If you want to communicate BFCC-QIO information, please email Acentra Health at QIOCommunications@acentra.com and request a newsletter insert or fact sheet for your organization. Please do not copy and paste information from Case Review Connections.

in this issue:

• Medical Director's Corner
• Appeals Update
• Short Stay Reviews
• Acentra Health Resources - PSAs and Medicare Rights Video
• Rural Health Updates
• National Caregivers Awareness Month

medical director's corner - jessica whitley, md, mba

Acentra Health's Newest Review Type

Higher-Weighted Diagnosis-Related Group (HWDRG) reviews conducted by the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) validate claims adjusted by hospitals to a HWDRG for increased payment. As of September 19, 2025, the BFCC-QIOs are performing HWDRG reviews according to the Centers for Medicare & Medicaid Services (CMS) regional assignments instead of one national contractor. This ensures that claim review services align with the case review services.

• Acentra Health is performing HWDRG reviews for CMS Regions 1, 4, 6, 8, and 10.
• Commence Health (Livanta) is responsible for CMS Regions 2, 3, 5, 7, and 9.

How will this affect your facility?

• Your facility will be receiving requests for medical records related to HWDRG reviews during the first week of December.
• In preparation, please make sure that your contact information is updated, so the appropriate individuals receive the requests. We will send medical record request faxes to the contact information listed for the Medical Records department for each facility. Please note that this contact will be used for all QIO medical record requests, except for appeals.
• Medical records must be submitted electronically on Acentra Health’s website. Submission information will be available soon.
• Before making any corrections affecting DRG assignment or medical necessity, the hospital will be provided with an opportunity for discussion. If the hospital does not respond to the opportunity for discussion, the initial findings will be made final. The Medicare Administrative Contractor (MAC) will be notified of the change for claim adjustment.
• Denials will be sent to the QIO Liaison contact.

Questions?

If you have any questions about this change, visit our website at www.acentraqio.com/providers/hwdrg or email ClaimReview@acentra.com.

appeals update

Regarding records submission: Please take extra care to upload records for one Medicare patient at a time. Each patient record should be accompanied by a unique case ID. We’ve seen an increase in submissions where multiple patients are included under a single case ID, which can cause delays.

Case ID numbers: The format of the appeals Case ID numbers will be changing soon to a 9-digit number. This change will affect both the Case Status tool and the medical record upload file.

Video: Please share our updated Medicare appeals video with patients and others you serve if they have questions about appeals or the appeals process.

short stay reviews

On May 22, 2025, CMS announced a significant policy update:

Effective September 1, 2025, MACs will take over responsibility for conducting medical reviews of Short Stay inpatient hospital claims. In addition to performing these reviews, MACs will also lead related provider education efforts to support accurate billing and compliance.

For more information, visit the CMS website.

acentra health resources - psas and medicare rights videos

We’ve developed two new resources to help you learn about our services.

• Public service announcements (PSAs): Available in English and Spanish, these 30-second spots highlight our Appeals and Immediate Advocacy services.
• YouTube video: A short 2-minute overview designed specifically for Medicare beneficiaries. Visit the Medicare Rights Video page on our website to access a toolkit for guidance on how to use the video most effectively.

We invite you to explore these new resources and share them with others who may benefit.

rural health updates

CMS announced new guidance for states seeking funding from the $50 billion Rural Health Transformation Program, established under the Working Families Tax Cuts Act. This historic investment is the largest in rural health care to date. It aims to modernize infrastructure, expand access, and improve quality and outcomes across rural America.

The United States Health and Human Services Secretary, Robert F. Kennedy, Jr., and CMS Administrator, Dr. Mehmet Oz, emphasized that the program will deliver long-term, sustainable improvements that ensure dignity, affordability, and dependable care for rural communities.

Program Goals:

• Healthier communities: Expand preventive care and address root causes of disease.
• Sustainable access: Help rural providers operate efficiently and remain viable care hubs.
• Workforce development: Recruit and retain skilled health professionals in rural areas.
• Innovative care models: Improve outcomes through coordinated and flexible care approaches.
• Technology innovation: Advance digital health, data security, and efficient care delivery.

Learn more and access the Notice of Funding Opportunity: CMS Rural Health Transformation Program.

Watch CMS' message on the program’s impact: YouTube Video.

We value your feedback. Please let us know if there is any content that you would like to see covered in this newsletter by emailing QIOCommunications@acentra.com.

Publication No. R146810-214-11/2025. This material was prepared by Acentra Health, a Medicare Quality Improvement Organization under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.