Resource Aid Center

7 min read · Last updated August 12, 2026

In this article

• The first 24 hours after a disputed discharge
• Concurrent review is not prior authorization
• The noon deadline almost no one knows about
• What a missed window actually costs
• The next 30 days
• Frequently asked questions

David’s father was discharged from the hospital to a skilled nursing facility (SNF) on a Tuesday afternoon. He was already in the bed by dinnertime. Three days later, the family got a letter: the insurer had never signed off on the stay, and the bill for those first five days came to $1,650.

This happens because a hospital discharge and an insurance approval are two separate clocks, and nobody tells families that the first one can start running before the second one finishes.

The first 24 hours after a disputed discharge

Call the insurer’s utilization review line within the first day and ask for the claim or authorization number tied to the SNF stay. Write down the date and time you called and the name of whoever you spoke to. If the hospital or SNF gives you a written discharge or termination notice, keep the envelope, not just the letter. The postmark is the evidence for every deadline that follows.

If your family member is on Medicare Part A, ask the discharge planner directly whether this is a Quality Improvement Organization (QIO) fast-track situation. A QIO is an independent medical reviewer that Medicare pays to referee exactly this kind of dispute. It is not the insurance company, and it is not a judge. It is a neutral second opinion with a very short fuse.

If your family member is on an employer or marketplace health plan instead of Medicare, the relevant federal rule is the urgent-care claims procedure under the Employee Retirement Income Security Act (ERISA), the 1974 federal law that sets minimum standards for most employer-sponsored health plans. Ask the plan directly, in writing if possible, whether this stay is being treated as “concurrent care” or as a new claim. The answer changes which clock applies, covered next.

Concurrent review is not prior authorization

Prior authorization is the insurer’s sign-off before any care happens. Concurrent review is the insurer checking, while care is already underway, whether it is still medically necessary. Federal regulation 29 CFR 2560.503-1 draws this exact line: a “concurrent care decision” governs an already-approved course of treatment, while a decision made before care starts is a separate category entirely.

That distinction is not academic. It decides who is financially exposed. If the insurer had already approved the SNF stay and is now trying to cut it short, the plan must give you enough notice to appeal before the benefit actually stops. If the insurer never affirmatively approved the stay in the first place, as in David’s father’s case, some plans treat the entire admission as an unapproved claim instead of a protected reduction, which is exactly the gap that let the $1,650 bill happen.

The noon deadline almost no one knows about

Every article about insurance appeals repeats “72 hours” as if that is the reader’s deadline. It usually is not. Under 42 CFR 405.1202, the 72 hours is the QIO’s deadline to issue a decision after receiving your request, not your deadline to file one.

Your actual deadline, for a Medicare SNF discharge dispute, is noon of the calendar day after you receive the provider’s written notice of termination. If the notice arrives Tuesday afternoon, your window to request the fast-track review closes Wednesday at noon, not Wednesday at midnight and not Thursday.

File by that noon deadline and the facility legally cannot bill you for the disputed days while the QIO reviews the case. Miss it, and you fall into the slower standard reconsideration process, where that no-billing protection does not apply the same way.

For a non-Medicare employer or marketplace plan, there is no noon cutoff, but there is still a real deadline: ERISA’s urgent-care rule requires the plan to decide your appeal within 72 hours of receiving it, and a separate 24-hour clock applies if you are asking the plan to extend a course of treatment that is about to run out, provided you ask at least 24 hours before it ends.

What a missed window actually costs

Days uncovered	Semi-private room ($315/day)	Private room ($355/day)	Medicare Part A coinsurance, days 21-100 ($217/day)
1 day	$315	$355	$217
3 days	$945	$1,065	$651
5 days	$1,575	$1,775	$1,085
7 days	$2,205	$2,485	$1,519

David’s family faced the middle row. Five uncovered days at the semi-private median of $315 a day, reported in the CareScout Cost of Care Survey, works out to $1,575, close to the $1,650 they were actually billed once a few incidental charges were added. Medicare’s own Part A coinsurance schedule shows why even covered days are not free: $217 a day applies from day 21 through day 100. Neither figure includes therapy, medication, or any other add-on charge, just the bed itself.

The next 30 days

At day 7, request a peer-to-peer review if you have not already. This is an informal call, not itself a deadline-bound step, where the treating physician talks directly to the insurer’s reviewing physician. It sometimes resolves a denial faster than any formal appeal.

At day 14, if the QIO or plan has ruled against you, file the next-level appeal in writing and reference the specific regulation, either 42 CFR 405.1202 for Medicare or 29 CFR 2560.503-1 for an ERISA plan. Attach the discharge notice, the envelope, and your written log of every call.

At day 30, if the standard appeal path is the one you are on, most private plans owe you a decision by now under the standard (non-urgent) timeline. If it has not arrived, ask in writing for the specific regulatory citation the plan is relying on to extend the review, and keep every uncovered day’s bill rather than paying it outright while the appeal is open.

If your family is also managing a serious diagnosis on top of a disputed discharge, the first two weeks after a serious diagnosis walks through the parallel coverage decisions that often land in the same week. And if the hospital claim itself, not just the rehab stay, has already been denied once, the appeal deadlines after an insurer denies a hospital claim covers the standard (non-urgent) track in full.

Frequently asked questions

Is the 72-hour clock the same for Medicare and for an employer health plan? No. Medicare’s Quality Improvement Organization (QIO) has 72 hours to decide once it receives your request, but you must request it by noon the day after the discharge notice arrives. An employer plan under ERISA has its own 72-hour clock to decide an urgent appeal, measured from when the plan receives your appeal, with no noon cutoff.

What happens if I miss the noon deadline for a Medicare SNF appeal? You can still request a standard reconsideration, but the rule that bars the facility from billing you while the review is pending no longer applies the same way. You may become responsible for the disputed days while the slower process runs.

Does “concurrent review” mean the same thing as “prior authorization”? No. Prior authorization is sign-off before any care happens. Concurrent review checks an already-underway course of treatment. Federal regulation 29 CFR 2560.503-1 treats them as separate categories with separate notice rules, which affects who is financially exposed during a dispute.

What is a peer-to-peer review, and is it required before I can appeal? A peer-to-peer review is an informal call between your treating physician and the insurer’s reviewing physician. It is not a required legal step and has no fixed deadline, but requesting one early sometimes resolves a denial faster than waiting for a formal written appeal decision.

Can the rehab facility bill me while my appeal is still pending? For a timely-filed Medicare fast-track appeal, federal regulation bars the facility from billing you for the disputed days until the review is finished. For most employer or marketplace plans, this depends on the plan’s own terms, so ask in writing whether billing is paused during your specific appeal.