A skilled nursing facility appeals a Medicare denial through five levels, beginning with redetermination by the Medicare Administrative Contractor within 120 days of the initial determination. Each level has its own deadline and decision-maker. Most SNF denials are overturned at redetermination or reconsideration when the facility argues from the clinical record rather than restating that care was necessary.

The uncomfortable truth about SNF denials is that a large share of them are appealable and never appealed. Not because the facility agrees with the denial, but because appealing takes hours the business office does not have, and the deadline passes while the packet sits on someone's desk.

That is an expensive way to lose money, because the appeal levels below are genuinely winnable. A denial is an assertion that the record does not support the care. If the record does support it, the job is to show where — page, date, and clinician.

Key takeaways

• There are five levels of Medicare fee-for-service appeal, each with a distinct deadline and decision-maker.
• Redetermination is due within 120 days of the initial determination; reconsideration within 180 days of the redetermination.
• The strongest appeals cite specific documentation by date and author rather than asserting medical necessity in general terms.
• An Additional Documentation Request is the last chance to prevent a denial — treat it as an appeal, not a mailing task.
• Medicare Advantage appeals follow the plan's process and different timelines, not the fee-for-service ladder.
• The NOMNC expedited QIO pathway is separate and moves in days, not months.

Before the denial: responding to an ADR

Most large SNF denials begin with an Additional Documentation Request. The contractor selects a claim and asks for the medical record supporting it. Facilities generally have 45 days to respond, and a non-response is an automatic denial.

The most common and costly mistake at this stage is sending the record without an argument. A reviewer receiving four hundred unindexed pages will find what is easy to find. A reviewer receiving the same four hundred pages with a two-page cover narrative pointing to the skilled interventions by date will find those.

Include with every ADR response:

• A cover narrative stating the coverage criteria at issue and where each is met
• Physician certification and all recertifications
• Skilled nursing and therapy documentation for the billed period
• The MDS assessments supporting the HIPPS code billed
• Hospital records establishing the qualifying stay
• An index so the reviewer can navigate

Treat the ADR as the first appeal. It is cheaper to win here than anywhere downstream.

The five levels of appeal

Levels 3 and 5 carry a minimum amount-in-controversy threshold that CMS adjusts annually. Claims below the threshold cannot proceed to those levels, though claims may be aggregated to meet it.

Level 1: Redetermination

Filed with the MAC that issued the denial, using Form CMS-20027 or a written request containing the equivalent information: beneficiary name and Medicare number, the specific service and dates at issue, the claim number, and the reason for disagreement.

This is where most appeals should be won, and where most are lost through weak drafting. A redetermination request that says the care was medically necessary and skilled has told the reviewer nothing they did not already consider. A request that says the resident required skilled nursing for wound care documented on specified dates by named clinicians, with the treatment described and physician orders attached, gives them something to act on.

Level 2: Reconsideration

Filed with a Qualified Independent Contractor, an entity independent of the MAC, using Form CMS-20033.

This level carries a trap worth knowing. Reconsideration is generally the last opportunity to introduce new evidence. Evidence not submitted by this stage may be excluded at the ALJ level absent good cause. Whatever you have, submit it here.

Level 3: ALJ hearing

Requested from the Office of Medicare Hearings and Appeals. Hearings are typically conducted by telephone or video. This is the first level with a live hearing and the first where a clinician can answer questions directly.

The statutory decision window is 90 days, but OMHA backlogs have historically run far longer. Facilities should plan cash flow accordingly and should not treat an ALJ appeal as a near-term recovery.

Levels 4 and 5

Medicare Appeals Council review, then federal district court. Both are rare for individual SNF claims and generally worth pursuing only where a systemic policy interpretation is at stake across many claims.

The separate track: expedited QIO appeals

When a facility issues a Notice of Medicare Non-Coverage, the beneficiary may request an expedited determination from the Quality Improvement Organization. That process is not part of the five-level ladder and moves in days.

If the beneficiary appeals, the facility must supply a Detailed Explanation of Non-Coverage, generally by close of business the day the QIO notifies the facility. Same-day turnaround on a document requiring clinical rationale is the reason facilities should assemble the rationale when the NOMNC is issued, not when the appeal arrives.

How Medicare Advantage appeals differ

With roughly half of Medicare beneficiaries in MA plans, an increasing share of SNF denials never touch the fee-for-service ladder at all.

• The first level is a plan reconsideration, governed by the plan's process and timelines
• Adverse plan decisions go to an independent review entity contracted by CMS, not to a QIC
• Expedited pathways exist where a standard timeline would jeopardize the beneficiary
• Many MA denials are concurrent-review denials of continued stay rather than post-payment denials, which means the clock runs while the resident is still in the building

The practical implication is that MA denials must be worked in real time. A post-discharge appeal process designed for fee-for-service will lose MA days that were never authorized.

What a winning appeal actually contains

Structure the argument around the stated denial reason rather than around the stay chronologically.

1. Name the denial reason. Quote the contractor's stated basis so the reviewer knows you are answering it.
2. State the applicable criterion. Cite the coverage requirement at issue — the qualifying stay at 42 CFR 409.30, the skilled level of care requirement, the certification requirement at 42 CFR 424.20.
3. Map the record to the criterion. This is the whole appeal. For each element, cite the document, the date, the author, and what it establishes.
4. Address the contrary evidence. If three days of notes read custodial, say so and explain what else in the record establishes skilled need on those days. A reviewer who finds the weakness you concealed stops trusting the rest.
5. State the remedy. Specific dates of service and amount in dispute.

What does not work: asserting medical necessity without citation, resubmitting the same record with a cover letter, arguing hardship, or arguing that the reviewer misunderstood without showing what they missed.

The SNF denial reasons most often overturned

• Level of care not supported. Frequently overturned when the facility surfaces skilled documentation the reviewer did not locate in an unindexed packet.
• Missing physician certification. Often a filing problem rather than an absence — the certification exists in a different part of the chart.
• Therapy not reasonable and necessary. Winnable where evaluations, goals, and progress notes establish a skilled plan.
• HIPPS mismatch. Usually a technical correction rather than a coverage dispute.
• Qualifying stay not established. Overturned when hospital records confirming inpatient status are obtained and submitted.

The pattern: most overturns come from producing and organizing evidence, not from new clinical argument. The care was skilled. The record said so. Nobody pointed at the right pages.

Building an appeals process that actually runs

• Log every denial the day it arrives with the appeal deadline calculated, not the receipt date. Deadlines missed by a week are the most common cause of unrecovered revenue.
• Set an internal deadline at half the external one.
• Assign a single owner. Appeals distributed across whoever has time do not get filed.
• Track outcomes by denial reason. A reason you lose repeatedly is a documentation problem upstream, not an appeals problem.
• Feed findings back to clinical. If level-of-care denials keep landing, the fix is in how skilled need is charted, not in how appeals are written.

Where AI helps with denials and appeals

Appeal drafting is document synthesis under deadline, which is the single clearest use case for AI in the SNF revenue cycle. The work is finding what is already in the record and organizing it against a legal standard.

• Read the full denial packet and the medical record together, and produce a map of which documented interventions support which coverage criterion, with page citations.
• Draft the redetermination or reconsideration request structured around the stated denial reason, citing only what the record contains.
• Identify gaps before filing. Flag days in the billed period where documentation does not support skilled need, so the facility knows the weak point before the reviewer does.
• Assemble and index ADR responses, including the cover narrative.
• Draft the DENC against the same-day QIO turnaround.
• Analyze denial patterns across a quarter to identify which documentation practice is generating them.

The constraint most tools hit here is size and format. A denial packet is hundreds of pages of scanned material with handwritten physician orders in it. Hathr.AI runs Anthropic Claude models inside AWS GovCloud under a FedRAMP High authorization boundary, reads handwriting, and processes single documents exceeding 500,000 words in one pass — so a finding on page 30 and a finding on page 380 stay connected instead of being split across uploads.

A tool that chunks a 400-page record is not reading the record.

The boundary: AI must never assert a clinical fact the record does not contain. An appeal built on generated support for care that was not documented is falsification, and it converts a revenue problem into a fraud problem. Every draft is reviewed and signed by qualified staff.

Test it on a denial you already have

Upload one denied claim with the corresponding medical record and ask Hathr.AI to draft the redetermination request with page citations. Compare it against what you would have written by hand.

Start a free trial — $47 a month, no seat minimum, BAA in 24 hours →

Frequently asked questions

How long does a SNF have to appeal a Medicare denial?
A redetermination request must be filed with the Medicare Administrative Contractor within 120 days of receiving the initial determination. Each subsequent level has its own deadline.

What are the five levels of Medicare appeal?
Redetermination by the MAC, reconsideration by a Qualified Independent Contractor, a hearing before an Administrative Law Judge at OMHA, review by the Medicare Appeals Council, and judicial review in federal district court.

What form is used for a Medicare redetermination?
Form CMS-20027, or a written request containing the same information. Reconsideration uses Form CMS-20033.

When is the last chance to submit new evidence?
Generally at reconsideration. Evidence introduced later may be excluded at the ALJ level without a showing of good cause.

How long does a facility have to respond to an ADR?
Generally 45 days. Failure to respond results in denial of the claim.

Do Medicare Advantage denials follow the same process?
No. MA denials follow the plan's reconsideration process and then an independent review entity, with different timelines and often concurrent rather than post-payment review.

Part of the HIPAA-Compliant AI for Skilled Nursing Facilities hub. Related: SNF Billing Guide · What Is PDPM?

This article is general regulatory information, not legal or billing advice. Appeal deadlines, forms, and amount-in-controversy thresholds are subject to change. Verify current requirements with your MAC and the Medicare Claims Processing Manual before filing.