2015 Survey of Payers' ICD-10 Transition Strategies, Version 2. July 2015

Transcription

1 2015 Survey of Payers' ICD-10 Transition Strategies, Version 2 July 2015

2 Questions 1. Please select your organization. 2. When will the payer first accept ICD-10 codes on claims? 3. How should a provider submit inpatient claims that span the ICD-10 implementation date? 4. How should a provider submit outpatient claims that span the ICD-10 implementation date? 5. Will the payer support dual submission of ICD-9 and ICD-10 diagnosis and procedure codes after the compliance date? 6. Will the payer accept 837 batches with both ICD-9 and ICD-10 claims spanning the conversion deadline, as long as both codes are not contained on the same claim? 7. What ICD-10 compatible grouper will the payer use as of October 1, 2015? 8. What is the payer s approach to Claims Adjudication? 9. Will claims that do not comply with ANSI 5010 specifications be rejected at point of receipt or will a denial be issued? 10. How long will the payer support ICD-9 coding for corrected claims/appeals? 11. Will the payer be requiring coding that differs from, or expands, ANSI v5010? 12. Will the payer have a new appeal process in place to support disagreements connected to ICD-10 code selection and/or DRG classifications that were used for reimbursement? 2

3 Questions (cont d) 13. Will the payer's EOB/remittance remarks explicitly state reason for denials if related to no coverage? 14. What restrictions, if any, will the payer place on the acceptance of unspecified codes for ICD-10? 15. Will the payer require ICD-9 codes for authorization of services that occur before October 15, 2015 and ICD-10 codes for authorization of services that occur on or after October 15, 2015? 16. If the payer has set a date, by what date will the payer begin accepting prior authorizations with ICD-10 codes for services with dates of service on or after October 1, 2015? 17. If the payer has set a date, by what date will the payer begin accepting inpatient notifications with ICD-10 codes for dates of admission on or after October 1, 2015? 18. Will the payer require an ICD-10 diagnosis/procedure code when providers generate referrals on behalf of staff primary care physicians or obtain referrals from non-staff primary care physicians for specialty visits? 19. Is the payer using InterQual SmartSheet for prior authorizations? 20. If yes, will the payer incorporate ICD-10 diagnosis and procedure lists, map from ICD-9 to ICD-10, or accommodate ICD-10 in some other way? 3

4 Questions (cont d) 21. If the payer will be using SmartSheet, will it be available on-line to providers for administrative simplicity? 22. Does the payer expect payment, medical necessity and/or medical policies to change to support ICD-10? 23. Has the payer included, or will you include, ICD-10 diagnosis and procedure codes in any policies? 24. If not already available, by when will medical policies amended for ICD-10 be available? 25. If the payer reimburses for a condition described by only one ICD-9 code today that explodes into multiple new codes in ICD- 10, will the payer approve all ICD-10 diagnostic codes for payment? For example, Chrohn s Disease has one code in ICD-9 but 28 codes in ICD Will the payer be using CMS GEMs as part of its process? 27. Will the payer provide the mapping of ICD-9 to ICD-10 they will be utilizing? 28. Will the payer support acknowledgement testing with providers? (A Pass or Fail response will be returned for each 837 file submitted.) 4

5 Questions (cont d) 29. Will the payer support validation testing with providers? (A 999 and 277CA will be returned for each 837 file submitted.) 30. Will the payer support end-toend testing with providers? (An 835, 999 and 277CA will be returned for each 837 file submitted.) 31. If the payer responded to any one or number of the test approaches, is there a limit on the number of transactions that can be submitted? 32. If the payer responded to any one or number of the test approaches, will the payer accept fictitious or anonymized claims data? 33. If the payer responded to any one or number of the test approaches, in what format should test claims be submitted? 34. Has the payer tested, or will the payer be testing with clearinghouses (e.g., SSI, RelayHealth)? 35. How often will the payer provide ICD-10 status updates? 36. Can the payer's provider updates be found online? 37. Does the payer's companion guides reflect ICD-10 updates? 5

6 Completed s Awaiting Q1: Please select your organization. Boston Medical Center HealthNet Plan MassHealth Health Aetna Anthem Cigna ConnectiCare Health Plan Neighborhood Health Plan United Healthcare 6

7 Payer October 1, 2015 Boston Medical Center HealthNet Plan October 1, 2015 Q2: When will the Health Plan first accept ICD-10 codes on claims? October 1, 2015 October 1, 2015 MassHealth October 1, 2015 October 1, 2015 Health October 1, 2015 October 1, 2015 October 1,

8 Q3: How should a provider submit inpatient claims that span the ICD- 10 implementation date? Payer Boston Medical Center HealthNet Plan MassHealth Tufts Health Plan / Network Health Health Claims for services provided prior to October 1, 2015 must be billed separately from services provided on or after October 1, Claims that span October 1, 2015 must be submitted with ICD-10 coding for the full admission period. Inpatient bills must be billed as one claim. Inpatient claims with date of discharge before October 1, 2015 must be billed with ICD-9 codes. Inpatient claims with date of discharge on or after October 1, 2015 must be billed with ICD-10 codes. Claims for services provided prior to October 1, 2015 must be billed separately from services provided on or after October 1, In patient claims that span the implementation date must include ICD-10 codes. Interim billing for services prior to 10/1/15 must be billed separately from services provided after 10/1/15. ICD codes on inpatient claims should be submitted based on discharge date. ICD-9 codes for claims with discharge date 09/30/2015 and prior. ICD-10 codes for discharge date 10/01/2015 and after. Claims for services provided prior to October 1, 2015 must be billed separately from services provided on or after October 1, Claims for services provided prior to October 1, 2015 must be billed separately from services provided on or after October 1, Claims for services provided prior to October 1, 2015 must be billed separately from services provided on or after October 1,

9 Payer Q4: How should a provider submit outpatient claims that span the ICD- 10 implementation date? Boston Medical Center HealthNet Plan Harvard Pilgrim Health Care MassHealth Tufts Health Plan / Network Health Claims for services provided prior to October 1, 2015 must be billed separately from services provided on or after October 1,

10 Payer If, please elaborate Q5: Will the payer support dual submission of ICD- 9 and ICD-10 diagnosis and procedure codes after the compliance date? Boston Medical Center HealthNet Plan Only I-9 codes with Dates of Service prior to 10/1/15 and I-10 codes after 10/1/15. MassHealth Claims with dates of service before 10/1 can continue to be billed using ICD-9 codes (e.g. resubmittals, adjustments, etc..) after the cut-over date. However, claims for services on or after 10/1/15 must include ICD-10 codes. Tufts Health Plan / Network Health ICD codes should be applied based on the date of service/date of discharge. Tufts Health Plan will accept both code sets based on that criteria. Health Health is not planning to decommission ICD-9 capabilities on 10/1/

11 Q6: Will the payer accept 837 batches with both ICD-9 and ICD-10 claims spanning the conversion deadline, as long as both codes are not contained on the same claim? Payer Boston Medical Center HealthNet Plan MassHealth 11

12 Payer APR-DRG Grouper v26.1 Q7: What ICD-10 compatible grouper will the payer use as of October 1, 2015? Boston Medical Center HealthNet Plan MassHealth APR-DRG Grouper v30 The Grouper is based on provider contract. Both APR-DRG v30 (or above) and MS-DRG v30 (or above) EAPG for out-patient claims Commercial: APR-DRG Grouper v30 NH and TMP: MS-DRG Grouper v32 (Updated version once released in Fall) APR DRG v30 for use with providers contracted to pay using this methodology MS DRG Grouper v32 MS DRG Grouper v33 12

13 Q8: What is the payer s approach to Claims Adjudication? Payer Boston Medical Center HealthNet Plan MassHealth Native ICD-10 Adjudication Native ICD-10 Adjudication. Reverse mapping is being performed for APR DRG Grouper V30 but natively within the grouper software. Native ICD-10 Adjudication Native ICD-10 Adjudication Native ICD-10 Adjudication Native ICD-10 Adjudication Native ICD-10 Adjudication Native ICD-10 Adjudication Native ICD-10 Adjudication 13

14 Q9: Will claims that do not comply with ANSI 5010 specifications be rejected at point of receipt or will a denial be issued? Payer Boston Medical Center HealthNet Plan MassHealth Same as current process. Rejections and denials will be routed through the same process as it is today for ICD-9 codes. Rejected at point of receipt Rejected at point of receipt Rejected at point of receipt Rejected at point of receipt Rejected at point of receipt Respondent skipped this question This is handled at the clearinghouse level Denial issued 14

15 Q10: How long will payer support ICD- 9 coding for corrected claims/appeals? Payer Boston Medical Center HealthNet Plan MassHealth t anticipating any change in policies for corrected claims/appeals Greater than 90 days Greater than 90 days Greater than 90 days Greater than 90 days time frame. Based on claims date of service, filing limits and appeal guidelines. Time frame has yet to be defined. The length of time will be held according to the timely filing limits set for PAR and NONPAR providers Varies according to contract 15

16 Q11: Will the payer be requiring coding that differs from, or expands, ANSI v5010? Payer Boston Medical Center HealthNet Plan MassHealth 16

17 Q12: Will the payer have a new appeal process in place to support disagreements connected to ICD- 10 code selection and/or DRG classifications that were used for reimbursement? Payer Boston Medical Center HealthNet Plan MassHealth - This has not been discussed at this time. 17

18 Payer Q13: Will the payer's EOB/ remittance remarks explicitly state reason for denials if related to no coverage? Boston Medical Center HealthNet Plan MassHealth

19 Payer Will follow current CMS guidelines Q14: What restrictions, if any, will the payer place on the acceptance of unspecified codes for ICD-10? Boston Medical Center HealthNet Plan MassHealth - Will follow current CMS guidelines HPHC will handle unspecified codes for ICD-10 as we do today for ICD-9 unless otherwise specified in published policies. Will follow current CMS guidelines Will follow Tufts Health Plan Medical Necessity Guidelines Will follow current CMS guidelines Will follow current CMS guidelines Will follow current CMS guidelines 19

20 Q15: Will the payer require ICD-9 codes for authorization of services that occur before October 1, 2015 and ICD-10 codes for authorization of services that occur on or after October 15, 2015? Payer Boston Medical Center HealthNet Plan MassHealth - - Health requires ICD-10 codes for authorizations with date of service on or after 10/1/2015. t 10/15/ Fallon will require ICD-9 codes for authorization of services that occur before 10/1/15 and ICD-10 codes for authorization of services that occur on or after 10/1/15. 20

21 Q16: If the payer has set a date, by what date will the payer begin accepting prior authorizations with ICD-10 codes for services with dates of service on or after October 1, 2015? Payer 10/1/2015 Boston Medical Center HealthNet Plan 8/17/2015 8/1/2015 _ MassHealth - 8/17/ /01/ /1/ /1/

22 Q17: If the payer has set a date, by what date will the payer begin accepting inpatient notifications with ICD-10 codes for services with dates of service on or after October 1, 2015? Payer 10/1/2015 Boston Medical Center HealthNet Plan 8/17/2015 8/1/2015 _ MassHealth - 8/17/ /01/ /01/ /01/

23 Payer Comment Q18: Will the payer require an ICD-10 diagnosis/procedure code when providers generate referrals on behalf of staff primary care physicians or obtain referrals from non-staff primary care physicians for specialty visits? BCBSMA does not use ICD-9 codes in the processing of referral transactions. It will remain the same with ICD-10. Boston Medical Center HealthNet Plan Harvard Pilgrim Health Care HNE does not require referrals for in-plan specialty visits, however I-10 required for DOS on or after 10/1/15 MassHealth - Tufts Health Plan / Network Health - Referral guidelines will not be changing. does not use diagnosis codes in the referral process 23

24 Q19: Is the payer using InterQual SmartSheet for prior authorizations? Payer Boston Medical Center HealthNet Plan MassHealth Do not know 24

25 Q20: If yes, will the payer incorporate ICD-10 diagnosis and procedure lists, map from ICD-9 to ICD-10, or accommodate ICD- 10 in some other way? Payer Boston Medical Center HealthNet Plan BCBS will incorporate ICD-10 and map from ICD-9 to ICD-10 NA NA NA Incorporate ICD-10 NA NA Our system is configured to be ICD-10 ready. We will use ICD-10 diagnosis codes in the system. If providers do not submit with ICD- 10 codes, we return requests back to be completed with the appropriate codes. 25

26 Q21: If the payer will be using SmartSheet, will it be available online to providers for administrative simplicity? Payer Boston Medical Center HealthNet Plan MassHealth NA NA NA NA NA NA 26

27 Payer If, please elaborate Q22: Does the payer expect payment, medical necessity and/or medical policies to change to support ICD-10? Boston Medical Center HealthNet Plan Harvard Pilgrim Health Care Policies have been updated to reflect appropriate ICD-10 coding. will modify it's policies to reference the related ICD-10 codes applicable where an ICD-9 code is referenced. Do not know HNE is actively updating their policies as needed. Tufts Health Plan / Network Health ICD-10 codes have been added to our medical necessity guidelines/policies. has conducted a thorough evaluation of our medical and payment policies. Where applicable, policies were updated; policies currently list both ICD-9 and ICD-10 codes. The ICD-9 codes will be removed from policies after the transition to ICD-10 is complete 27

28 Payer Comment Q23: Has the payer included, or will you include, ICD-10 diagnosis and procedure codes in any policies? Boston Medical Center HealthNet Plan Harvard Pilgrim Health Care MassHealth - Tufts Health Plan / Network Health Do not know will modify it's policies to reference the related ICD-10 codes applicable where an ICD-9 code is referenced. We have one policy that currently includes ICD-9 codes that will be updated with ICD-10 codes. Do not yet know Where applicable 28

29 Payer - Boston Medical Center HealthNet Plan - Q24: If not already available, by when will medical policies amended for ICD- 10 be available? 8/1/2015 9/1/2015 MassHealth /01/2015 Respondent skipped this question Respondent skipped this question 29

30 Q25: If the payer reimburses for a condition described by only one ICD-9 code today that explodes into multiple new codes in ICD-10, will the payer approve all ICD-10 diagnostic codes for payment? Payer Boston Medical Center HealthNet Plan MassHealth - BCBSMA will reimburse claims as appropriate, based on how they were coded To the extent that all ICD10 for a given policy have been deemed reimbursable and covered, yes, they will be approved for payment. There may however be instances where, for example, 1 of the 28 is specific enough to draw the conclusion that the service is either not covered, non-reimbursable, etc. HPHC will update our policies posted on our external website to reflect ICD-10 codes where applicable., all applicable codes will be approved for payment., each claim must provide unique, specific and documented ICD-10 diagnosis code(s). As part of neutrality intentions, reimbursement will not be impacted. However, this can only be assessed on a case by cases basis depending on the designation of new codes. In the ICD 9 to ICD 10 mapping there are many cases where 1 ICD 9 codes maps to 'many' ICD 10 codes. All codes will be acceptable but, providers should apply the most appropriate ICD 10 code. Do not know 30

31 Q26: Will the payer be using CMS GEMs as part of its process? Payer Boston Medical Center HealthNet Plan MassHealth 31

32 Payer Comment Maps already available via MHDC website. Q27: Will the payer provide the mapping of ICD-9 to ICD-10 they will be utilizing? Boston Medical Center HealthNet Plan Harvard Pilgrim Health Care MassHealth Tufts Health Plan / Network Health NA NA HPHC published policies will delineate the mapping from ICD-9 to ICD-10. NA Available upon request 32

33 Q28: Will the payer support acknowledgement testing with providers? (A Pass or Fail response will be returned for each 837 file submitted.) Payer Boston Medical Center HealthNet Plan MassHealth 33

34 Payer Comment Q29: Will the payer support validation testing with providers? (A 999 and 277CA will be returned for each 837 file submitted.) 999 only. Boston Medical Center HealthNet Plan 999 only. MassHealth 999 only. This has been completed for some but will not be offered for all providers Providers will receive A999 and

35 Payer Comment Completed end-to-end testing in Q30: Will the payer support end-toend testing with providers? (An 835, 999 and 277CA will be returned for each 837 file submitted.) Boston Medical Center HealthNet Plan Providers will get a provided on a limited basis, based on time and resource availability. To be determined HPHC plans on supporting 835 but not yet able to do so. Only for selected hospitals and provider groups. MassHealth 835 and 999 will be issued, but MassHealth does not support the 277CA. Completed end-to-end testing in This has been completed for some but will not be offered for all providers. Providers will receive A999 and

36 Payer Comment Q31: If the payer responded to any one or number of the test approaches, is there a limit on the number of transactions that can be submitted? TBD Boston Medical Center HealthNet Plan Maximum of 25 claims or less in a batch file. Initial test cycles limited to fewer than 50 claims. Subsequent tests may allow for increased volume. MassHealth 25 from providers; 50 from vendors. 36

37 Payer Comment Q32: If the payer responded to any one or number of the test approaches, will the payer accept fictitious or anonymized claims data? Acknowledgement testing does not perform subscriber or member matching. Boston Medical Center HealthNet Plan The Plan s test environment is a subset of production data and can accept current production active members/providers only. MassHealth The aforementioned format testing is data agnostic. SWH will accept fictitious claim date but, data must be valid member, provider, CPT codes and ICD 10 codes. 37

38 Payer Q33: If the payer responded to any one or number of the test approaches, in what format should test claims be submitted? ANSI 5010 Boston Medical Center HealthNet Plan ANSI 5010 ANSI 5010 ANSI 5010 MassHealth ANSI 5010 ANSI 5010 ANSI 5010 Health offers format testing using a tool called Ramp Manager. We will also work directly with providers to submit spreadsheets if they do not go through their clearinghouse. 38

39 Q34: Has the payer tested, or will the payer be testing with clearinghouses (e.g., SSI, RelayHealth)? Payer Boston Medical Center HealthNet Plan MassHealth works directly with Emdeon. Emdeon has created a portal for payers and providers to utilize in testing ICD 10. With that being said, Emdeon has taken the 'hands off' approach for most testing. SWH will work directly with the providers in the Beta Testing process to complete the end to end tests 39

40 Q35: How often will the payer provide ICD-10 status updates? Payer Boston Medical Center HealthNet Plan MassHealth As-needed As-needed As-needed Planning to complete a test cycle approximately every two weeks. Monthly As-needed Quarterly As-Needed As-Needed 40

41 Q36: Can the payer's provider updates be found online? Payer Boston Medical Center HealthNet Plan MassHealth ( nnouncements/icd-10.aspx ) 41

42 Q37: Does the payer's companion guide reflect ICD-10 updates? Payer Boston Medical Center HealthNet Plan MassHealth t yet Currently being updated to be published by June 15, 2015., the HIPAA modifications for ICD-10 are "required" data elements. Therefore, CG modifications are not required. updates are needed as the 5010 is already ICD-10 compliant. t Yet will complete the Companion guide prior to 10/1/15 42