A Skilled Nursing Facility’s Certification & Recertification Guide

Certification and recertification can feel like routine checkpoints, but they hold the keys to keeping your skilled nursing facility (SNF) running smoothly — and getting paid on time. When done correctly, they protect your revenue and ensure you're meeting Medicare's standards without unnecessary headaches.

In this article, we’ll cover:

• Certification and recertification for a skilled nursing facility

• Key Medicare rules (20-day rule, 60-day break rule) and CMS compliance requirements

• CMS recertification requirements

• Best practices to streamline documentation and avoid reimbursement issues

Understanding certification and recertification for skilled nursing facilities

At its core, certification confirms that a patient genuinely needs skilled nursing care covered by Medicare. It’s the initial statement that verifies your facility is providing daily, medically necessary services that can’t be delivered in a less intensive setting.

Recertification, on the other hand, keeps that approval active. Medicare doesn’t assume ongoing need — it requires updates. The first recertification is required no later than the 14th day of the resident’s SNF stay, with subsequent recertifications required at intervals not exceeding 30 days after the previous recertification.

Role of physicians and SNF staff in the certification process

For certifications and recertifications to hold up under Medicare scrutiny, the right people need to sign off.

This includes:

• The attending physician

• A facility-based physician familiar with the patient;

• Or qualified non-physician practitioners like NPs, CNSs, or PAs

–– as long as they are working in collaboration with a physician, and their scope of practice and state law permits.

What are the most common mistakes SNFs make in certification and recertification?

Even the most experienced SNFs run into trouble here. Common pitfalls include:

• Late or missed recertifications: Deadlines matter, and even a single oversight can trigger a denial.
  
  

• Incomplete documentation: Missing details about medical necessity weaken your case for coverage.
  
  

• Wrong signatories: Only specific providers can legally certify or recertify. Make sure your team knows the rules.
  
  

• No explanation for delays: If you miss a deadline, Medicare expects a clear explanation with supporting evidence.

The fix is to tighten your internal systems. Set clear timelines, educate your staff on exactly who can sign, and have a plan for catching errors before they reach the claims stage. This proactive approach helps your facility avoid unnecessary denials and keeps your reimbursements on track.

Medicare certification for skilled nursing facilities

Getting Medicare certification for your skilled nursing facility isn’t just about ticking boxes — it’s about setting up your facility for long-term success. Without it, you’re locked out of a major revenue stream, and more importantly, you’re limited in the care you can provide to Medicare beneficiaries.

Let’s walk through how it works, what CMS expects, and where facilities often run into trouble.

Steps to obtain initial Medicare certification

The first step is understanding that Medicare certification begins well before you admit your first resident. It’s a multi-stage process that involves preparation, inspection, and approvals from both state and federal agencies.

Here’s the typical path:

• Step 1: Apply to your State Survey Agency.
  Start by submitting an application through your state’s health department. They’ll guide you on state-specific requirements and schedule your facility survey.
  
  

• Step 2: Undergo a survey and inspection.
  Your facility will be inspected to ensure it meets both health and safety standards. Surveyors look closely at everything from resident care to infection control protocols.
  
  

• Step 3: Correct any deficiencies.
  If the survey finds issues, you’ll need to submit a plan of correction and follow through. Certification can’t move forward until deficiencies are resolved.
  
  

• Step 4: Receive CMS approval.
  Once your state gives the green light, CMS will issue your Medicare provider agreement, officially certifying your facility to serve Medicare beneficiaries.

Each step builds on the last, so keeping your documentation and policies airtight from the start will make the process much smoother.

For a complete, step-by-step breakdown of both processes for Medicare and Medicaid, refer to this detailed guide on obtaining certifications.

CMS requirements for SNF certification

CMS requires that skilled nursing facilities provide services that are reasonable and necessary for the patient's condition, including:

• Nursing care under the supervision of a registered nurse

• Physical, occupational, or speech-language therapy as needed

• Medical social services to support patient well-being

• Necessary medications, supplies, and equipment for inpatient care

• Bed and board in connection with nursing care.

In addition, your facility needs to comply with the three-day prior hospitalization rule. This means patients must have had a medically necessary inpatient hospital stay of at least three consecutive days, not including the discharge day or any pre-admission time spent in the emergency room or outpatient observation, before they qualify for SNF care under Medicare.

Overview of 42 CFR Part 424 Subpart B regulations

If you want to understand the backbone of Medicare certification, 42 CFR Part 424 Subpart B is where it lives. This section of the federal regulations lays out the certification and recertification rules for SNFs in clear terms.

Key takeaways from the regulation include:

• The initial certification must be obtained at the time of admission or as soon thereafter as is reasonable and practicable.
  
  

• Certifications must confirm that daily skilled care is necessary and that the services can only be provided in a skilled nursing facility or swing-bed hospital.
  
  

• Certifications and recertifications must be signed and dated by an authorized provider.

Understanding this regulation is essential because it shapes every part of your certification process. Even small oversights, like missing a date or unclear wording, can create compliance risks.

Common challenges in meeting Medicare certification standards

Many facilities underestimate just how detailed Medicare certification requirements are. Common stumbling blocks include:

• Incomplete documentation of services: It’s not enough to provide care — you have to document every element clearly. If a patient receives physical therapy, for example, your records need to show that therapy was medically necessary and provided under a qualified plan of care.
  
  

• Overlooking the three-day hospital stay requirement: Medicare is strict here. Time spent in observation or the emergency room doesn’t count. Facilities that skip verifying this detail risk non-payment.
  
  

• Missing physician certifications: Remember, routine admission orders don’t meet Medicare’s definition of certification. You need a separate, signed statement confirming the patient needs daily skilled care.
  
  

• Assuming state approval equals Medicare approval: State licensure is not the same as Medicare certification. Both are required, and each has its own process.

When you build strong internal processes, train your staff thoroughly, and stay organized, you’ll not only meet Medicare standards but set your facility up for smoother operations and fewer reimbursement headaches down the road.

Medicare recertification for skilled nursing facilities

Getting through initial certification is a big milestone, but keeping that certification active is just as critical. Medicare recertification is what keeps the door open for ongoing coverage and timely reimbursements.

Let’s go step by step.

How Medicare recertification works for SNFs

Once a patient is admitted and certified for skilled nursing care, the clock starts ticking on recertification requirements. Medicare requires ongoing confirmation that the patient still meets the criteria for skilled care, and they’ve set a clear schedule for this:

• First recertification: Must happen by day 14 of the stay.
  
  

• Subsequent recertifications: At least every 30 days after the initial recertification.

These are Medicare’s way of making sure continued care remains medically necessary. The process involves a review of the patient’s condition, a clear statement that skilled services are still required, and a signed, dated recertification by the appropriate provider.

When done consistently and on time, recertifications protect your reimbursements and support smooth claims processing.

Role of Medicare certification and recertification for a skilled nursing facility

Here’s a helpful clarification: Medicare doesn’t require a specific form for certification or recertification. Instead, the requirement is about the content and signatures, not the format.

What matters is that your documentation includes:

• A statement confirming the need for daily skilled nursing or rehabilitation services.

• Confirmation that services can only be provided in a skilled nursing facility or swing-bed hospital.

• For recertifications: the reasons for ongoing SNF care, estimated length of stay, and any plans for home care.

• A signed and dated statement from the certifying physician or qualified practitioner.

Many facilities choose to use dedicated forms to stay organized, but Medicare will accept certifications embedded in regular patient care notes or other records — as long as all required elements are there. What’s most important is consistency and clarity across your documentation.

Guidelines for certifying continued skilled care needs

When recertifying, the physician or practitioner isn’t just signing off blindly. They’re confirming that:

• The patient’s condition still requires skilled nursing care or skilled rehabilitation.

• Services are still needed on a daily basis.

• Care can’t be safely provided outside of an SNF setting.

• If the patient developed a new condition while already in your facility, this is clearly noted.

It’s critical that these points are well documented. Medicare reviewers look for clear, objective support for continued care. That means up-to-date clinical notes, therapy progress reports, and evidence of medical necessity all need to be part of the patient’s record.

How missed or late recertifications impact reimbursement

Here’s where things can get painful. If a recertification is late — or worse, missing entirely — it can result in denied claims. Medicare expects these reviews to happen on schedule, and delays can throw your reimbursement cycle off track.

While Medicare does allow for delayed recertifications in certain situations (like an isolated oversight), they expect a full explanation. You’ll need to document:

• The reason for the delay

• Any medical or administrative evidence to support your explanation

• A completed, signed, and dated recertification statement

Still, it’s far better to stay ahead of the schedule and avoid having to explain delays after the fact.

How often does Medicare require recertification for skilled nursing care?

Medicare sets clear expectations here:

• Initial certification at admission

• First recertification by day 14

• Subsequent recertifications at intervals no longer than 30 days

If your facility is facing low census challenges, it’s important to address them proactively to maintain financial health and operational efficiency.

Your facility should have a written procedure outlining this timeline and specifying how you track and complete recertifications. Some SNFs also involve their utilization review committee in managing long-stay cases, which can help keep things on track beyond the initial 30-day periods.

Understanding cognitive assessments like the BIMS score can also support appropriate patient placement and care planning in skilled nursing facilities.

The key takeaway: Treat recertification as a built-in part of your patient care routine. It’s not an add-on task — it’s essential for compliance, care continuity, and cash flow.

Key Medicare rules and their impact on SNF certification

Medicare sets specific rules that directly affect how your skilled nursing facility manages certification and reimbursement. Two of the most important are the 20-day rule and the 60-day break rule.

Both determine how long Medicare covers SNF services, how much the patient pays, and how your team needs to manage certification timelines. Let’s go through them carefully.

Medicare 20-day rule

The 20-day rule is straightforward but essential. When a patient qualifies for SNF care under Medicare, the first 20 days are fully covered — as long as they continue to meet Medicare’s criteria for skilled care.

There’s no co-payment required from the patient during these first 20 days. However, the coverage doesn’t run on autopilot. Your team still needs to stay on top of certifications, recertifications, and daily documentation to confirm the patient continues to need skilled care throughout this period.

How patient eligibility is determined within the first 20 days

Eligibility isn’t assumed just because the first 20 days are covered. Medicare looks for confirmation that:

• The patient had a qualifying three-day hospital stay.

• Skilled services are being provided daily.

• The services are reasonable and necessary for the patient’s condition.

Your clinical documentation and physician certifications are what prove this. It’s important to track this closely from the very start, especially if there’s a chance the patient’s condition could improve quickly or change unexpectedly.

What happens after Day 20, including co-payments and private pay options

After the first 20 days of full coverage, Medicare requires the patient to pay a daily coinsurance for days 21 through 100 of the SNF stay.

For days 21 through 100, the patient becomes responsible for a daily co-pay (Medicare sets this amount annually). Many patients rely on secondary insurance or Medicaid to help with this cost, but it’s something your administrative team needs to confirm in advance.

If the patient’s skilled care needs continue beyond Day 100, Medicare coverage ends, and the patient must transition to private pay or another form of coverage, such as Medicaid. It’s crucial to prepare families early for this possibility, both to avoid confusion and to ensure continuity of care.

Medicare 60-day break rule

The 60-day break rule refers to the time between skilled care stays. If a patient is discharged from SNF care and does not receive inpatient hospital care or skilled nursing care for 60 consecutive days, their benefit period ends, and a new benefit period begins upon the next admission.

This means:

• After 60 days, the patient qualifies for a new 100-day benefit period.

• They must meet all initial eligibility requirements again, including the qualifying three-day hospital stay.

Your admissions and administrative teams need to track these timelines carefully, especially for patients who are frequently in and out of care settings.

Impact of hospital readmissions on certification timelines

Hospital readmissions within the 60-day window can interrupt — or restart — the clock. If a patient is readmitted to the hospital and then returns to your SNF before the 60 days are up, it’s considered part of the same benefit period. You won’t get a new 100 days of coverage.

This directly affects your certification schedule. You’ll continue with recertifications based on the original admission date, not start over. Keeping precise records of hospital discharge and readmission dates is essential to staying compliant and avoiding billing errors.

Strategies to manage patient transitions and avoid unnecessary coverage gaps

To protect your facility and help patients maintain coverage:

• Track discharge and readmission dates closely. Knowing exactly when a patient leaves and if they’ve hit the 60-day mark avoids confusion later.
  
  

• Coordinate with hospitals and case managers. Timely information-sharing ensures you know if a patient is readmitted before 60 days.
  
  

• Educate patients and families. They need to understand how readmissions affect their coverage and benefit periods.
  
  

• Audit your records regularly. Verifying timelines helps prevent errors that could lead to denied claims.

Best practices for managing certification and recertification

The way you handle certification and recertification behind the scenes makes a direct impact on your reimbursement and compliance. These strategies will help you stay organized and reduce the risk of errors.

Implementing a structured process for tracking physician certifications

Every SNF should have a clear internal system for tracking certifications. Even a basic tracker — digital or manual — helps prevent missed deadlines. Assigning responsibility to specific staff members ensures accountability.

Go a step further by:

• Setting internal deadlines earlier than Medicare’s

• Holding brief weekly reviews of upcoming certification needs

• Keeping a shared record that’s updated in real time

This keeps your entire team aligned and aware of critical dates.

Ensuring timely documentation to meet Medicare guidelines

Documentation delays usually happen when no one has clear ownership of the task. Build internal checkpoints with these steps:

• Assign staff to monitor certification timelines daily.

• Set calendar alerts well in advance of deadlines.

• Conduct quick file reviews before claims are submitted.

When documentation becomes part of daily routines, it rarely falls behind.

Using electronic health records (EHRs) to streamline certification tracking

An EHR system can help you manage certifications automatically. Look for functions that allow you to:

• Set automated reminders for due dates.

• Flag incomplete or missing documentation.

• Keep everything centralized for easy auditing.

Key insight: Take the time to customize your EHR alerts and workflows to fit Medicare’s recertification schedule. It’s a one-time setup that pays off every day.

Training SNF staff on recertification protocols to prevent administrative delays

Your staff plays a huge role in avoiding delays. When they understand the “why” behind the process, they’re more likely to stay proactive.

Effective training includes:

• Clear instructions on Medicare timelines

• Walkthroughs of correct documentation procedures

• Case studies of past errors and how to prevent them

Consider brief refreshers during staff meetings to keep this knowledge top of mind.

Building strong communication between clinical and billing teams

Gaps often happen when clinical updates don’t reach the billing team in time. Regular communication between these groups helps:

• Ensure all required information is captured before claims submission.

• Clarify any unclear documentation points.

• Keep everyone aware of timing requirements.

Even short weekly syncs can prevent avoidable mistakes.

Running periodic internal audits to catch issues early

Instead of waiting for external audits or denied claims, check your own work regularly. Internal audits help:

• Identify missing certifications before they delay payment.

• Spot patterns in errors and correct them early.

• Build a habit of compliance across your team.

Monthly audits are a good starting point, but increase frequency if your claim volume is high.

How can SNFs ensure compliance with recertifications?

Staying compliant with recertification rules really comes down to having control over your process — not scrambling to fix mistakes after they’ve happened. Facilities that stay ahead of deadlines, rather than reacting to them, avoid the stress (and cost) of late paperwork and denied claims.

The most reliable approach is to treat recertifications like any other critical clinical task. Build them into your daily and weekly workflows. Make sure everyone knows who is responsible for what — from tracking due dates to preparing physician documentation.

Use your EHR to set automatic reminders well in advance, and run internal reviews of your records regularly, not just when an audit is looming.

It also helps to think of recertifications as part of patient care rather than just a compliance requirement. When you connect these reviews to clinical updates and care planning meetings, they feel like a natural step rather than extra paperwork.

That shift in mindset keeps your team engaged and reduces the risk of tasks falling through the cracks.

Lastly, make room for backup plans. If the person tracking deadlines is out sick, or a physician is delayed, your process should be flexible enough to keep moving.

What roles do nurses and administrative staff play in the recertification process?

Nurses and administrative staff are the backbone of keeping recertifications on track. While physicians provide the final clinical sign-off, it’s the daily work of your team that makes sure everything is prepared and running smoothly behind the scenes.

Nurses are often the first to notice if a patient’s condition is changing, which is crucial for timely and accurate recertifications. Their notes, assessments, and care updates give physicians the context they need to justify ongoing skilled care. When nurses keep clear, up-to-date records, it makes the physician’s review far more straightforward.

Administrative staff, on the other hand, are your organizers and gatekeepers for compliance. They monitor timelines, make sure recertification paperwork is complete, and follow up when signatures or documentation are pending.

They’re also the ones who often catch issues before they become problems — like a missed deadline or an incomplete form — because they’re watching the process end to end.

Both roles are equally important.

How ExaCare assists with compliance and certification

Throughout this article, we’ve focused on the day-to-day realities of maintaining compliance through accurate certification and recertification for your skilled nursing facility — a crucial part of keeping your facility eligible for Medicare reimbursement.

But certification workflows are just one piece of the larger puzzle. Before you can even reach that stage, there’s the admissions process itself: handling hospital referrals, reviewing patient information, and making fast, well-informed decisions about who to admit.

That’s where ExaCare comes in. While your internal processes manage ongoing certification compliance, ExaCare helps you get admissions right from the very start. By using AI to process referral packets and surface the most important clinical and financial details, ExaCare equips your team to act quickly and confidently when a new patient opportunity comes in.

This reduces manual errors, speeds up decision-making, and gives you a clearer view of potential reimbursement considerations from the outset — setting the stage for smoother operations as the patient moves through your care.

Here’s how ExaCare supports your team:

• AI-powered referral screening: Reviews hospital packets in minutes, so you can make fast, accurate admission decisions.
  
  

• Centralized referral management: Pulls all your referrals into one easy-to-use platform — no more toggling between systems.
  
  

• Customizable analytics: Tracks response times, denial reasons, and referral sources to help improve performance and strengthen hospital relationships.
  
  

• Financial and reimbursement insights: Flags high-cost medications, estimates insurance coverage, and highlights potential reimbursement risks.
  
  

• Streamlined hospital collaboration: Keeps your communication with hospital case managers smooth and responsive, helping you secure more referrals.

Ready to see how ExaCare can help your facility respond faster and improve compliance? Schedule a demo and see the platform in action.

Schedule a demo.