How much notice does a skilled nursing facility have to give before Medicare coverage ends?

Under 42 CFR 405.1200(b)(1), the facility must deliver the Notice of Medicare Non-Coverage no later than 2 days before the proposed end of covered services. If the stay is expected to run fewer than 2 days, the notice must be given at admission instead. The notice has to be signed and dated by the beneficiary or representative to count as delivered; a refusal to sign is treated as receipt on the date of the refusal.

What is the deadline to request a fast appeal after getting a NOMNC?

Noon of the calendar day after the beneficiary receives the notice, under 42 CFR 405.1202(b)(1). If the QIO cannot take the request that day, the deadline moves to noon of the next day it is open. A request made after that window is still accepted and reviewed, but the 72-hour turnaround and the protection against billing for the disputed days no longer apply under paragraph (b)(4).

What is a DENC and when does it show up?

The Detailed Explanation of Non-Coverage, CMS-10124, is not sent automatically. Under 42 CFR 405.1202(f)(1), the facility only has to send it after the QIO notifies the facility that a beneficiary requested a fast appeal, and it is due by close of business that same day. It has to name the specific coverage rule the facility is relying on and the facts of the case that make the rule apply.

Do I have to pay for the disputed days while the QIO is reviewing?

No bill can be issued while it is pending. Under 42 CFR 405.1202(g), once a beneficiary requests an expedited determination on time, the provider may not bill for the disputed services until the QIO's determination — and the reconsideration, if one is requested — is complete. That is a billing protection, not an extension of coverage: under paragraph (c), coverage itself runs only to the date and time on the termination notice unless the QIO reverses the decision. Two exceptions push the date. If the QIO finds valid notice was never delivered, coverage continues until at least 2 days after valid notice is given; and if the provider's delay in handing over records delays the decision, paragraph (e)(7) lets the QIO make the provider pay for the extra days.

Filing a Fast Appeal of a Skilled Nursing Discharge

A single sheet gets handed across a desk. Near the top is a date — the day Medicare stops paying for a skilled nursing stay. Everything about the page invites you to treat that date as the deadline.

It is not the deadline. If the sheet is a Notice of Medicare Non-Coverage and it is handed over on a Wednesday afternoon, the number that decides whether a fast appeal is available is noon on Thursday, whatever Friday's coverage-end date suggests. Two days of warning printed on the form; one day and a few hours to act on it. Call inside that window and a federal reviewer who has never met the patient gets 72 hours to decide whether the facility is right. Miss it and the printed date stands.

The notice is called a NOMNC, and it starts a very short clock

The form is the Notice of Medicare Non-Coverage, CMS-10123. Under 42 CFR 405.1200(b)(1), a skilled nursing facility — along with a home health agency, a comprehensive outpatient rehabilitation facility, or a hospice, the four provider types this rule covers — must deliver it no later than 2 days before the proposed end of covered services. If the whole stay was expected to run under 2 days, the notice goes out at admission instead.

Delivery only counts if it is valid, and validity has a specific shape under (b)(3): the beneficiary or representative has to sign and date it to show they received it and could understand it. A refusal to sign does not stop the clock — the facility can note the refusal, and the date of that refusal becomes the date of receipt.

The current NOMNC is the January 2025 edition, form CMS-10123, OMB control number 0938-0953, posted with its instructions on CMS's own Beneficiary Notices Initiative page, last modified 13 May 2025 and read 19 August 2026. If the sheet in hand carries an older edition line, that is worth raising with the facility before anything else.

The instruction sheet for that form also settles an argument that comes up constantly, in a single line: "Note: The two-day advance requirement is not a 48-hour requirement." A notice delivered at four in the afternoon on Wednesday for a Friday termination satisfies the two-day rule. Counting hours is the wrong count.

What the notice has to contain, under (b)(2), is narrower than families expect: the date coverage ends, the date financial liability for continued services begins, a description of the right to an expedited determination — including, in the regulation's own words, "a beneficiary's right to submit evidence showing that services must continue" — and notice that the more detailed explanation described below can be requested.

It does not have to explain why coverage is ending. That part comes later, and only if you ask. The right to submit evidence, on the other hand, exists from the moment the page is signed, and almost nobody uses it.

The deadline that actually matters: noon, the next calendar day

This is the number to write on the notice itself, in pen, the moment it is handed over.

42 CFR 405.1202(b)(1) gives a beneficiary the right to request an expedited determination from the state's BFCC-QIO — in writing or by phone — no later than noon of the calendar day following receipt of the termination notice. Wednesday-afternoon delivery means a Thursday-noon deadline, full stop, regardless of what Friday's coverage-end date suggests. If the QIO is unable to accept the request that day, the regulation moves the deadline to noon of the next day the QIO is available.

A request filed after that window does not vanish into nothing. Under (b)(4) the QIO still has to accept it and review it "as soon as possible." What disappears is the leverage: the 72-hour turnaround requirement and the rule that the facility cannot bill for the disputed days both stop applying once the noon deadline has passed.

There are two separate rights buried in (a), and which one applies depends on where the person is:

Setting	The right that applies
Residential provider (SNF, hospice) or the SNF stay itself	Beneficiary disagrees with the decision to discharge — (a)(2)
Non-residential provider, same beneficiary still receiving service	Beneficiary disagrees that services should be terminated, and a physician certifies stopping care puts health at significant risk — (a)(1)

For a skilled nursing stay, it is almost always the discharge branch: no physician certification is required to trigger the review, just disagreement with the decision and a timely call.

What actually happens in the 72 hours

Call, and several things start moving the same day, laid out in 405.1202(e):

The QIO notifies the facility immediately that a fast appeal has been requested.
The facility must send a Detailed Explanation of Non-Coverage (more on this below) to the beneficiary by close of business that day.
The facility must also hand the QIO everything it needs — medical records, the coverage rule it is relying on — by close of business that same day.
The QIO reviews the record, solicits the beneficiary's own account, and gives the facility a chance to explain itself.
No later than 72 hours after the request, the QIO notifies the beneficiary, the beneficiary's physician, and the facility of its decision.

Two structural points matter more than the mechanics, and the second one is routinely described wrongly.

Under (d), the burden of proof sits with the facility, not the family. The facility has to demonstrate that termination is the correct decision, on medical necessity or on another Medicare coverage policy. Nobody has to prove the parent still needs care.

The second point is that requesting the appeal does not extend Medicare coverage. Paragraph (c) says coverage "continues until the date and time designated on the termination notice, unless the QIO reverses the provider's service termination decision" — so the printed date still governs unless and until the reviewer overturns it. What the request buys immediately is different and easy to confuse with coverage: under (g), the provider may not bill for the disputed services until the expedited determination, and any reconsideration, is finished. Being unbillable is not the same as being covered, and a facility that says "coverage ended Friday" is not contradicting the appeal.

Two situations do push the date itself. If the QIO finds the beneficiary never received valid notice, coverage continues until at least 2 days after valid notice is actually received. And continuation is not required at all where the QIO determines that continued coverage "could pose a threat to the beneficiary's health or safety."

If the facility drags its feet handing over records and that delays the QIO's decision, (e)(7) lets the QIO hold the facility financially liable for the resulting extra days of coverage — a detail worth mentioning out loud on the phone if a facility seems in no hurry to respond.

The DENC only shows up after you call — not before

Families sometimes wait for a second letter explaining the reasoning behind a discharge. It is not coming unprompted.

The Detailed Explanation of Non-Coverage, CMS-10124, exists specifically for beneficiaries who requested a fast appeal. Under 405.1202(f)(1), once the QIO notifies the facility of the request, the facility must send the DENC to the beneficiary by close of business that day. It has to include:

a specific, detailed explanation of why the service is no longer reasonable and necessary, or no longer covered;
the applicable Medicare coverage rule or policy, with a citation or instructions for getting a copy of it; and
facts specific to this person's case that connect the general rule to the actual decision.

So the sequence runs backwards from what feels intuitive: the vague NOMNC comes first, the reasoned explanation comes only after the beneficiary has already committed to disputing it. That is a reason to call before noon even when undecided — the DENC is often the first document in the whole packet that says anything concrete, and it only exists once the appeal is already in motion.

Who picks up the phone: two organizations, recently renamed

The QIO is a Beneficiary and Family Centered Care Quality Improvement Organization, or BFCC-QIO, and as of this writing there are exactly two covering the entire country. According to CMS's own program page, last modified 4 August 2026 and read on 19 August, they are Acentra Health (formerly Kepro) and Commence Health (formerly Livanta) — the second name change happened in the past year, so an older printout or an admissions packet still referencing "Livanta" or "Kepro" is describing the same organization under a new name, not a defunct one.

Coverage is split by state, and the assignment does move as contracts change, so rather than print a number here that could be wrong by the time this page is read, use the two organizations' own lookup tools:

Acentra Health — find your state's BFCC-QIO phone number. Its beneficiary helpline page groups its states into five regions with a separate toll-free number for each, and tells anyone whose state is not listed to contact Commence Health instead. Hours are 9:00 a.m. to 5:00 p.m. on weekdays and 10:00 a.m. to 4:00 p.m. on weekends and holidays, local time — which matters, because the noon deadline does not pause for a Saturday.
Commence Health — contact information by state

If neither loads or the state assignment is unclear, 1-800-MEDICARE (1-800-633-4227) can route the call. Confirm the number verbally with whoever answers before hanging up — this is exactly the kind of detail worth double-checking at the official CMS source rather than trusting a number copied from an old form.

If the QIO agrees with the facility

The review does not end there. Under 42 CFR 405.1204, a beneficiary dissatisfied with the QIO's determination can request an expedited reconsideration from a Qualified Independent Contractor, or QIC — again by noon of the calendar day after the QIO's decision is received, again with a 72-hour turnaround, and again with billing protection while it is pending under (f). A beneficiary can also ask the QIC for up to 14 extra days to gather more, under (c)(6), which suspends the 72-hour clock in exchange for a longer look.

Missing that second deadline does not end the story either — it drops the case into the standard Medicare claims appeal process (redetermination, then reconsideration, and on to an Administrative Law Judge), the same track used for an ordinary denied claim. That path can still succeed. It simply loses the two things that make the fast-track worth using in the first place: a decision inside days instead of months, and a guarantee that nobody gets billed while it runs.

There is one more provision worth knowing about because it is the only one that rewards the QIC missing its own deadline. Under (c)(5), if no decision arrives within 72 hours and no extension was requested, the QIC has to tell the beneficiary about the right to escalate the case straight to an Administrative Law Judge at OMHA, provided the amount still in dispute clears the threshold in 42 CFR 405.1006. Silence past 72 hours is not a dead end; it is a door.

This is a different document from the one that ends an assisted living stay

It is easy to conflate this notice with an eviction notice from a residency agreement, and the two get confused constantly because both use the word "discharge" and both feel like the floor dropping out.

They are not the same thing, and they do not come from the same rulebook. The NOMNC and the fast-appeal process described here exist because Medicare is deciding whether to keep paying for skilled nursing care under 42 CFR 405.1200–405.1204. A residency agreement's involuntary discharge clause is a contract and a state licensing rule deciding whether a person can keep living somewhere at all, on six narrower grounds for a certified nursing facility and on a state-by-state basis for assisted living. A person can lose a fast appeal and still have every right to remain in the building privately; a person can win a fast appeal and still be served a separate discharge notice under an entirely different clause. Read the paper in hand carefully enough to know which document it actually is before deciding which clock applies.

Who is allowed to make the call

The regulation says "the beneficiary, or his or her representative," in more than one place — 405.1202(b)(1) lets the request come from either, and (b)(2) requires the representative to be available to answer the QIO's questions. What makes someone a representative for this purpose is not defined inside this rule; it is set by whichever authority document names that person, and not every document that says "power of attorney" reaches medical decisions like this one. Have that document, or at minimum know exactly which one applies, before dialing — a QIO intake line moving on a same-day clock is not the moment to sort out which sibling has authority to speak for a parent.

What to do in the hour after the notice arrives

Order matters here more than most checklists admit, because everything downstream depends on getting the first two items right immediately:

Write the exact date and time of delivery on the notice itself, and work out noon of the next calendar day in the same pen stroke.
Confirm which state's BFCC-QIO covers the facility from the lookup links above, not from a number already on hand.
A request can be withdrawn; a missed noon cannot be recovered. That asymmetry is the whole argument for calling before the deadline while still undecided.
405.1202(b)(2) requires someone to be reachable for the QIO's questions, so it is worth asking on that same call who that person is and how they can be reached.
The DENC, when it arrives, gets read against the chart rather than against the summary. It has to cite a specific coverage rule, and a citation is a thing that can be looked up.

If the discharge is also raising a question about what happens next — home care, a waiver program, another kind of coverage — that is usually a separate, slower-moving question with its own paperwork, including how a Medicaid HCBS waiver waiting list actually works if that is where the family is headed. It does not have to be solved on the same phone call as the fast appeal.

Sources

Every citation below was retrieved on 19 August 2026 and rechecked on 20 August 2026.

42 CFR 405.1200 (notice timing and content), 405.1202 (expedited determination procedures, the noon deadline, the 72-hour QIO turnaround, burden of proof, billing protection), and 405.1204 (expedited reconsideration by a QIC) — retrieved through the eCFR versioner API against the title 42 issue date of 13 August 2026.
CMS, FFS & MA NOMNC/DENC — current CMS-10123 and CMS-10124 forms, both effective January 2025; page last modified 13 May 2025. The two-days-is-not-48-hours note and OMB number 0938-0953 are from the NOMNC instructions posted there.
CMS, Beneficiary and Family Centered Care (BFCC)-QIOs — names and roles of the two current BFCC-QIOs, Acentra Health (formerly Kepro) and Commence Health (formerly Livanta); page last modified 4 August 2026.
State BFCC-QIO contact lookups: Acentra Health and Commence Health.

This page is general information, not legal, medical, or financial advice. See the terms.