Insurance, Benefit Days & Medicare Appeals

Insurance & appeals

Coverage status, how many days are left, and everything the family needs to fight a denial.

18 of 21 authorized days used

3 days remaining

Primary: Medicare Part A — Skilled Nursing Facility benefit

Policy: 1EG4-TE5-MK72

Secondary: Blue Cross Blue Shield of Texas (Medigap Plan G)

Authorization: Auth #SNF-2026-88421 · approved through Aug 23, 2026

Cost share: Days 1–20: $0/day · Days 21–100: $209.50/day (covered by Medigap Plan G)

Case manager: L. Freeman, LCSW · (972) 555-0163

Aug 19
Medicare reviewer approved 3 additional days based on PT progress notes. New end date Aug 23.
Aug 14
Day 14 utilization review completed. Continued skilled need documented: wound care + gait training.
Aug 3
Benefit period opened. Qualifying 3-night hospital stay verified (Jul 30 – Aug 2).

Not filed — preparing

Deadline: Noon the day after the Notice of Medicare Non-Coverage (NOMNC) is delivered

1. You receive the NOMNC
Done
The facility must hand you a Notice of Medicare Non-Coverage at least 2 days before coverage ends. Sign it — signing only means you received it, not that you agree.
2. Call the BFCC-QIO immediately
Next
Livanta is the QIO for Texas: 1-888-524-9900 (TTY 1-888-985-9295). Call by noon the day after you get the notice. This is a free, fast appeal and care continues while they review.
3. Facility sends the Detailed Explanation of Non-Coverage (DENC)
Next
Within one day of your call the facility must give you and the QIO a DENC explaining why they believe skilled care is ending. Ask for a copy for your records.
4. QIO decision within 72 hours
Next
A doctor reviewer decides. If they agree with you, Medicare keeps paying. If not, you can escalate to a Reconsideration by a Qualified Independent Contractor, then an ALJ hearing.

· Write a short letter describing what your loved one still cannot do safely alone (stairs, bathing, transfers, medication management) with specific examples and dates.
· Ask therapy for the last 3 progress notes and the current goal sheet — measurable gains support continued skilled need.
· Ask the physician for a statement that skilled nursing or therapy is still medically necessary.
· Document every fall, new wound, infection, or medication change since admission.
· Never agree verbally to discharge before the QIO decision; put every request in writing through this portal.
· Contact your state Long-Term Care Ombudsman — free advocate, Texas: 1-800-252-2412.