CMS-10868 Medicare Change of Status Notice (MCSN)

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Medicare Change of Status Notice
Patient name:

Patient number:

Your hospital changed your status from inpatient to outpatient receiving observation
services. This means:
•

Your hospital bill might change depending on the Part B coinsurance you’ll owe as an
outpatient. If your Part B coinsurance is less than the Medicare inpatient hospital
deductible, you’ll get a lower bill. If your Part B coinsurance is higher than the inpatient
deductible, you’ll get a higher bill. Check with your hospital for more detailed billing
information.

•

You won’t have Medicare coverage in a skilled nursing facility (SNF) after you
leave the hospital.

Your Right to Appeal This Decision:
• You have the right to an immediate, independent medical review (appeal) of the
hospital’s decision to change your status. Medicare authorized an independent Quality
Improvement Organization (also known as a QIO) to perform this review.
• If you choose to appeal, the QIO will ask for your opinion. The QIO will also look at
your medical records and/or other relevant information. You don’t have to prepare
anything in writing, but you have the right to if you’d like.
• If the QIO disagrees with your status change to an outpatient receiving observation
services, you may qualify for a Medicare-covered SNF stay after you leave the
hospital. You’ll be responsible for the Medicare inpatient hospital deductible.
• If the QIO agrees with your status change to an outpatient receiving observation
services, you won’t qualify for a Medicare-covered SNF stay after you leave the
hospital. You’ll be responsible for Medicare Part B copays.

How to Appeal your Status Change:

• Call your QIO at: {insert QIO name and toll-free number of QIO}, or if you have
questions.
• You should ask for an appeal as soon as possible and before you leave the hospital.
• The QIO will notify you of its decision as soon as possible, usually within 1 day of
getting all the necessary information.
See page 2 of this notice for more information.

If You Miss the Deadline to Appeal, You May Have Other Appeal Rights:
• Call the QIO listed on Page 1.
You have the right to get Medicare information in an accessible format, like large print, braille, or
audio. You also have the right to file a complaint if you feel you’ve been discriminated against.
Visit Medicare.gov/about-us/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE
(1-800-633-4227) for more information. TTY users can call 1-877-486-2048.

Additional Information (Optional):

Please sign below to indicate you received and understood this notice.
I have been notified of my change in status from a hospital inpatient to a hospital
outpatient receiving observation services. I understand I may contact my QIO to appeal
this decision. I also understand if I win my appeal, my hospital charges will be different,
and possibly higher.

Signature of Patient or Representative
Form CMS 10868 (Exp. xx/xx/20xx)

Date / Time
OMB approval 0938-xxxx