CaseWhy Hub · CaseWhy Appeals · Facilities · Skilled nursing · Admission
Stop letting insurance denials block your admissions
A Medicare Advantage plan can refuse to cover a skilled nursing admission before the resident even arrives. When these denials are appealed, they are overwhelmingly overturned. Most are never appealed.
The data: what the federal numbers say
An HHS OIG report published in June 2026 (OEI-09-24-00331) looked at the 109,400 skilled nursing admission requests that the 19 largest Medicare Advantage organizations, covering 86% of MA enrollment, processed in June 2024:
- 12% of the requests were denied.
- Only 18% of those denials were appealed.
- 95% of the appeals that were filed were overturned.
The 95% is the share of filed appeals that succeeded. It is not the chance that any given denial would be overturned, because most denials were never appealed. It is also one month at the largest organizations, not every plan.
Pre-admission appeals run on a different clock
Mid-stay appeals go to a QIO, with a noon-the-day-before deadline. A pre-admission appeal follows a two-step federal track.
| Step | Who reviews it | You file within | They decide within | If expedited |
|---|---|---|---|---|
| 1. Plan reconsideration | A different reviewer at the plan | 60 days of receiving the denial (65 counting mail time) | 30 days | 72 hours |
| 2. Independent review | Forwarded automatically if the plan upholds the denial or misses its deadline, to the independent review entity (currently C2C Innovative Solutions) | — | 30 days | 72 hours |
Standard timelines can be extended by up to 14 days.
How CaseWhy handles it
- Upload the plan's denial notice. CaseWhy recognizes it and puts both deadlines on the case.
- The case is built around the Medicare skilled-level-of-care test.
- CaseWhy drafts the reconsideration letter with the governing regulations cited.
- CaseWhy prepares CMS-1696, the appointment-of-representative form, so your facility can file on the resident's behalf.
The appeal is the resident's. CMS-1696 is what lets your facility act as their appointed representative.
Sources: HHS OIG, OEI-09-24-00331 (June 2026); 42 CFR §§422.566–422.590 (organization determinations and reconsiderations), including §422.582 (time to request).
The other way a plan denies a resident: the mid-stay flow — notice, clocks, fast-appeal request →