Medicare Claim Review Services
Important Notice
The National Claim Review contract concluded on August 11, 2025. Following this date, claim reviews will transition as outlined below:
- Short Stay Reviews (SSR) will be conducted by the Medicare Administrative Contractors (MACs) beginning September 1, 2025.
- Higher Weighted Diagnosis-Related Group (HWDRG) reviews will be conducted by the Beneficiary and Family Centered Care–Quality Improvement Organizations (BFCC-QIOs), according to CMS Regional assignments.
For additional details, please visit the SSR and HWDRG web pages.
Short Stay Review (SSR) Transition
On May 22, 2025, the Centers for Medicare & Medicaid Services (CMS) announced that Medicare Administrative Contractors (MACs) will assume responsibility for short stay inpatient hospital medical reviews and provider education, also known as patient status reviews, beginning September 1, 2025.
To learn more, including details and answers to frequently asked questions, please visit the official CMS notice and FAQs:
CMS Patient Status Reviews
HWDRG Reviews Continuing Under BFCC-QIOs
The BFCC-QIOs will continue to perform HWDRG reviews according to CMS Regional assignments. This ensures that claim review services remain aligned with the case review services.
Commence Health will perform HWDRG reviews for CMS Regions 2, 3, 5, 7, and 9.
| CMS Region | States |
|---|---|
| Region 2 | New Jersey, New York, Puerto Rico, U.S. Virgin Islands |
| Region 3 | Delaware, Maryland, Pennsylvania, West Virginia, Washington, D.C. |
| Region 5 | Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin |
| Region 7 | Iowa, Kansas, Missouri, Nebraska |
| Region 9 | Arizona, California, Hawaii, Nevada, American Samoa, Guam, Northern Mariana Islands |
Acentra will perform HWDRG reviews for CMS Regions 1, 4, 6, 8, and 10.
| CMS Region | States |
|---|---|
| Region 1 | Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont |
| Region 4 | Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee |
| Region 6 | Arkansas, Louisiana, New Mexico, Oklahoma, Texas |
| Region 8 | Colorado, Montana, North Dakota, South Dakota, Wyoming, Utah |
| Region 10 | Alaska, Idaho, Oregon, Washington |
Updates
October 07, 2024
Mailing address update: As of October 7, 2024, our mailing address has changed to
BFCC-QIO Program
Commence Health
PO Box 2687
Virginia Beach, VA 23450
Please note that all postal mail and package deliveries from USPS and private package
carriers should be directed here.
November 01, 2021
Commence Health samples claims for review on a monthly basis for both HWDRG and SSR. For sampled claims, Commence Health requests the corresponding medical records and completes the reviews. The weeks that Commence Health plans to request medical records for sampled claims through 2022 are posted under the respective Review Type (HWDRG and SSR).
October 14, 2021
HWDRG requests for medical records will be sent to hospitals the week of 10/18/21 via fax where possible. If fax information for the medical record point of contact is not available, the medical record requests will be mailed via USPS to the medical record point of contact submitted on the MOA. If a hospital MOA has not been submitted with appropriate points of contact, then Commence Health uses the medical record point of content entered in the CMS Program Resource System (PRS) for sending the medical records requests.
September 30, 2021
SSR requests for medical records will be sent to hospitals the week of 10/04/21 via fax where possible. If fax information for the medical record point of contact is not available, the medical record requests will be mailed via USPS to the medical record point of contact submitted on the MOA. If a hospital MOA has not been submitted with appropriate points of contact, then Commence Health uses the medical record point of content entered in the CMS Program Resource System (PRS) for sending the medical records requests.
September 17, 2021
HWDRG requests for medical records will be sent to hospitals the week of 09/20/21 via fax where possible. If fax information for the medical record point of contact is not available, the medical record requests will be mailed via USPS to the medical record point of contact submitted on the MOA. If a hospital MOA has not been submitted with appropriate points of contact, then Commence Health uses the medical record point of content entered in the CMS Program Resource System (PRS) for sending the medical records requests.
Privacy Policy · Site Map
· Accessibility
Copyright © 2023 · All Rights Reserved
