The beneficiary may be informed by the SNF that his stay is noncovered and he may
desire to file an appeal before he receives the disallowance notice. In this case,
see GN 03101.070. The beneficiary may also be informed that part of his 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
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 he is dissatisfied with the explanation, assist
him 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.