Fill out CMS-1763 (Medicare Advance Written Notice of Non-Coverage) online
Form CMS-1763 is used by hospitals and other institutional providers to notify Medicare patients that their inpatient hospital stay or certain services are expected to end or will no longer be covered by Medicare. It gives patients advance written notice so they can decide whether to continue receiving services at their own expense or exercise their appeal rights.
How to fill out CMS-1763 (Medicare Advance Written Notice of Non-Coverage)
Review the patient information
Verify the patient's name, Medicare Beneficiary Identifier (MBI) number, and the date the notice is being delivered.
Specify the reason for non-coverage
Indicate why Medicare is expected to stop covering the services. Common reasons include the patient no longer meeting inpatient care criteria or reaching the limit of covered days.
Enter the effective date
Specify the date on which Medicare coverage is expected to end. The patient must receive this notice at least two calendar days before this date.
Obtain patient acknowledgment
Have the patient (or their representative) sign and date the form to acknowledge receipt. Provide the patient with a copy and retain the signed original.
About CMS-1763 (Medicare Advance Written Notice of Non-Coverage)
Who needs this form
Hospitals and institutional providers use this form to notify Medicare patients. Patients receive this form when Medicare coverage for their hospital stay or services is about to end.
Where to submit
This form is delivered to the patient by the hospital or institutional provider. The patient keeps their copy. If the patient wants to appeal, they contact their Quality Improvement Organization (QIO) as instructed on the form.
Source and content freshness
- Filing deadlines may shift for weekends and holidays. Verify due dates with official instructions.
Common mistakes to avoid
- Not delivering the notice to the patient at least two days before coverage ends
- Failing to explain the specific reason Medicare coverage is ending
- Not informing the patient of their right to appeal through the QIO
- Omitting the estimated date that Medicare coverage will end
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Can I appeal if I receive this notice?
Yes. If you disagree with the decision to end Medicare coverage, you have the right to request an immediate review from your Quality Improvement Organization (QIO). The QIO contact information is included on the form. You must request the review by noon of the first business day after receiving the notice to avoid being financially responsible during the review period.
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