Form CMS-10868 Medicare Change of Status Notice (MCSN)

Patient name: Patient number: Hospital name: Hospital address:

Medicare Change of Status Notice

Important! You’re getting this notice because your hospital changed your status from “hospital inpatient” to “hospital outpatient receiving observation services.”

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The box marked below shows what applies to you:

You Can Appeal

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  You can appeal your status change to a Quality Improvement Organization right away. Quality Improvement Organizations are independent of Medicare.

• If you decide to appeal, your Quality Improvement Organization will look at your records and give you its decision about 2 days after you ask for an appeal.

• Call your Quality Improvement Organization to appeal at:

• You should ask for an appeal as soon as possible and before you leave the hospital.

• After you leave the hospital, you still have appeal rights. Call your Quality Improvement Organization.

Form CMS 10868 No. 10868 • XX/XXXX • OMB approval 0938-XXXX

What Happens After I Appeal?

• You’ll get the appeal decision from the Quality Improvement Organization about 2 days after you appeal, even if you leave the hospital.

• If you decide to stay in the hospital beyond your planned discharge date you may be responsible for payment of services you get during the appeal process.

• If your appeal is favorable to you, Medicare may cover your skilled facility nursing stay after you leave the hospital.

Questions?

• If you think you may want to appeal and want more information about the appeals process, call your Quality Improvement Organization at:

• For more information about your Medicare coverage, call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

Additional Information (Optional):

Sign below to show you received and understood this notice.

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.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-10868. This information collection implements new appeals procedures as set forth in CMS-4204-F, “Medicare Program: Appeal Rights for Certain Changes in Patient Status” and notifies affected beneficiaries of their appeal rights under the regulations. The time required to complete this information collection is estimated to average less than 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is required of hospitals to deliver the notice to Medicare patients so that the patient may obtain or retain a benefit under 42 CFR 405.1210. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Paid for by the Department of Health & Human Services.