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Appeals We are the Beneficiary and Family Centered Care Quality Improvement Organization, working to improve the quality of care for Medicare beneficiaries. Our site offers beneficiary and family-centered care information for providers, patients, and families. Welcome! |
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- Overview
- Beneficiary Complaints
- Other Reviews
- Medical Record Electronic Submission
- Educational Resources
- Physician Acknowledgement Monitoring
- QIO Liaison
- Memorandum of Agreement
- Update Your Contact Information
- Become a Peer Reviewer
- Case Status Check
contact acentra health
Click below to get Acentra Health's telephone number, fax number and mailing address for your state.
check status of an appeal
You can check the status of an appeal online using our Case Status tool.
overview
hospital discharge appeals
Patients who have Medicare (including Medicare Advantage), have the right to appeal a hospital discharge if they feel too sick to be discharged. The hospital gives patients a form called An Important Message from Medicare. This form tells patients how to appeal the discharge. During the appeal, patients do not have to leave the hospital and do not have to pay for the extra days in the hospital.
skilled service termination appeals
Patients who have Medicare (including Medicare Advantage) also have the right to file a skilled service termination appeal if they do not agree with the decision that skilled services will be stopped. Facilities must give patients a letter called a Notice of Medicare Non-Coverage explaining how to appeal.
This Process Flow Chart (PDF) shows the appeals process on page 1 and the beneficiary complaint process on page 2.
hospital discharge appeals: a new process from the centers for medicare & medicaid services (cms)
This process applies only to Medicare beneficiaries with Original (Fee-for-Service) Medicare who call regarding a hospital discharge appeal.
To address concerns Medicare patients and their families have with hospital discharges, the Centers for Medicare & Medicaid Services (CMS) has tasked the Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) with collaborating closely with healthcare facilities to ensure that Medicare beneficiaries with Original Medicare and/or their representatives clearly understand their home discharge plans.
Starting May 1, 2024, Medicare beneficiaries with Original Medicare who call Acentra Health about hospital discharge concerns were connected with our Immediate Advocacy (IA) team. This team reviews concerns, addresses any misunderstandings, and provides additional guidance if needed. While the IA team communicates directly with providers, the formal discharge appeal process will continue at the same, without any delays.
If more help is needed, the IA team will involve the hospital's case management team, which may include a three-way call with the beneficiary, their representative, and the hospital. If an in-person meeting is requested, Acentra Health staff will join by phone.
This process helps beneficiaries and their representatives better understand their discharge plans. If concerns are resolved and the beneficiary chooses to stop the appeal, Acentra Health will close the case and notify the hospital. Both the beneficiary and provider will receive a letter summarizing the resolution.
hospital observation appeals
The Final Rule for Hospital Observation Appeals, published by CMS, introduces the process by which eligible Medicare Fee-for-Service (FFS) beneficiaries can appeal hospital decisions to reclassify their status from inpatient to outpatient receiving observation services.
CMS has published a fact sheet regarding this rule.
For more information:
- Hospitals must deliver the Medicare Change of Status Notice (MCSN) to all beneficiaries eligible for this expedited determination process. Please see: New Notice & Appeals Process for Original Medicare Beginning February 14, 2025.
- Medicare Change of Status Notice (MCSN) Manual Instructions (PDF) (November 2024)
- Billing Instructions: Expedited Determinations Based on Medicare Change of Status Notifications (PDF) (December 2024)
- Hospitals with questions about the new Hospital Observation Appeal process, should send a message to CMS at the following email, which is a resource mailbox for hospitals: HospitalStatusQIOappeal@cms.hhs.gov
updating appeals forms
- We encourage providers to update their notices – the Important Message from Medicare (IM) and the Notice of Medicare Non-Coverage (NOMNC) – by changing “Kepro” to “Acentra Health” when convenient. Notices will not be made invalid if they have “Kepro” listed. Copies of these forms can be found on the BNI page on the CMS web site. For more information about our name change, please visit our Q&A page.
- Hospitals Must Use Renewed Beneficiary Notices Starting January 1. The Office of Management and Budget (OMB) has renewed the Notice of Medicare Non-Coverage (NOMNC, CMS-10123), and the Detailed Explanation of Non-Coverage (DENC, CMS-10124). Providers must use the current notices until December 31, 2024, and are required to use the new NOMNC and DENC beginning January 1, 2025. The updated notices, including Spanish versions, are available on the FFS & MA NOMNC/DENC page on the CMS website.
NOTE: If Acentra Health receives a NOMNC on the old form on or after January 1, 2025, the form will NOT be made invalid.
cms final rule
On November 27, 2006, CMS published a final rule, CMS-4105-F: Notification of Hospital Discharge Appeal Rights. Beginning July 1, 2007, hospitals must deliver the Important Message from Medicare (IM) to inform all Medicare inpatients, including Medicare Advantage enrollees, Medicare as a Secondary Payor (MSP), and dual-eligible patients about their hospital discharge appeal rights.
Hospitals are required to give a Detailed Notice of Discharge (DND) to patients who choose to appeal a discharge decision. The DND outlines the specific reasons for discharge and applicable Medicare coverage guidelines.
Current versions of the Important Message from Medicare (IM), Form CMS-10065, and the Detailed Notice of Discharge (DND), Form CMS-10066, are posted on the Hospital Discharge Appeal Notices page of the CMS website under Downloads.
hospital requested review (hrr)
HINN 10, or the Notice of Hospital Requested Review (HRR), is issued by hospitals when they request a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) review of a discharge decision without a physician's agreement. It applies to both Original Medicare beneficiaries and Medicare Advantage enrollees.
To initiate an HRR, the hospital staff should call Acentra Health, and then electronically send the medical record. HRRs are completed Monday to Friday and will be completed within two business days of the receipt of all pertinent information requested.
expedited determinations
Home health agencies (HHAs), skilled nursing facilities (SNFs), comprehensive outpatient rehabilitation facilities (CORFs), and hospices with patients that have Medicare are required to notify them of their right to an expedited review process when these providers anticipate that Medicare coverage of their services will end.
HHAs, SNFs, hospices, CORFs, and swing beds (under instruction) are required to provide a Notice of Medicare Non-Coverage to Medicare patients (including those patients with a Medicare Advantage plan) to alert them that a Medicare-covered item or service is ending and give patients the opportunity to request an expedited determination from a BFCC-QIO. A Detailed Notice is given when the BFCC-QIO review is requested in order to provide more explanation on why coverage is ending.
