Notice of Medicare Noncoverage

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Main Street Hospital 1234 Main Street, Washington, DC 20005
1-800-323-4000

Medicare Change of Status Notice

Patient name:					Patient number:


Your hospital changed your status from “inpatient” to “outpatient” receiving observation services,” Because of this change, Medicare won’t cover your skilled nursing facility (SNF) stay after you leave the hospital.

The box marked below show what applies to you:
    • Your hospital stay will be billed to Medicare Part B instead of Part A. 
Depending on the Part B coinsurance you owe as an outpatient, your hospital bill may be lower or higher than the Part A inpatient deductible. Ask your hospital for your exact billing information.
    • You don’t have Medicare Part B, so the hospital may charge you the full cost of your outpatient hospital stay.

You Have the Right to Appeal This Decision
    • You have the right to appeal the hospital’s decision to change your status right away. An independent Quality Improvement Organization (also known as a QIO) authorized by Medicare will perform this review.  

    • If you choose to appeal, the QIO will look at your medical records and/or other relevant information. The QIO will also ask for your opinion. 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. Because your status will be changed from an outpatient receiving observation services back to an inpatient, 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 if you have Medicare Part B. If you don’t have Medicare Part B, you may be responsible for the full cost of your outpatient hospital stay.

How to Appeal your Status Change
    • Call your QIO to appeal at: {insert QIO name and toll-free number of QIO}.

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

    • Even if you already left the hospital, you still have appeal rights. 


What Happens Next
    • The QIO will notify you of its decision as soon as possible, usually within 1 day of getting all the necessary information. 

    • Even if you leave the hospital, you’ll still get a notice of the appeal decision.

    • If you decide to stay in the hospital during the appeals process and the QIO agrees with the original decision to change your status, you’ll be responsible for payment of services you get during the appeal process. 

Get help 
You can also get for free, personalized help from your local State Health Insurance Assistance Program (SHIP). Visit SHIPhelp.org or call 877-839-2675 to find the SHIP near you.


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.







Please sign below to indicate you received and understood this notice.

I have been notified of my status change from hospital “inpatient” to an “outpatient receiving observation services”. I understand I can contact my QIO to appeal this decision. I also understand if I win my appeal, my hospital charges may be different depending on my coverage and situation.


			                Signature of Patient or Representative					        Date / Time 


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