Medicare Discharge Appeal Process Washington

Two Forms Trigger Two Different Appeal Pathways

When Medicare decides to stop paying for your parent's care — whether it is a hospital stay, skilled nursing facility rehabilitation, or home health services — the family receives a formal notice. Which notice you receive determines which appeal process to follow, and the deadlines are measured in hours, not weeks.

Washington families have the same federal appeal rights as every other state, but the specific organization that handles the initial review is Acentra Health, the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) designated for Region 10, which covers Washington.

Acentra Health helpline: 1-888-305-6759 (TTY: 711)

The Important Message from Medicare (Hospital Stays)

Every Medicare patient admitted to a hospital receives the "Important Message from Medicare" (Form CMS-10065). Federal rules require the hospital to deliver this form within two days of admission and again within two days of the planned discharge.

The IM explains:

• The patient's right to receive all medically necessary hospital services
• The right to be involved in discharge planning decisions
• The right to file an expedited appeal if the patient believes the discharge is premature

How to appeal a hospital discharge:

1. Call Acentra Health at 1-888-305-6759 before the patient leaves the hospital and by noon on the planned discharge date.
2. Tell them you want an expedited review of the discharge decision.
3. Explain specifically why you believe the discharge is premature — the patient is clinically unstable, the home situation is unsafe, necessary services have not been arranged.
4. Acentra contacts the hospital and requests the medical records.
5. The hospital must provide the records promptly. The discharge is frozen while the review is pending — the hospital cannot proceed with the discharge and cannot bill the patient for additional days during the review.
6. Acentra issues a decision within one calendar day of receiving the complete records.

If you miss the noon deadline or the patient has already left the building, you may lose the fast-review window. Other appeal rights may remain, so follow the notice's instructions or contact Acentra about the available route.

The Notice of Medicare Non-Coverage (SNF, Home Health, Hospice)

When Medicare coverage is ending for skilled nursing facility care, home health services, hospice care, or comprehensive outpatient rehabilitation, the provider delivers a "Notice of Medicare Non-Coverage" (NOMNC) at least two days before the proposed termination date.

The NOMNC tells the patient:

• The date Medicare coverage will end
• The reason coverage is being terminated
• The right to request an expedited review

How to appeal a coverage termination:

1. You must request the review from Acentra Health by noon on the day before the proposed termination date. If the notice says coverage ends on Thursday, you must call by noon Wednesday.
2. Acentra reviews the medical records and determines whether the termination is appropriate.
3. If you request the review timely, Medicare continues to pay for the services until Acentra issues its decision.
4. If Acentra upholds the termination, you become financially responsible for services starting the day after the termination date stated in the NOMNC.

The noon-the-day-before deadline is the tightest constraint in the Medicare appeal system. Missing it by an hour eliminates the expedited pathway.

The Detailed Notice of Discharge

If you request an expedited review and Acentra upholds the original decision, the hospital or provider must issue a "Detailed Notice of Discharge" (Form CMS-10066). This form provides a more detailed clinical explanation of why the discharge or termination is medically appropriate.

The Detailed Notice is your bridge to the next appeal level. It contains the clinical reasoning you need to evaluate whether a further appeal is worth pursuing.

The Five Levels of Medicare Appeals

If the initial Acentra review does not go in your favor, Medicare has a multi-level appeal system:

Level 1 — Redetermination. A written request to the Medicare Administrative Contractor (MAC) for a second look at the coverage denial. Filed within 120 days of the initial determination. The MAC generally responds within 60 days.

Level 2 — Reconsideration. If the redetermination is unfavorable, request a reconsideration from a Qualified Independent Contractor (QIC). Filed within 180 days of the redetermination. The QIC reviews the case independently of both Medicare and the provider.

Level 3 — Administrative Law Judge (ALJ) hearing. If the amount in controversy meets the threshold ($200 in 2026), you can request a hearing before an ALJ at the Office of Medicare Hearings and Appeals (OMHA). File using Form OMHA-100 within 60 days of the QIC's decision.

Level 4 — Medicare Appeals Council review. If the ALJ rules against you, appeal to the Medicare Appeals Council within 60 days.

Level 5 — Federal court. Judicial review in federal district court if the amount in controversy meets the threshold ($1,960 in 2026). Filed within 60 days of the Council's decision.

Most families resolve their disputes at Level 1 or Level 2. The ALJ hearing is the first level where you can present your case in person (or by phone/video), and the reversal rate at this level is historically higher than at the MAC and QIC levels.

SHIBA Counselors Can Help

Washington's Statewide Health Insurance Benefits Advisors (SHIBA), operated by the Office of the Insurance Commissioner, provide free, unbiased counseling to Medicare beneficiaries. SHIBA volunteers can help you:

• Understand which appeal pathway applies to your situation
• Prepare the documentation for a written appeal
• Navigate the differences between Original Medicare and Medicare Advantage appeal rules (Medicare Advantage plans have their own internal appeal process before reaching the QIO)

Contact SHIBA through the Washington Office of the Insurance Commissioner website (insurance.wa.gov) or by calling their helpline.

Medicare Advantage Appeals Are Different

If your parent is enrolled in a Medicare Advantage plan rather than Original Medicare, the first level of appeal goes to the plan itself, not to Acentra. The plan must respond to an expedited appeal within 72 hours when waiting for a standard decision could seriously jeopardize the patient's life, health, or ability to regain maximum function.

If the plan upholds the denial, the case then goes to a QIC for independent review. From there, the appeal ladder follows the same structure as Original Medicare (ALJ, Appeals Council, federal court).

The critical difference: Medicare Advantage plans can require prior authorization for services that Original Medicare covers without it. If the plan denied a service based on prior authorization, the appeal challenges the plan's authorization decision — not a Medicare coverage rule.

Timing Is Everything

The recurring theme across every Medicare appeal pathway is deadlines. Noon on the discharge date. Noon the day before coverage ends. 120 days for a redetermination. 60 days for an ALJ request. Missing a deadline can forfeit the appeal at that level, although Medicare may accept a late request when you show good cause.

The Hospital-to-Home Transition Guide includes pre-formatted appeal scripts for each scenario — hospital discharge, SNF coverage termination, and home health cessation — with the specific Acentra contact information, form references, and deadline tracking checklists that keep families from missing the windows that matter.

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