Medicare Denied Skilled Nursing Facility Stay

What This Means

If the facility handed you a Notice of Medicare Non-Coverage (NOMNC) — the written notice a skilled nursing facility (SNF) must give you before your Medicare-covered care ends — you have until noon of the day after you received it to request a fast appeal. Do that first: call the independent reviewer whose contact information is printed on the notice and ask for an expedited review. For Original Medicare that reviewer is your BFCC-QIO (Beneficiary and Family Centered Care Quality Improvement Organization); for Medicare Advantage it is an independent review entity under contract with Medicare — not your plan (42 CFR 422.626). Calling your plan instead can burn the deadline. The reviewer must decide within 72 hours (fast appeals).

Were you already receiving Medicare-covered SNF care that stopped without a valid NOMNC — for example, a mid-stay reclassification of your care as custodial? Then coverage must continue until at least 2 days after you receive valid notice, unless continuing it would threaten your health or safety (42 CFR 405.1202; 422.626 for Medicare Advantage). Raise that with the facility and the reviewer rather than assuming only the slower standard appeal is left to you.

If there was never a covered stay to end — most often because the 3-day inpatient hospital stay requirement was not met — the fast-appeal deadline does not apply and the standard deadlines govern: 120 days from the date you receive your Medicare Summary Notice for Original Medicare — receipt is presumed 5 days after the date printed on it, and the MSN states your exact deadline — or 65 days from the date on your denial notice for Medicare Advantage (appeals). The sections below cover each denial reason and the appeal path that fits it.

Not sure this is your situation? Broad searches often land here when a neighboring guide is the better fit:

• Was your hospital stay classified as observation instead of inpatient? Start with observation vs. inpatient — observation days do not count toward the 3-day inpatient rule.
• Is a hospital, not a nursing facility, telling you to leave too soon? See Medicare is discharging you too soon.
• Did coverage end because you used all 100 covered days? See benefit limit reached.

SNF denials can be very costly. Without Medicare coverage, you could be responsible for the facility’s full daily rate, which can run several hundred dollars per day and varies widely by location and level of care.

Why This Happens

• You did not meet the 3-day inpatient hospital stay requirement. For Original Medicare, you must have been admitted as a hospital inpatient for at least 3 consecutive days before entering the SNF. The 3 days must be actual inpatient days — time on observation status does not count. This is the single most common reason for SNF coverage denials.
• Your hospital stay was classified as observation. If the hospital placed you on observation status instead of admitting you as an inpatient, those days do not count toward the 3-day requirement. You may not have even known you were on observation. (See our observation vs. inpatient guide for more.)
• Medicare determined your care is “custodial.” Medicare covers skilled nursing care — things like physical therapy, wound care, IV medications, or monitoring by a nurse. It does not cover custodial care, which is help with daily activities like bathing, dressing, and eating. If Medicare decides your care is custodial, it will deny coverage.
• Medicare says skilled care is no longer needed. Even if your stay was initially approved, Medicare may stop coverage if it determines you no longer need skilled care. This often happens during a continued-stay review.
• You exceeded the 100-day benefit limit. Medicare covers up to 100 days of SNF care per benefit period. After day 100, there is no more Medicare coverage regardless of medical need.
• Your Medicare Advantage plan denied authorization. MA plans often require prior authorization for SNF stays and may apply stricter criteria than Original Medicare.

Should You Appeal?

What To Do Next

1. Get the written notice. Before your covered care ends, the facility must give you a Notice of Medicare Non-Coverage (NOMNC) — this is the notice that starts your fast-appeal clock and explains your rights. (A different notice, the SNFABN, is used when Medicare may not cover care because it is custodial or not medically necessary.)
2. Request a fast appeal if coverage is ending now. If your SNF coverage is stopping, ask the independent reviewer listed on your NOMNC for an expedited review — a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for Original Medicare, or a Medicare-contracted independent review entity for Medicare Advantage. Route this to that reviewer rather than to your Medicare Advantage plan (42 CFR 422.626). Act quickly: request it by noon of the day after you get the NOMNC, and the reviewer must decide within 72 hours (fast appeals).
3. Get documentation from your care team. Ask your doctor, nurses, and therapists for notes explaining why you still need skilled care. If they support continued coverage, their documentation is your strongest evidence.
4. Check whether the 3-day rule was met. Review your hospital records to confirm whether you were admitted as an inpatient and whether your stay was at least 3 full days. If observation status is the issue, consider appealing the hospital classification as well.
5. File a formal appeal. Follow the instructions on your denial notice to file within the deadline. Include your doctor’s supporting statement and any relevant medical records.
6. Get free help. Contact your State Health Insurance Assistance Program (SHIP) for free counseling, or call 1-800-MEDICARE (1-800-633-4227). Medicare’s claims & appeals guide walks through the SNF appeal steps.

Sources

• Medicare.gov: Skilled Nursing Facility Care — the 3-day inpatient rule, the 100-day limit, and 2026 cost-sharing ($0 for days 1–20; $217/day for days 21–100).
• 42 CFR 409.30: Basic requirements for SNF coverage — the 3-consecutive-day qualifying inpatient stay, in regulation.
• Medicare.gov: Fast (expedited) appeals — the NOMNC-triggered BFCC-QIO appeal when covered care is ending (72-hour decision).
• CMS: Jimmo Settlement — Medicare covers skilled maintenance care regardless of improvement potential.
• Federal Register: Appeal Rights for Certain Changes in Patient Status (Oct 2024) — the Alexander v. Azar rule letting Original Medicare patients appeal observation status.
• HHS OIG: Medicare Advantage Appeal Outcomes (OEI-09-16-00410) — MA plans overturned 75% of their own denials on appeal (2014–2016); only about 1% of denials were appealed.

Frequently Asked Questions