By the time most skilled nursing facilities run an eligibility check, the admission decision has already been made. The referral came in, clinical acceptance happened within the hour, the family was called, the bed was committed and somewhere in that sequence, “run the insurance” became a task for tomorrow morning. That is not pre-admission verification. That is documentation of a decision that cannot be undone.
The 2024 Medicare Fee-for-Service Supplemental Improper Payment Data puts the SNF inpatient improper payment rate at 17.9%, with a projected improper payment amount of $5.6 billion and insufficient documentation accounts for 75.5% of those errors (Source: CMS 2024 Medicare Fee-for-Service Supplemental Improper Payment Data). Most of those documentation failures trace back to something that happened or did not happen before the resident arrived. Pre-admission verification is the earliest intervention point in that chain. It is also the most consistently skipped.
Pre-admission eligibility verification is the process of confirming a prospective resident’s insurance coverage, benefit status, and authorization requirements before the admission decision is finalized. Before the bed is offered, before the family is called, before the discharge planner marks the referral accepted. When it runs in that sequence, it is a decision gate. When it runs after, it is paperwork.
This guide covers the payer-by-payer verification process for Medicare Part A, Medicaid, and Medicare Advantage/HMO admissions; the timing framework that determines whether verification actually protects revenue; the protocol for when coverage cannot be confirmed; and the documentation file every admission should have on record. It is written for SNF admissions coordinators, business office managers, and billing staff who own this process in practice.
For a broader look at how pre-admission verification fits into the full eligibility workflow, including mid-stay recheck and post-denial recovery, see our SNF eligibility verification workflow.
Why Timing Is Everything in Pre-Admission Verification
Pre-admission verification has a timing problem, and it is more widespread than most facilities recognize.
The referral arrives from the hospital discharge planner. The DON or admissions coordinator reviews the clinical packet and accepts the resident as appropriate for the facility’s level of care. The bed is offered. The family is notified. Transport is scheduled. And somewhere in that sequence, often that evening, sometimes the next morning, the business office runs the insurance check.
That sequence is the problem. Most SNFs that believe they have a pre-admission verification process actually have a same-day-of-admission verification process. The eligibility check runs, but it runs after the commitment has been made. At that point, if coverage cannot be confirmed, the facility faces three bad options: delay transport and damage the discharge planner relationship, proceed with admission under unconfirmed coverage, or reverse an acceptance the family was already told about. None of those are acceptable. All of them are avoidable.
The verification must run at referral intake, when the hospital calls, before clinical acceptance is communicated, before the bed is offered. That is the only moment when the eligibility result can actually change the admission decision.
The role that owns this step is the admissions coordinator, not the billing team, not the business office. Routing pre-admission verification to billing places the check downstream of the decision. The admissions coordinator is the first person in the facility to touch the referral. The eligibility check belongs at that stage, as a condition of acceptance, not as a follow-up task after the bed is committed.
Denial codes CO-27 (insurance expired or terminated) and CO-29 (time limit for filing has expired) are both avoidable with 24-hour lead time at the referral stage. When they appear on a remittance, they are almost always evidence of a timing failure, not a coverage failure. The resident was eligible. The check just ran too late to catch the gap before admission.
For facilities using eligibility verification software, automated payer checks return results within minutes of referral intake, eliminating the Friday-afternoon problem where a manual call to Medicare pushes confirmation to Monday morning, by which point the discharge planner has placed the resident elsewhere.
Medicare Part A: What to Verify Before Admission
Medicare Part A SNF coverage has three eligibility gates, and a prospective resident can fail any one of them independently. A beneficiary who is enrolled in Medicare, carries an active card, and has never had a coverage issue can still be ineligible for SNF benefits on a given admission. Verify all three gates at the referral stage, not after transport.
The 3-Day Qualifying Hospital Stay
Medicare Part A SNF coverage requires a minimum of three consecutive inpatient days in an acute care hospital or critical access hospital immediately preceding SNF admission. Observation days do not count toward this requirement. This distinction costs SNFs revenue every year.
When the hospital discharge summary arrives with the referral packet, confirm admission status explicitly. If the packet references observation care, or if the hospital issued a Medicare Outpatient Observation Notice (MOON), the 3-day qualifying requirement may not be met. Do not assume inpatient status from the length of stay. Confirm it from the hospital’s admission records.
The most common failure: the hospital lists a 4-day stay in the discharge summary, the admissions coordinator counts 4 days toward the qualifying requirement, and Medicare denies the claim because 2 of those days were under observation status. The denial code is CO-B7, not covered as billed. The appeal is winnable only if the hospital reclassifies the stay, which requires their cooperation and takes weeks. The alternative is a write-off that should never have happened.
Verify through HETS (Healthcare Eligibility Transaction System) via your clearinghouse, the Medicare beneficiary portal at Medicare.gov, or by direct contact with Medicare. Request a copy of the hospital’s inpatient admission orders if observation status is in question.
Benefit Period Status
Medicare Part A SNF benefits reset after a 60-day break in skilled care. A resident who received SNF benefits within the past 60 days may have used some or all of their current benefit period days. A resident who exhausted all 100 days in a prior benefit period, without a subsequent 60-day break, has zero SNF days available regardless of what the Medicare card says.
At referral, confirm how many days have been used in the current benefit period, how many remain, and whether a new benefit period has opened. This information is available through HETS or the Medicare beneficiary portal. Do not rely on the referring hospital to provide it. Their discharge planners work from their own records, which may not reflect the resident’s full Medicare history.
Skilled Care Requirement
Medicare Part A SNF coverage requires physician certification that the resident needs daily skilled nursing or skilled therapy services. This is a clinical requirement, not an administrative one, and at the referral stage the documentation supporting it must already exist.
Review the hospital discharge summary for the physician’s documentation of skilled care need. If the discharge summary does not explicitly state that the resident requires skilled nursing or skilled therapy services, request an addendum from the attending physician before transport. Do not rely on the MDS coordinator to establish clinical rationale post-admission. Documentation that did not exist at the time of admission cannot be created retroactively, and without it a Medicare audit results in a denial regardless of the care the resident actually received.
For a full walkthrough of the Medicare verification process for SNF providers, see our Medicare eligibility verification guide.
Medicaid: Verification Before Admission Is Not the Same as Verification at Billing
Medicaid eligibility verification at the pre-admission stage is not the same process as checking Medicaid status on the billing screen. Active status in the state portal confirms that the resident is enrolled in the Medicaid program. It does not confirm SNF level-of-care approval, that coverage is active for the admission date, or that the facility is enrolled as a Medicaid provider in good standing with that state’s program. Those are separate checks. Run all of them.
Active vs. Pending Medicaid
Active Medicaid means the resident’s application has been approved and coverage is current. Verify active status in the state portal before admission: for Illinois facilities, that is the MEDI system; Indiana uses the IHCP portal; Iowa uses the Iowa Medicaid portal; Wisconsin uses ForwardHealth. Active status at the time of verification does not guarantee coverage for the full stay, but it confirms the starting point.
Pending Medicaid is the higher-risk scenario. The resident has applied but has not yet been approved. Coverage, if approved, may be retroactive to the application date, but retroactive approval is not guaranteed, and the timeline for determination varies by state and by case complexity.
Here is the mistake most facilities make with pending Medicaid admissions: it is not the decision to admit. It is admitting without a written private-pay agreement in place. A resident admitted under pending Medicaid with no written agreement leaves the facility with no contractual basis for billing if Medicaid is denied. The risk is not the pending status itself. The risk is the missing paperwork.
If a pending Medicaid resident is admitted, the facility must have a signed private-pay agreement with a Medicaid conversion clause executed before or at admission. That agreement must specify the private-pay daily rate, the trigger for conversion to Medicaid billing upon approval, and the process for retroactive rate adjustment. This is a legal document. Have it reviewed by healthcare counsel before it becomes part of the standard admission packet.
At the referral stage, document the pending case number, the application date, and the expected determination date. These three data points determine whether the admission is financially viable and when the facility needs to follow up with the state agency.
Level-of-Care Authorization
Some states require a separate Medicaid level-of-care (LOC) authorization for SNF admission, independent of Medicaid eligibility. In states with this requirement, a resident who is eligible for Medicaid may still need a separate LOC determination before the facility can bill for SNF services. Admitting before LOC approval in those states creates a billing gap Medicaid will not fill retroactively.
Confirm your state’s LOC authorization requirement at the referral stage. If your state requires it, treat LOC authorization as a hard stop in the pre-admission checklist, the same way prior authorization is a hard stop for Medicare Advantage admissions.
Dual Eligibility
Residents eligible for both Medicare and Medicaid require verification of both coverages at the referral stage. For these residents, Medicare pays first and Medicaid covers the cost-share. If the Medicare benefit period has been exhausted, billing defaults to Medicaid-primary, a different per diem rate with different documentation requirements.
Confirm both coverages are active. Confirm benefit period status for the Medicare component. Confirm the Medicaid coverage type: full dual eligibility eliminates the Medicare cost-share; partial dual eligibility (QMB, SLMB) covers only specific cost-share components. Getting this wrong creates either an underpayment or a compliance exposure, neither of which is recoverable without significant administrative work after the fact.
For detailed Medicaid verification guidance by state, see our Medicaid eligibility verification guide.
Medicare Advantage and HMO: The Most Commonly Missed Verification Step
Medicare Advantage verification is not one step. It is three, and most facilities only run one of them.
Prior authorization is required for skilled nursing facility stays by 99% of Medicare Advantage plans (Source: KFF Medicare Advantage 2024), and in 2024, nearly 53 million prior authorization requests were submitted to Medicare Advantage insurers, of which 4.1 million (7.7%) were denied. For SNFs, a denied prior authorization is not just a billing problem. It is an admission that generated no reimbursement, cannot be billed to the resident under federal law, and cannot be recovered. The front end of that problem is a verification failure. The back end is a write-off.
Running a single eligibility check that confirms the resident is an active plan member is necessary but not sufficient. A resident can be an active Medicare Advantage member and still be unable to use your facility.
In-Network Confirmation
Medicare Advantage plans contract with specific SNFs. A resident enrolled in an Aetna Medicare Advantage plan can only receive covered SNF benefits at a facility in Aetna’s contracted network. Out of network, the stay is either uncovered or covered at a significantly reduced rate, and the facility cannot collect the balance from the resident.
Verify network status before accepting the referral. Call the plan’s provider relations line and confirm your facility’s NPI is listed as an in-network SNF provider for that specific plan. Online provider directories are not always current. Call to confirm. Network confirmation is a separate step from eligibility confirmation. Both are required.
Prior Authorization
Securing prior authorization for a Medicare Advantage SNF admission requires submitting clinical documentation, typically the hospital discharge summary, medication list, and physician orders, to the plan’s utilization management team. What to capture when authorization is granted: the authorization number, the approved level of care, the authorization start date, and the number of approved days. Document all four data points. The authorization number alone is not sufficient.
An authorization number confirms that a prior authorization exists. It does not tell you what was authorized. Admissions coordinators who log the auth number and stop there are missing the two fields that actually govern billing: approved level of care and approved days. If the plan authorized custodial care and the facility is billing at skilled nursing level, the plan will deny on appeal, regardless of what the auth number says, regardless of the care provided. The approved level of care is what the plan agreed to pay for. Verify it matches what the facility is planning to deliver.
The number of approved days determines when the authorization renewal window opens. Most plans require renewal requests 5 to 7 days before the current authorization expires. A business office manager who is not tracking approved days against the authorization start date will file the renewal late. The facility will deliver uncompensated care during the gap. That gap is not appealable. It is a scheduling failure, not a coverage dispute.
Coordination of Benefits for Dual-Eligible MA Residents
Some Medicare Advantage members also carry Medicaid coverage. Dual Eligible Special Needs Plans (D-SNPs) are designed specifically for this population and carry different billing and coordination rules than standard Medicare Advantage plans. Verify plan type at the referral stage. A D-SNP resident bills differently than a standard MA resident, and the prior authorization and cost-share rules are not the same.
For additional guidance on commercial and managed care payer verification, see our commercial payer verification guide.
What to Do When Coverage Cannot Be Confirmed
Pre-admission verification sometimes produces an answer the facility did not want. A coverage gap, an exhausted benefit period, a pending Medicaid case, a plan that requires prior authorization but cannot process it until Monday. These outcomes happen. The facility needs a protocol for each one. Figuring it out after admission is not a protocol. It is how eligibility denials become written-off balances.
Hold the Admission Pending Verification
If coverage cannot be confirmed within a defined window, typically 24 hours for standard referrals, faster for urgent transfers, flag the referral as pending verification, not accepted. Communicate that status to the hospital discharge planner directly: verification is in process, and confirmation of acceptance will follow within a specified timeframe. Do not commit a bed before coverage is confirmed.
Most discharge planners expect this. They work with multiple SNFs and recognize that responsible facilities verify before they commit. What damages the relationship is not a brief verification hold. It is accepting a referral, committing a bed, and reversing the acceptance after the family has been notified. A transparent verification hold is professional. A last-minute reversal is not.
Admit Under Private Pay With a Conversion Agreement
When Medicaid is pending or Medicare eligibility cannot be fully confirmed before the resident needs to transfer, the facility can admit under a private-pay agreement with a conversion clause. The agreement specifies the private-pay daily rate, the conditions under which billing converts to the confirmed payer, and the process for retroactive rate adjustment.
This agreement must be in writing and signed before or at admission. A verbal agreement is not enforceable. A conversion clause that was never documented is not a conversion clause. Have this form reviewed by healthcare counsel before it becomes part of the standard admission packet.
Document the Coverage Gap
Whatever decision is made, hold, private-pay admission, or proceeding with partial confirmation, document it. What was checked, when, what the result was, and what decision was made and why. This record protects the facility in the event of a later denial and supports an appeal argument that the facility acted in good faith with the information available at the time of admission. Facilities that cannot produce this documentation have no appeal footing.
The Pre-Admission Verification Documentation File
Every referral that proceeds to admission should produce a verification file. If the information is not documented, it does not exist, and it will not support an appeal.
Medicare Part A
- Confirmation of 3-day qualifying inpatient stay (source and date of verification)
- Benefit period days used and days remaining
- Skilled care certification: physician name and documentation reference
- Verification method (HETS, Medicare portal, or phone) and verification date
Medicaid
- Active or pending status with state portal confirmation and date
- Pending case number, application date, and expected determination date (if applicable)
- Level-of-care authorization number and approval date (if required by state)
- Private-pay agreement with conversion clause (if pending admission)
- Dual eligibility status and coverage type (QMB, SLMB, full dual)
Medicare Advantage / HMO
- Network confirmation: plan name, confirmation method, and date
- Prior authorization number
- Approved level of care
- Authorization start date
- Number of approved days and calculated expiration date
- Plan type (standard MA or D-SNP)
This file is created at the referral stage by the admissions coordinator, reviewed by the business office manager at admission, and referenced by the billing team when the first claim is generated. It is not an administrative nicety. It is the paper trail that makes denials appealable and audits survivable.
For a complete reference on eligibility verification documentation across all payer types, see our complete SNF eligibility verification guide.
Why Most SNFs Get Pre-Admission Verification Wrong
The failure is structural, not personal. Most SNF billing and admissions staff are capable of running thorough eligibility checks. The problem is that the process is assigned to the wrong role, running at the wrong stage, through a workflow that was built to handle volume rather than catch risk.
When verification is routed to the billing team, it enters a queue. The billing coordinator is processing claims, managing denials, handling prior auth renewals. A new referral verification lands at the bottom of that list, and by the time it surfaces, the admissions coordinator has already told the hospital the bed is available.
The fix is a role reassignment and a timing correction. The admissions coordinator owns pre-admission verification as a condition of referral acceptance. The eligibility check must complete before verbal or written acceptance is communicated to the hospital. That requires either a fast manual process, which depends on hold times, portal availability, and staff capacity, or an automated system that returns payer results in minutes.
Manual verification workflows are built to catch errors. Automated workflows are built to prevent them. The SNFs that consistently lose revenue to pre-admission eligibility failures are not running bad processes. They are running slow ones, in the wrong sequence, owned by the wrong role. The distinction matters because the fix for a slow process is different from the fix for a bad one.
Frequently Asked Questions
Pre-admission eligibility verification is the process of confirming a prospective resident's insurance coverage, benefit status, and authorization requirements before the admission decision is finalized. For SNFs, this means verifying Medicare Part A eligibility gates, Medicaid active or pending status, and Medicare Advantage prior authorization, all before the bed is committed, not after.
At referral. Verification that runs on the day of admission, or after the bed is committed, is not a decision gate. It is documentation of a decision that has already been made. If coverage cannot be confirmed at that point, the facility's options are limited and all of them carry a cost.
Through HETS (Healthcare Eligibility Transaction System) via a clearinghouse, through the Medicare beneficiary portal at Medicare.gov, or by direct contact with Medicare. Verify all three eligibility gates independently: the 3-day qualifying inpatient stay, remaining benefit period days, and physician documentation of skilled care need.
The facility can admit under a private-pay agreement with a Medicaid conversion clause, specifying the private-pay rate and the terms under which billing converts upon approval. This agreement must be in writing and signed before or at admission. Document the pending case number, application date, and expected determination date at the referral stage.
Prior authorization is required for skilled nursing facility stays by 99% of Medicare Advantage plans. The authorization must be secured before admission. Document the authorization number, approved level of care, start date, and number of approved days, not just the authorization number.
A payer-specific verification file: for Medicare Part A, confirmation of the qualifying stay, benefit period days, and skilled care certification; for Medicaid, portal confirmation of active or pending status, case number, and any LOC authorization; for Medicare Advantage, network confirmation, prior auth number, approved level of care, start date, and approved days.
Who This Is For
LTC Apps is built for you if:
- You operate a skilled nursing facility or small regional SNF group and eligibility denials are surfacing on remittances that should have been caught before admission
- Your admissions coordinator and billing team are running verification separately, or verification is happening after the bed is committed
- You want a modular platform that handles eligibility verification, admissions intake, and billing workflow without requiring a full EHR replacement
This is not the right fit if:
- You are looking for a full clinical EHR with physician-facing charting
- You need software designed for assisted living without a skilled nursing component
- You require an enterprise implementation with a dedicated project team from day one
What Happens When You Request a Demo
Here is the process:
- A member of our team reaches out within one business day to schedule a call
- We run a 30-minute live walkthrough of the modules most relevant to your facility, eligibility verification, admissions intake, or both
- You receive pricing specific to your facility size and module selection
Most facilities have a clear picture of fit and pricing within one week of reaching out.
Common questions before booking: No long implementation timelines. Most facilities are live on their first module within 2 to 4 weeks. No minimum facility size. We work with single-facility operators and regional groups. If you are mid-contract with another vendor, we can run a parallel evaluation so you are ready to switch at contract end.
Stop Verifying After the Decision Is Already Made
If your eligibility check runs after the bed is committed, you are not running pre-admission verification. You are documenting a denial that may already be in progress. The fix is not a new process. It is a role reassignment and a timing correction on a process you are already running.
LTC Apps was built for SNF admissions and billing teams that need eligibility results at referral intake, not the next morning, not after transport is scheduled. If pre-admission verification is creating revenue risk at your facility, we can show you exactly how the verification workflow functions in practice.
