MA Denied Your SNF Stay After Hospital? How to Appeal

You or a loved one just left the hospital, expecting to move straight into a skilled nursing facility to recover. Then the Medicare Advantage plan says no. It feels unfair, confusing, and scary—especially when you're worried about where care will happen next. The good news is that this type of denial is appealable, and appeals like this succeed far more often than most people realize.

Why Medicare Advantage Plans Deny SNF Stays After a Hospital Stay

Most Medicare Advantage plans require prior authorization before they'll pay for a skilled nursing facility (SNF) admission following a hospital stay. That means your hospital or the SNF has to ask the plan for approval before you're admitted, or shortly after. Plans deny these requests for a variety of reasons, including:

• The plan says you don't meet its criteria for needing a "skilled" level of care (as opposed to custodial care)
• The plan believes you didn't have a qualifying inpatient hospital stay of the right length or type
• The paperwork submitted didn't clearly show medical necessity
• The plan's own internal coverage criteria are stricter than what a treating doctor believes is needed

You can find a plan's specific prior authorization rules in its Evidence of Coverage and in the plan's separately published prior authorization list—not in the general provider directory. It's worth asking your discharge planner or the SNF's admissions office to show you exactly what the plan's stated reason for denial was.

Make Sure You Have the Right Kind of Denial

Before you appeal, it's important to know which situation you're in, because the process is different.

This Article Covers: Prior Authorization Denials

If your Medicare Advantage plan refused to approve the SNF admission in the first place—before you were even admitted, or very early in your stay—that's a prior authorization (organization determination) denial. This is the kind of denial covered in this article, and you appeal it directly to your plan.

Not Covered Here: Notice of Medicare Non-Coverage (NOMNC)

If you were already admitted to the SNF and the plan is now saying it will stop paying for continued care, that's a different process. You would receive a Notice of Medicare Non-Coverage (NOMNC), and a fast-track appeal would go to the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), not to your plan. That process has its own separate deadlines and is not what we're covering here. If that's your situation, look for guidance specifically about NOMNC fast-track appeals.

Your Right to Appeal: Level 1 Reconsideration

If your plan denied the SNF admission, you (or someone you authorize, like a family member or the facility, with your permission) have the right to ask the plan to reconsider. This is called a Level 1 appeal, or a plan reconsideration.

Your denial should arrive as a Notice of Denial of Medical Coverage or Payment (NDMCP, Form CMS-10003), often called the Integrated Denial Notice (IDN). This notice explains the plan's reason for denying coverage and how to appeal.

The Deadline You Need to Know

You must file your Level 1 appeal within 65 calendar days from the date on the denial notice—not from when you received it in the mail. This deadline applies whether you're requesting a standard or an expedited appeal. Because it's counted from the notice date itself, you don't have to guess about mail delivery time; just count from the date printed on the notice. If you miss this window, you can ask the plan for a good-cause extension, explaining why your appeal is late.

Requesting an Expedited Appeal

If waiting for a standard appeal decision could seriously harm your health, you can ask for an expedited (fast) reconsideration. Your doctor can support this request by stating that a delay would jeopardize your health. Expedited Medicare Advantage reconsiderations must be decided within 72 hours—this timeframe applies to all expedited Part C appeals, including those involving Part B drugs. There is no shorter option at the appeal stage, so don't expect a 24-hour turnaround once you're appealing a denial.

How to File

Your denial notice will include instructions for submitting your appeal, including where to send it and what to include. In general, a strong appeal request should include:

• A copy of the denial notice (the NDMCP/IDN)
• A written statement from you or your representative explaining why the SNF stay was medically necessary
• Supporting documentation from your doctor, hospital, or SNF—such as physician notes, therapy evaluations, and discharge summaries
• Any records showing the qualifying hospital stay that preceded the SNF admission

Remember, if you have a Medicare Advantage plan, you won't receive a Medicare Summary Notice (MSN)—that document is only for people with Original Medicare. Instead, your plan sends you an Explanation of Benefits (EOB), and your denial itself arrives as the Integrated Denial Notice described above.

What Happens Next: The Independent Review Entity (IRE)

If your plan upholds its denial after the Level 1 reconsideration, you don't have to file a separate request to move to the next level. Medicare Advantage denials that are upheld at Level 1 are automatically forwarded to the Independent Review Entity (IRE)—currently MAXIMUS Federal Services, a contractor working on behalf of CMS. This is a key difference from Original Medicare, where the next level is handled by a Qualified Independent Contractor (QIC). For Medicare Advantage, it's always the IRE, not the QIC.

The IRE takes a fresh, independent look at your case. Many denials that a plan upholds internally are still reversed at this stage, so this automatic review is a meaningful safeguard, not just a formality.

The Odds Are Good—So Don't Give Up

Here's something every family facing an SNF denial should know: appeals of these decisions succeed far more often than they fail. According to HHS OIG (June 2026), based on 2024 data, roughly 95% of appealed prior-authorization denials for SNF admission are overturned. That's a strikingly high success rate.

Yet the same HHS OIG data found that only about 18% of denied SNF-admission prior-authorization requests are ever appealed. In other words, the vast majority of people who receive one of these denials simply accept it and never challenge it—even though the odds of winning, if they had appealed, were strongly in their favor.

More broadly, KFF's 2024 analysis found that around 80.7% of appealed Medicare Advantage prior-authorization denials of all kinds are overturned, while only about 11.5% of denied prior-authorization requests are appealed at all. The pattern is the same across Medicare Advantage: denials are often reversed on appeal, but most people never take that step.

If you're facing a denial of an SNF stay after a hospitalization, this data is a strong reason not to simply accept the plan's initial decision. Appealing takes effort and paperwork, but the odds suggest it is often worth pursuing.

Tips for a Strong Appeal

• Act quickly. Even though you have 65 calendar days from the notice date, filing sooner gives you more time to gather documents and reduces stress around deadlines.
• Get your doctor and the SNF involved early. Their clinical notes and letters of medical necessity carry real weight.
• Keep copies of everything you submit, along with proof of when and how you sent it.
• If your health could be harmed by delay, ask specifically for an expedited appeal.
• Don't be discouraged by an initial denial from the plan—remember that many denials are reversed either at the plan's own reconsideration or at the IRE.

If Your Appeal Continues Beyond the IRE

If the IRE also upholds the denial, you still have further appeal rights. You can request a hearing before an Administrative Law Judge (Level 3) within 60 calendar days of receiving the IRE's decision. If needed after that, you can appeal to the Medicare Appeals Council (Level 4) within 60 calendar days of receiving the ALJ's decision, and finally to federal district court (Level 5) within 60 calendar days of receiving the Council's decision. Each of these later levels counts from when you receive the decision, not the date printed on it, so keep track of when notices actually arrive.

Because deadlines and procedures can be detailed and specific to your situation, always confirm the exact dates, forms, and current rules for your case at Medicare.gov or by calling 1-800-MEDICARE. A denial letter is not the end of the road—it's often just the start of a process where the odds may actually be in your favor.

This article is general education, not legal or medical advice. Medicare rules, deadlines, and dollar amounts change; confirm the current details for your situation at Medicare.gov or by calling 1-800-MEDICARE. MedicareClaimDenied.com is not affiliated with or endorsed by Medicare, CMS, or any insurer.