How to Win a Medicare Appeal for Skilled Nursing

A denial isn't the end of the claim. Most skilled nursing denials that get appealed are overturned, but only a fraction are ever appealed. Knowing the process is the difference between recovering the revenue and writing it off.

Skilled nursing runs on thin margins and a heavy claims burden, and Medicare denials are a constant. Here's the encouraging part: when skilled nursing denials are appealed, they're overturned at strikingly high rates. A 2026 HHS Office of Inspector General report found that Medicare Advantage plans overturned 95% of appealed SNF admission denials, which means most of those denials shouldn't have happened in the first place. The discouraging part: only 18% of denials were appealed at all. Every un-appealed denial is revenue the facility earned, delivered care for, and then walked away from.

This is a practical guide to the appeal process: the levels, the deadlines that will sink you if you miss them, and what actually makes an appeal win. It covers both the fast appeal you file when coverage is being cut off mid-stay and the standard claim appeal you file after a claim is denied, because they run on completely different clocks.

First, know which appeal you're running

There are two separate tracks, and confusing them is the fastest way to lose. Which one you're on depends on what the payer did.

The first is the expedited (fast) appeal, which applies when Medicare coverage for a current resident is being terminated and you or the resident believe it's ending too soon. This is triggered by a Notice of Medicare Non-Coverage (NOMNC) and runs through a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) on a deadline measured in hours, not days.

The second is the standard claim appeal, which applies when a claim you submitted comes back denied. This runs through the five-level Medicare appeals process, starting with a redetermination, on deadlines measured in months. Original Medicare (fee-for-service) and Medicare Advantage each have their own version of this five-level path.

Figure out which situation you're in before you do anything else, because the deadlines are radically different and a missed deadline ends the appeal on its own.

The expedited appeal: when coverage is cut off mid-stay

When a plan or Medicare decides a resident's covered stay should end, the resident gets a NOMNC at least two days before coverage stops. That notice starts a very fast clock. To challenge it, the resident or their representative contacts the BFCC-QIO by noon of the day before coverage is set to end. The QIO reviews the medical records and the facility's documentation and issues a decision quickly, and the facility provides a Detailed Explanation of Non-Coverage laying out why it believes skilled care is still needed.

If the QIO rules against continued coverage, there's a second fast step: an expedited reconsideration by a Qualified Independent Contractor (QIC). The resident's side generally has to call the QIC by noon of the calendar day after the QIO denial, and the QIC ordinarily issues a decision within 72 hours.

The entire point of this track is speed, because the resident is in the building and the coverage is ending now. Missing the noon deadline doesn't just slow things down, it forfeits the expedited appeal. For a facility, the operational lesson is that someone has to be watching for NOMNCs and ready to move the same day, not next week.

The standard claim appeal: the five levels

When a submitted claim is denied, the appeal runs through five levels. You don't jump straight to a judge; you climb the ladder, and most cases that are going to be won are resolved on the first two levels, before the process gets slow and formal. For Original Medicare, the levels are:

• Level 1, Redetermination. A review by the Medicare Administrative Contractor (MAC), handled by someone not involved in the original decision. You have 120 days from receipt of the initial determination to file. This is your best and cheapest shot, so it's worth making it your strongest.
• Level 2, Reconsideration. An independent review by a Qualified Independent Contractor (QIC). You have 180 days from the redetermination decision to file.
• Level 3, OMHA / ALJ hearing. A hearing before an Administrative Law Judge at the Office of Medicare Hearings and Appeals. You have 60 days from the reconsideration decision, and the claim has to meet a minimum dollar amount, $200 for 2026.
• Level 4, Medicare Appeals Council. Review by the Council; 60 days from the ALJ decision.
• Level 5, Federal District Court. Judicial review; 60 days from the Council decision, with a higher dollar minimum, $1,960 for 2026.

Two things about the deadlines will cost you claims if you don't build them into your process. First, the clock at Level 1 starts from receipt of the determination, and Medicare presumes you received it five days after the date on the notice unless you can prove otherwise. Second, a missed filing deadline lets the reviewer dismiss the appeal without ever looking at the merits. A perfectly winnable claim dies on a calendar technicality. Track every denial's clock the day it arrives.

Medicare Advantage runs a parallel five-level process with its own wrinkles. At Level 1, if the plan upholds its own denial, it's required to forward the case automatically to an independent review entity at Level 2, so you don't file that step separately. Because the MA process is where most of the current denial volume sits, and because the rules have been shifting, always work from the plan's own denial notice and the current-year deadlines printed on it.

What actually wins the appeal

The levels and deadlines get you into the game. What wins is documentation that answers the exact reason the claim was denied. A few things separate the appeals that get overturned from the ones that don't.

Read the denial reason and rebut it directly. A SNF denial comes with a stated reason, and for skilled nursing it's usually one of a few: the skilled level of care wasn't supported, the documentation was insufficient, the qualifying hospital stay or benefit period wasn't met, or the coding didn't match the record. The winning appeal addresses that specific reason point by point, rather than making a general case that the care was good. If the denial says the skilled level of care wasn't supported, your appeal has to show, in the record, that it was.

Build the skilled-need record specific to SNF coverage. Medicare covers a SNF stay only when the resident needs skilled nursing or skilled rehabilitation on a daily basis, so the record has to prove that daily skilled need, not just that care was provided. That means the documentation Medicare actually weighs for a SNF claim: the MDS assessment that drives the PDPM rate, physician orders, skilled nursing and therapy notes with therapy minutes, the care plan, and contemporaneous progress notes tied to the resident's status. The record has to show the skilled need day over day, because that daily standard is exactly what a SNF denial tends to attack. General "the care was appropriate" language doesn't answer it; the dated clinical record does.

Know that "not improving" is not a valid denial reason. One of the most common and most beatable denials rests on the idea that a resident who isn't improving no longer qualifies for skilled care. That is not the standard. Under long-settled Medicare policy, skilled care is covered when it's needed to maintain the resident's condition or to slow decline, not only when the resident is expected to improve. If a denial leans on an "improvement" rationale, that is a strong basis for appeal, and it's one many facilities leave on the table because they assume the denial is correct.

Meet every deadline, and file complete. Submit the full supporting record with the appeal rather than promising to send it later, since late-arriving evidence slows the decision and weakens the case. And calendar every deadline the moment the denial lands.

Why the appeal is the last resort, not the strategy

Winning appeals matters, and the facility that appeals consistently recovers real money that the facility that shrugs at denials never sees. But it's worth being honest about what an appeal is. It's recovery after the fact, on care already delivered, requiring staff hours and weeks of delayed cash to claw back money the facility should have been paid the first time.

The high overturn rates on skilled nursing denials cut two ways. They mean appeals are very much worth filing. They also mean a lot of these denials were preventable, the product of missing eligibility checks, authorization gaps, or documentation that didn't support the claim at submission. The facilities in the strongest position both appeal aggressively and work to generate fewer denials in the first place, which is the subject of our guide to denial prevention in skilled nursing.

How Sunbound helps

Sunbound RCM runs the full skilled nursing revenue cycle, including denial management and appeals. When a claim is denied, Sunbound diagnoses the root cause and assembles the appeal, working from the clinical and coverage documentation already in the system rather than reconstructing it by hand. Just as important, its AI validates claims before submission and flags what would cause a denial in the first place, so the appeals queue shrinks over time instead of growing. The goal is to win the appeals you have to file and to have fewer of them to file.

The bottom line

A Medicare denial in skilled nursing is a decision you can challenge, not a loss you have to absorb. Know which appeal you're running, track the deadline from the day the denial arrives, build the medical-necessity record around the specific reason for the denial, and remember that "not improving" is not a lawful basis to cut skilled coverage. Appeal the denials you get. Then work upstream so you get fewer of them.

Want denials caught before they happen, and appeals handled when they do? See how Sunbound runs the skilled nursing revenue cycle.

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