As part of WVMI's contract with the Centers for Medicare & Medicaid Services (CMS), the Review Department has the responsibility of ensuring that Medicare beneficiaries receive services that meet medically accepted standards of care, are medically necessary, and are delivered in the most appropriate setting. Our task involves reviewing medical records. Non-physician reviewers as well as physician reviewers perform these reviews. WVMI maintains a complete roster of board-certified physician specialists who provide clinical input relating to the care a patient received.

The following links provide more detailed information about specific types of review and associated processes performed by the WVMI Review Department.

• Appeals for Beneficiary Protection, including the following:
  • HINN (Hospital Initiated Notice of Noncoverage)
  • IM (Important Message Hospital Discharge Appeal)
  • BIPA (Benefits Improvement and Protection Act Appeal)
  • MA (Medicare Advantage Appeals)
• Beneficiary Complaints
• Emergency Medical Treatment and Labor Act (EMTALA)
• Higher Weighted DRG Review (HWDRG)
• Hospital Payment Monitoring Program (HPMP)

Changes to appeals

Some changes in Beneficiary Notifications and Appeal Rights go into effect July 1, 2007. The following information and resources are available:

• Hospital Discharge Appeal Notices section of the CMS Web site
• Notification of Hospital Discharge Appeal Rights: Provider and QIO Responsibilities, WebEx recorded June 14, 2007
• Hospital Discharge Appeal Rights, PowerPoint presentation
• Form for providers to submit their Contact Information for Medicare Appeals to WVMI - Complete and fax to Libby Akers at 304-342-5527

Watch this site for more information.

If you have questions about a topic not listed, contact Cathy Bowles toll-free at 1-800-642-8686 ext. 4256 or at 304-346-9864 ext. 4256 or at cbowles@wvmi.org. Or contact Administrative Assistant Libby Akers at ext. 4232 or via eakers@wvmi.org.