Medicare Change of Status Notice (MCSN)

Notice Instructions: Medicare Change of Status Notice

Page 1 of the Medicare Change of Status Notice (MCSN)

The following blanks must be completed by the hospital. Information inserted may be typed or legibly hand-written in 12-point font or the equivalent.

Patient name:

Fill in the patient’s full name or attach patient label.

Patient number:

The Patient number may be a unique medical record or other provider-issued identification number. It may not be the Social Security Number, or any Medicare-issued number assigned to the beneficiary such as the MBI (Medicare Beneficiary Identifier) or HICN (Health Insurance Claim Number).

Hospital name:

Fill in the hospital’s name

Hospital address name:

Fill in the hospital’s name

Note: Hospitals may instead remove these two lines and include the hospital name and address (and logo, if wanted), at the top of this notice. However, the rest of the formatting must remain.

The box marked below shows what applies to you:

Hospitals must check the appropriate checkbox for the beneficiary receiving the notice. Checkbox 1 should be checked if beneficiaries have Medicare Part A and Medicare Part B. Checkbox 2 should be checked if beneficiaries have Medicare Part A only (no Medicare Part B but might have other insurance).

You Can Appeal:

Insert the appropriate QIO name and telephone number for the state in which the hospital giving the MCSN is located.

Page 2 of the MCSN

Questions?:

Insert the appropriate QIO name and telephone number for the state in which the hospital giving the MCSN is located.

Signature of Patient or Representative:

Have the patient or representative sign the notice to indicate that he or she has received it and understands its contents. If a representative’s signature is not legible, print the representative’s name by the signature.

Date/Time:

Have the patient or representative place the date that he or she signed the notice.

Note:

When delivering the MCSN, hospitals and CAHs are required to explain the notice and its content and answer all beneficiary questions to the best of their ability.

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.

Instructions CMS-10868

OMB expiration: xx-xx-202x