbor Lake Drive, Suite 1350 

                Columbia, SC 29223-4582

              Secure Fax number: 803-278-9541

What else should I send with my retrospective appeal request?

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

• A statement explaining why you believe you have good cause for late filing (for any requests that will be received after January 2, 2026).
• Why you believe you qualified for Part A inpatient coverage for your hospital stay. You can also include a statement explaining why 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 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.

Keep a copy of all the records that you send with your request.

Can I get help with my appeal?

If you have a trusted family member or friend who can help you with your appeal, you can appoint them as a representative.  However, under these new rules, the hospital or skilled nursing facility that provided the services you’re appealing can’t be your representative.  Information about appointing a representative is available here: Can someone help me file an appeal?

If the beneficiary who would have been eligible for an appeal is deceased, then a person who is authorized to act on behalf of the deceased beneficiary may be able to file an appeal. 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 if there is no estate, information about the state law that authorizes you to handle this person’s affairs).

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.

Who decides if I’m eligible for a retrospective appeal?

• CMS has contracted with Q2Administrators to make eligibility decisions.
• They’ll review the documents you submit and any information we can get from your provider(s) to determine if you’re eligible to appeal. They may contact you by mail if they need more information from you. 
• They’ll notify you of the decision about your eligibility for an appeal by mail, usually no later than 60 days after they gather all the records.
• If they determine that you’re eligible for an appeal, your information will automatically be sent to the Medicare Administrative Contractor to decide your appeal. Q2Administrators will mail you a letter letting you know their decision.
• If they 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. 

Who performs retrospective appeals?

Once you’re determined to be eligible for an appeal, Medicare Administrative Contractors (MACs) will perform the first level of appeal, followed by Qualified Independent Contractor (QIC) reconsiderations, Administrative Law Judge (ALJ) hearings, review by the Medicare Appeals Council, and judicial review. These are the same entities that perform existing Medicare claim appeals. 

What happens if the appeal is decided in my favor? 

You’ll be notified if the MAC determines 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 new Part A claim to Medicare for payment, but they are not required to submit a new claim. 

• If the hospital submits a Part A claim: The hospital is responsible for sending you (or the company that paid them) a refund of any payments received 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 received 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 received 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're entitled to a refund from the hospital, you should receive it within 60 days of the hospital getting the decision.
• If you included 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 received 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. If the SNF submits a Part A claim for payment, you'll have to pay the applicable coinsurance and/or deductible (if you have any).

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, or if applicable, the coverage requirements for skilled nursing facility services. 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.