SNF Denial Management
Denials read, root-caused, and appealed inside the window. CARC and RARC analysis. CO, PR, OA, PI claim adjustment groups decoded. Five-level Medicare appeal escalation. 120-day redetermination, 180-day reconsideration, ALJ threshold tracking. 800+ providers trust us. Pilot in 2 weeks.
0:55
0:48Denials sit unread. Appeal windows close. Money walks out the door.
SNF and home health initial denial rates frequently run 10 to 15 percent on Medicare Advantage claims per MGMA 2024 denial benchmarks. Rework can consume $25 per claim. Most never get appealed within the payer window. Each missed redetermination is cash that never comes back.
Denials not read on the remit
The 835 remit lists CARC and RARC codes in detail. Without a denial specialist, the codes get ignored and the claim closes as "adjusted" without anyone reviewing the root cause.
120-day window closes silently
Medicare allows 120 days from the initial determination date to file a redetermination. Miss the date and the appeal right is gone. No exceptions. The dollars convert to write-offs.
Five-level escalation not run
Most denials never get past level 1 redetermination. Level 2 reconsideration through the QIC, level 3 ALJ hearing at the $190 threshold, level 4 appeals council, level 5 federal court. Each level requires a specific packet.
Tell us about your agency.
Send us your situation and our team will scope the right setup, usually within one business day. No obligation.
What is SNF denial management ?
SNF denial management is the workflow of reading 835 remits, identifying the CARC (Claim Adjustment Reason Code) and RARC (Remittance Advice Remark Code) on every adjusted line, mapping the code to a root cause, and either correcting and resubmitting the claim or filing an appeal inside the payer window. CARCs come in four groups: CO (contractual obligation), PR (patient responsibility), OA (other adjustment), and PI (payer-initiated reduction). Each group requires a different next step.
What your denial management team handles, day to day
Eight production tasks every denied claim hits before it converts to paid or appealed.
835 remit read
Reads every 835 ERA file. Tags CO, PR, OA, PI adjustment groups. Logs the CARC and RARC codes per claim line.
CARC + RARC categorization
Maps each CARC code to category: medical necessity, coding error, authorization missing, eligibility issue, duplicate, timely filing.
Correct and resubmit decision
Decides whether to correct the claim and resubmit under the same control number, or file a formal appeal. Documented decision.
Medicare redetermination (Level 1)
Drafts redetermination letters within 120-day window. Packages supporting MDS, physician orders, therapy notes. Submits to MAC.
QIC reconsideration (Level 2)
Within 180 days of redetermination decision. Drafts reconsideration packet to Qualified Independent Contractor.
ALJ threshold tracking (Level 3)
At or above $190 (2026 threshold). Drafts ALJ hearing request within 60 days of QIC unfavorable decision.
MA plan and commercial appeals
Drafts MA plan and commercial appeals. Tracks payer-specific windows (usually 60 to 180 days). Logs reference numbers.
Denial trend reporting
Weekly top 10 CARCs by frequency and dollar. Root-cause categories. Appeal overturn rate by payer.
CARC, RARC, and 5-level appeal trained, not generic billers
Most outsourcing firms cannot tell CO from PR on a remit. We can. Our denial specialists pass a CARC and RARC assessment and a Medicare 5-level appeal procedure test before they ever touch a live denied claim.
CARC and RARC tested
Every specialist passes a written assessment on CARC categories (CO, PR, OA, PI), top 50 CARCs, top 30 RARCs, and the Medicare 5-level appeal ladder before placement on a live account.
Stacked compliance posture
HIPAA + SOC 2 Type II + ISO 27001 + HITRUST. Plus alignment with 42 CFR 405 Subpart I (appeals) and 45 CFR 164.514 de-identification. All four certificates available on request.
2-Week Risk-Free Pilot
Industry offers no trial. We give you 14 days of live denial workup at the same rate. Cancel before day 14, owe nothing. No annual contracts after.
Staffingly vs DIY in-house vs generic offshore
Cost math for a single full-time denial specialist at a mid-size SNF or LTC operator.
From "let's talk" to first appeal filed in 1 to 2 weeks
Six steps. Each one is documented.
Discovery call (15 min)
Share your top 10 CARC codes by frequency. We map the worst denial reason and quote a baseline overturn target.
BAA + access
BAA signed. Role-based access to your EMR and 835 remit archive.
Denial library calibration (2 to 3 days)
Top CARCs categorized by root cause. Appeal templates locked. Supporting documentation checklists per CARC.
Parallel denial work starts
Week 2 to 3. Specialist works the highest-dollar CARCs first. Daily 15-minute sync. You see every appeal before submission.
Decision point (end of week 2)
Appeal submission count, overturn rate so far, dollars recovered. Go or no-go. No penalty if you cancel.
Full handoff, cadence locked
Weekly denial trend report. Monthly overturn rate by payer. Quarterly CARC root-cause review with QAPI.
How your denial specialist's day actually looks
A real shift, hour by hour. Coverage rotates so your denial queue is never dark during business hours.
How Staffingly works, in practice
Inside the workA trained Staffingly specialist works inside your existing platform, with clear escalation back to your team.
One Flat Weekly Rate. No Surprises.
Dedicated senior care schedulers at a fixed weekly cost. Per scheduler FTE, per week. No contracts, no minimums, no hidden fees.
Want to compare against an in-house hire? Use the savings calculator.
Frequently asked questions
What are the four CARC categories?
CO (contractual obligation), PR (patient responsibility), OA (other adjustment), and PI (payer-initiated reduction). Each group requires a different next step.
What are RARCs and when do you use them?
RARCs (Remittance Advice Remark Codes) provide additional detail beyond a CARC. While CO 50 says non-covered, a RARC like N115 adds the basis (LCD). RARCs help target the appeal argument.
What are the 5 levels of Medicare appeals?
Level 1 Redetermination by MAC within 120 days. Level 2 Reconsideration by QIC within 180 days. Level 3 ALJ hearing at $190 threshold. Level 4 Appeals Council review. Level 5 Federal District Court at $1,900 threshold.
What is the ALJ threshold amount?
The 2026 amount-in-controversy threshold for an ALJ hearing is $190. The federal district court threshold (Level 5) sits at $1,900. CMS updates these annually.
How does Medicare redetermination work, and what is the 120-day window?
Redetermination is filed with the MAC within 120 days of the initial determination. The MAC must issue a decision within 60 days. Packet includes Form CMS-20027, claim, remit, supporting MDS, physician orders, therapy notes, and written argument.
What are the most common SNF denial root causes?
Medical necessity (CO 50), authorization (CO 197), service included (CO 97), non-covered (CO 96), duplicate (CO 18), eligibility (CO 31), timely filing (CO 29), PDPM HIPPS mismatch.
How does pricing work?
Per denial specialist FTE per week. $399 Standard, $349 Volume (3+), $299 Enterprise (10+). No setup fees. No annual contracts.
What is included in the 2-Week Risk-Free Pilot?
Two weeks of live denial workup. Specialist works highest-dollar CARCs first. Daily KPI reporting on appeals submitted, dollars in appeal, and overturn rate. No penalty if you cancel before day 14.
President and CEO, Staffingly, Inc. 25+ years in IT consulting and healthcare BPO operations. One of the earliest US operators to set up an RPO/BPO delivery network in India. Leads AI-driven home care workflows that help agencies, home health providers, and multi-branch operators cut admin cost without compromising care.
