How to Appeal a Medicare Coverage Termination in West Virginia

Your parent is in a skilled nursing facility doing rehab after a hip fracture. The therapy is working — she's walking with a walker for the first time since the fall. Then you get a Notice of Medicare Non-Coverage (NOMNC) saying Medicare will stop paying in two days.

This is one of the most stressful moments in elder care, and it happens constantly. The good news: you have the right to appeal, and the appeal process buys your parent additional covered days while the case is reviewed.

Understanding the NOMNC

The Notice of Medicare Non-Coverage is a standardized form that Medicare-certified providers — hospitals, skilled nursing facilities, home health agencies — must deliver before ending Medicare-covered services. The NOMNC states the specific date coverage will end and tells you how to appeal.

You'll typically receive a NOMNC in one of three situations:

• A hospital says the patient is ready for discharge
• A SNF says Medicare will no longer cover the rehab stay
• A home health agency says the patient no longer qualifies for skilled services

The notice must be delivered at least two days before the proposed end of coverage, giving you a narrow window to file an appeal.

Filing the Appeal with Commence Health

In West Virginia, Medicare appeals go through Commence Health, the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for the region. This is the organization that reviews your case — not the hospital, not Acentra Health.

Call Commence Health at (888) 396-4646 by noon of the day before the proposed coverage end date.

When you call:

1. State that you are appealing a NOMNC for a Medicare beneficiary
2. Provide the patient's name, Medicare number, and the facility name
3. Explain why you believe continued coverage is medically necessary — be specific about ongoing care needs, therapy progress, and functional limitations
4. Ask for confirmation that the appeal has been received and the coverage termination is stayed

Once the appeal is filed, the provider cannot terminate coverage while Commence Health reviews the medical records. If the QIO rules in the patient's favor, coverage continues. If the QIO rules against the patient, you can request a second-level reconsideration.

Commence Health vs Acentra Health: Know the Difference

This is where families consistently get confused, and calling the wrong organization wastes critical time.

Commence Health is the federal BFCC-QIO for West Virginia. They handle:

• Fast-track appeals of hospital discharge decisions
• Appeals of NOMNC coverage terminations in SNFs and home health
• Immediate Advocacy Discharge Assistance (IADA) for communication issues between families and clinical teams

Acentra Health is the state's Utilization Management Contractor for West Virginia Medicaid. They handle:

• Pre-Admission Screening (PAS-2000) assessments for nursing facility admission
• Medical necessity reviews for the Aged and Disabled Waiver
• Clinical eligibility determinations for Medicaid long-term care

If your fight is about Medicare coverage ending too soon, call Commence Health. If your question is about Medicaid waiver eligibility or nursing facility admission, contact Acentra Health.

Building Your Appeal Case

The strongest appeals document two things: clinical need and functional progress.

Clinical need — Is the patient still receiving skilled services? Wound care that requires a nurse? Medication adjustments? IV therapy? If the patient still needs interventions that only a licensed professional can provide, coverage should continue.

Functional progress — Is the patient improving with therapy? Document the trajectory. If your mother went from being unable to stand to walking 50 feet with a walker, and the therapy team says she needs four more weeks to safely navigate her home, that's a compelling case.

Ask the therapy team for their professional opinion on discharge readiness. If the therapists believe continued rehab is necessary but the facility is issuing a NOMNC anyway, get that opinion documented in the medical record — and mention it when you call Commence Health.

What Happens After the Appeal

Commence Health reviews the medical records and makes a decision, typically within one to two days for fast-track appeals. Three outcomes:

1. Coverage continues — Medicare keeps paying, and the patient stays
2. Coverage ends — You can request a reconsideration from a Qualified Independent Contractor (QIC), which is a second-level review
3. Partial extension — Coverage continues for a defined additional period

Even if the appeal is denied, you've gained additional covered days during the review period. Those days can make a significant difference in your parent's recovery.

The West Virginia Hospital Discharge Guide includes appeal letter templates, a timeline tracker for NOMNC deadlines, and scripts for calling Commence Health — designed so you can file a strong appeal even in the narrow window the process allows.

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