Changes to Medicare Advantage Appeal Rights for Inpatient Admission Denials based on updated CMS guidance effective September 14, 2026

Effective September 14, 2026, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is updating its Medicare Advantage appeals processes to align with revised Centers for Medicare & Medicaid Services (CMS) guidance, Parts C & D Enrollee Grievances, Organization/Coverage Determinations and Appeals Guidance issued in July of 2026 and available for review here: 2025 Medicare C D Appeals Guidance Update (PDF).

The updated CMS requirements affect appeal rights for members, physicians, and contracted hospitals based on the timing of the inpatient admission denial and whether the member has financial liability.

What Is Changing?

Beginning September 14, 2026, Blue Cross NC will review inpatient admission appeal requests in accordance with CMS Appendix 3, "Inpatient Hospital Admission Denial Appeal Access Chart."

Inpatient Admission Denied Before or During Hospitalization

The following parties may appeal:

• The enrollee or the enrollee's authorized representative
• Any physician acting on behalf of the enrollee may submit an expedited appeal request
• The treating physician acting on behalf of the enrollee may submit a standard appeal request

The following parties may not appeal:

• The contracted hospital appealing on its own behalf

Inpatient Admission Denied After Hospitalization but Before Claim Submission

The following parties may appeal:

• The enrollee or authorized representative only when the enrollee has financial liability associated with the denial
• The enrollee or authorized representative when the enrollee does not have financial liability associated with the denial

The following parties may not appeal:

• The contracted hospital that furnished the service(s) appealing on its own behalf

Inpatient Services Denied Upon Claim Adjudication

The following parties may appeal:

• The enrollee or authorized representative only when the enrollee has financial liability associated with the denial

The following parties may not appeal:

• The enrollee or authorized representative when the enrollee does not have financial liability associated with the denial
• The contracted hospital that furnished the service(s) appealing on its own behalf

Important Clarification Regarding Financial Liability

Under CMS guidance, member cost-sharing alone does not constitute financial liability for purposes of determining appeal rights when a favorable appeal decision would not reduce the member's financial responsibility.

Impact to Contracted Hospitals

Contracted hospitals should review their internal denial and appeal workflows to ensure appeals are submitted by the appropriate party based on the requirements set by CMS.

Beginning September 14, 2026:

• Blue Cross NC will no longer accept appeal requests that are not valid in accordance with CMS requirements.

Please Note: Contracted hospitals will continue to have the ability to appeal denials of payment on their own behalf following Blue Cross NC’s provider appeals process, which is not regulated by CMS.

Questions

If you have questions regarding this update or appeal submission requirements, please contact your Provider Relations Representative or Provider Customer Service call center.

Thank you for your continued partnership in serving our Medicare Advantage members.