CurrentUnitedHealthcarePolicy BIP163.N

Skilled Nursing Facility (SNF) Care

Defines UnitedHealthcare's benefit interpretation for Skilled Nursing Facility care, including how benefit periods are determined and where to find covered benefits and limits; applicable to members whose coverage is governed by this policy. Providers and plan administrators should reference members' Evidence of Coverage/Schedule of Benefits for specific day limits.

Policy Summary

PayerUnitedHealthcare

PolicySkilled Nursing Facility (SNF) Care

Policy CodePolicy BIP163.N

Change TypeAdded language clarifying benefit period start

Effective DateFeb 1, 2026

Next Review Date

Key ActionReference the member's Evidence of Coverage/Schedule of Benefits for prior authorization requirements and specific SNF day limits.

SourceLink

POLICY UPDATE CHANGES

Added language to clarify a benefit period begins on the date the member is admitted to a hospital or skilled nursing facility at a skilled level of care; a prior three-day stay in an acute care hospital is not required to begin a benefit period.

Clarifiedwhen a benefit period begins

60Benefit period inactivity (days)

See SOB/EOCSNF day limits

NoneFederal/state regs

Coverage Criteria

Policy Summary

PayerUnitedHealthcare

PolicySkilled Nursing Facility (SNF) Care

Policy CodePolicy BIP163.N

Change TypeAdded language clarifying benefit period start

Effective DateFeb 1, 2026

Next Review Date

Key ActionReference the member's Evidence of Coverage/Schedule of Benefits for prior authorization requirements and specific SNF day limits.

SourceLink

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Covered when

Covered when ALL of the following are met:

General coverage rules: Covered benefits are listed in Federal/State Mandated Regulations, State Market Plan Enhancements, and Covered Benefits sections; services must be medically necessary and are subject to the member's Evidence of Coverage/Schedule of Benefits limits.

See Home Health, Skilled, and Custodial Care Services medical policy for additional detail

Benefit period start/stop: A benefit period begins on the date the member is admitted to a hospital or skilled nursing facility at a skilled level of care and ends when the member has not been an inpatient receiving skilled care for 60 consecutive days.60 consecutive days

A prior three-day inpatient hospital stay is not required to begin a benefit period.

Refer to the Medical Policy titled Home Health, Skilled, and Custodial Care Services for details on items that are not covered and for additional guidance on covered benefits and limits. Covered benefits for Skilled Nursing Facility (SNF) care are listed across Federal/State Mandated Regulations, State Market Plan Enhancements, and the Covered Benefits sections; providers must also consult the member's Schedule of Benefits (SOB)/Evidence of Coverage (EOC) for the specific number of SNF days covered and any plan-specific provisions. If there is a discrepancy between this policy and the member's EOC/SOB, the member's EOC/SOB governs.

Services that are not medically necessary under the member's plan or as defined in the Medical Policy titled Home Health, Skilled, and Custodial Care Services are not covered. All services must meet the plan's medical necessity requirements and any coverage limitations, exclusions, or prior authorization rules found in the member's EOC/SOB.

Coding and Regulatory Notes

No codes listedmixed

No codes listed

Benefit period inactivity

Inactivity period that ends a benefit period60 consecutive days

Definition contextA benefit period ends when the member has not been an inpatient receiving skilled care in a hospital or SNF for 60 consecutive days.

New benefit period start requirementA new benefit period can begin only after any existing benefit period ends.

Provider Actions and Requirements

Prior Authorization

Prior Authorization and Benefit Limits

Prior authorization and benefit limits: Prior authorization is required when specified by the member's Evidence of Coverage (EOC) / Schedule of Benefits (SOB) or plan-specific provisions. Providers must verify the member's EOC/SOB for any SNF day limits, benefit maximums, and whether Home Health, Skilled, or Custodial Care Services require prior authorization per the referenced Medical Policy. Services that exceed the EOC/SOB limits or are not preauthorized per plan requirements may be denied.

Verify prior authorization requirements in the member's EOC/SOB before scheduling services.
Confirm the number of covered SNF days in the member's Schedule of Benefits; benefits cannot exceed SOB limits.
Obtain and document prior authorization when required by the plan or Medical Policy.

Denial Risk

Denial Triggers

Denial triggers: Services may be denied if they are not medically necessary, exceed the member's EOC/SOB limits, lack required prior authorization, or if supporting documentation is incomplete or absent. Providers should proactively supply complete clinical documentation to avoid denials.

Service not medically necessary per plan or Medical Policy.
Requested services exceed the member's EOC/SOB limits (e.g., SNF day maximums).
No prior authorization on file when the plan requires it.
Insufficient clinical documentation to support medical necessity or level-of-care determinations.

Documentation Required

Required Documentation and References

Required documentation and references: Always include clear clinical rationale and documentation that supports medical necessity and the specific level of care. Reference the member's EOC/SOB for coverage specifics, limits, and exclusions. Follow documentation guidance in the Medical Policy for Home Health, Skilled, and Custodial Care Services.

Include history, assessment, plan of care, skilled nursing or therapy notes, and frequency/duration justification.
Attach prior authorization approval and any utilization review determinations when available.
Document why care cannot be safely provided in a lower level of care (if applicable).

Note

Provider Reminder

Provider-facing reminder: Always resolve any discrepancy between this policy and the member's EOC/SOB in favor of the EOC/SOB. Confirm medical necessity, authorization, and benefit limits before delivering or billing services to reduce the risk of retroactive denials or claims adjustments.

Check EOC/SOB for plan-specific provisions and limits.
Confirm authorization and document medical necessity prior to service.
Coordinate with utilization management when questions arise.

Background

A benefit period for SNF care begins on the date the member is admitted to a hospital or a skilled nursing facility at a skilled level of care. The benefit period ends when the member has not been an inpatient receiving skilled care in a hospital or skilled nursing facility for 60 consecutive days. A new benefit period can only begin after any existing benefit period ends. A prior three-day inpatient stay in an acute care hospital is not required to begin a benefit period.

Definitions

Benefit period

Benefit period startBegins on the date the member is admitted to a hospital or skilled nursing facility at a skilled level of care

Benefit period endEnds when the member has not been an inpatient receiving skilled care for 60 consecutive days

Prior hospitalization requirementA prior three-day inpatient hospital stay is not required to begin a benefit period

Reference for day limitsRefer to the member's Schedule of Benefits/Evidence of Coverage for the number of SNF days covered; benefits shall not exceed SOB limits

Admission Criteria for SNF Care

SNF — admission criteria

Admission to SNF is covered when ALL of the following are met:

Admission to benefit period: Member admitted to a hospital or skilled nursing facility at a skilled level of care; admission date starts benefit period.

Prior three-day inpatient hospital stay is not required.

Continued Stay Criteria

SNF — continued stay criteria

Continued SNF stay is covered when ALL of the following are met:

Continued stay: Continued skilled level of care is required and services must be medically necessary; day limits set by the member's Schedule of Benefits apply.

Days out of SNF for transfer to acute hospital are not counted toward SNF day limits when transferred back.

Discharge Criteria

Discharge from SNF benefit coverage occurs when the member has not been an inpatient receiving skilled care in a hospital or skilled nursing facility for 60 consecutive days; at that point the existing benefit period ends and a new benefit period may begin only after the prior period has ended.

Day Limits and Benefit Periods

SNF day limits

SNF day limitsVariable per member plan; refer to the member's Schedule of Benefits/Evidence of Coverage for specific number of days covered

Governing documentsDay limits and benefit period limits are set by the Schedule of Benefits and applicable State Market Plan Enhancements or Federal/State Mandated Regulations

Transfers to acute hospitalDays spent out of an SNF when transferred to an acute hospital are not counted toward SNF day limits when transferred back