C. Denied SNF claims

The beneficiary may be informed by the SNF that their stay is noncovered and they may desire to file an appeal before they receive the disallowance notice. In this case, see GN 03101.070 . The beneficiary may also be informed that part of their stay was covered but that as of a certain date, the coverage was terminated.

Provide the inquirer with the basic information as to what constitutes covered services. It should be remembered that a physician may appropriately recommend a patient's stay in an SNF without knowing whether Medicare will pay for the care provided. A physician's decision may be influenced by social and other factors including the unavailability of friends or relatives to care for the patient at home. While such considerations are appropriate for the physician, they do not affect the intermediary's coverage determination.

If the entire SNF stay has been denied after a considerable period of time has elapsed since the date of admission, explain to the beneficiary that generally, the intermediary can make a determination on the claim only after it has been received and evaluated. Do not give the impression that either the provider or the intermediary is at fault when a retroactive denial is made.

If the beneficiary indicates that they are dissatisfied with the explanation, assist them in filing a request for reconsideration.

The waiver of liability provision applies to SNF admissions when the beneficiary (or the provider) did not know, and had no reason to know that the care was not medically necessary or reasonable or constituted custodial care.