What Is Skilled Nursing Facility (SNF)
A Skilled Nursing Facility (SNF) is a licensed medical facility that provides short-term rehabilitative and nursing care to patients who no longer need hospital-level care but cannot yet return home. SNFs differ from regular nursing homes because they employ registered nurses and licensed therapists who deliver medical treatment, not just custodial care. Medicare and most commercial insurers cover SNF stays only after a qualifying hospital admission of at least three consecutive midnights.
Insurers frequently deny SNF claims by arguing the patient does not meet medical necessity standards or that the hospital stay was not long enough to trigger coverage. Understanding how SNF coverage works directly impacts your ability to challenge these denials on your Explanation of Benefits (EOB).
SNF Coverage Requirements
Medicare covers up to 100 days of SNF care per benefit period, with the patient paying coinsurance after day 20. The three key requirements are:
- A hospital stay of at least three consecutive midnights immediately before SNF admission (observation days do not count)
- Admission to the SNF within 30 days of hospital discharge
- Medical necessity for skilled nursing or rehabilitation services that cannot be delivered at home or in an outpatient setting
Commercial insurers apply similar rules but often impose stricter limits. Many commercial plans cover only 30 to 60 days of SNF care and require prior authorization before admission. If your claim was denied, check your EOB to see which requirement the insurer cited.
How SNF Denials Are Appealed
SNF claims generate two types of appeals. Internal appeals, filed with your insurer within 30 to 180 days depending on your state, must address the specific reason cited on your EOB. If the denial states "not medically necessary," your appeal should include your discharge summary, physician notes documenting functional decline, and therapy orders. External appeals go to an independent state insurance commissioner or accredited independent review organization (IRO) if your internal appeal fails. Some states allow expedited external appeals for ongoing SNF stays.
Prior authorization denials are easier to overturn if your facility submitted the request late or incompletely. Request the denial letter and all prior auth documents from your insurer to identify gaps in the original submission.
Common Questions
- Does observation time at the hospital count toward the three-day requirement? No. Medicare explicitly excludes observation stays. Only time counted as an inpatient (admitted as an inpatient under a hospital's inpatient prospective payment system) counts. This is a frequent source of wrongful denials.
- What happens if my SNF claim is denied after I am already admitted? You are responsible for paying the facility until the denial is resolved. File an internal appeal immediately and request expedited review if your state allows it. Many facilities will hold your account while the appeal processes.
- Can I appeal a SNF denial after discharge? Yes. You have up to one year from the date of service to file an appeal in most states, though commercial insurers may impose shorter deadlines. Check your policy documents.