Answers to Provider Questions about ICD- 10. Health Plan/Payer Specific Questions

Transcription

1 Answers to Provider Questions about ICD- 10 Health Plan/Payer Specific Questions Below are commonly asked questions with answers that are specific to each health plan. If and as appropriate, additional details may be on each health plan s web site. Other information resources may be there are well. Direct links to each health plan s ICD10 information are: Aetna Asuris NW Health CHPW Cigna FCH GHC HCA L&I Molina Premera Regence United df/general_icd10_faq.pdf Premera Blue Cross: Premera Blue Cross Blue Shield of Alaska: LifeWise Health Plan of Oregon: Note: The answers to these questions are likely to be refined over time as more specific information becomes available. Page 1

2 ICD- 10 Pre- Auth Questions Note: The terms ICD9, ICD10, ICD code(s) refers to codes and/or descriptions for diagnoses and/or procedures. Answers should reflect the broad definition of these terms. Questions & Answers Do you outsource any part of the pre-auth process? If yes - should providers contact that organization about their readiness or just work through you? If providers need to contact them who are they? Aetna Our ICD-10 Program encompasses planning for any vendors that we use. As a result, there isn t a need for providers to contact any vendors directly. Asuris Asuris does outsource the pre-auth process for some services such as AIM Specialty Health and CareCoreNational. Asuris is currently working with the vendors about their readiness and will provide updates. We will provide an update as this process is defined if the vendors need to be contacted directly. CHPW Cigna FCH GHC HCA L&I Molina Premera Regence United Yes, for some specific areas we have vendor assistance with pre-auth. Providers should contact CHPW. We outsource some pre- authorizations for example high- tech radiology and are testing with all of our vendors and trading partners. Though we do not anticipate a problem with authorizations, we encourage Health Care Professionals to test with any vendor they may utilize during their normal course of business FCH does not outsource any part of the pre auth process. No, we do not outsource any part of the pre-auth process. Yes, for some specific areas such as MRIs and Pet Scans Yes, the department does outsource some parts of some of the prior authorizations. Providers should contact the department, who will make the expectations know to the contractor. The UR process currently contracts with Qualis Health and we are working with them on planning and readiness. We do in a few areas but we will be working directly with those vendors to ensure readiness and develop testing strategies; providers should work through Molina. Yes, we use AIM Specialty Health for imaging services. Providers should contact their provider network representative with questions about readiness. Regence does outsource the pre-auth process for some services such as AIM Specialty Health and CareCoreNational. Regence is currently working with the vendors about their readiness and will provide updates. We will provide an update as this process is defined if the vendors need to be contacted directly. We have vendors that we use for certain services, for example some radiology services, but providers should work through us. Page 2

3 In all situations where your organization is responsible for overseeing, managing or otherwise conducting the pre-auth process. Pre-Auth Lists, Clinical Guidelines & Forms Questions & Answers 1. Will your pre-authorization policy AND/OR your guidelines for requesting pre-authorizations change with the implementation of ICD-10 If yes, how will they change and when will the revised policy/guidelines be published? Aetna We do not anticipate significant changes at this time. Asuris We do not anticipate at this time that our pre-authorization policy will change based upon implementation of ICD-10. CHPW Policies and guidelines are not anticipated to change since CHPW requires service codes rather than ICD procedure codes in its pre-authorization process Cigna No, currently ICD 9 codes are utilized to issue pre-authorization. This process will continue with ICD 10. FCH Since ICD-specific information does not need to be supplied to us for any pre-authorization, our preauthorization and medical necessity guidelines/lists/processes will not be affected by the ICD10 implementation. As such, updated materials, tools and forms will not be required. For all procedures requiring a pre-authorization, providers should continue to supply the type of information, e.g. general diagnosis description, that they do now. If ICD9 or ICD10 information is supplied by the provider at the time of pre-authorization, it will be accepted regardless of date. GHC Pre-authorization and medical necessity guidelines/lists/processes currently do not include ICDspecific information and will not be impacted by the ICD10 implementation. As such, updated materials, tools and forms will not be required. For all procedures requiring a pre-authorization, providers should continue to supply the type of information that they do now. After October 1, 2014, we will only accept ICD10 codes if a diagnosis code is being provided on a request for authorization. HCA We do not anticipate significant changes at this time. L&I Prior auth requirements / policy will not change. Most of our requirements are based on CPT codes Molina We do not anticipate any changes to our policies at this time. Premera No. Regence We do not anticipate at this time that our pre-authorization policy will change based upon implementation of ICD-10. Page 3

4 United Our goal is to keep processes as they are today, but these plans have not yet been finalized. 2. When does your health plan intend to update and release your pre-authorization lists to include ICD-10 codes/descriptions? Aetna Our pre-auth requirements are based on services and not strictly based on diagnosis. We do not currently intend to change our pre-auth requirements at this time. CHPW The CHPW pre-authorization list is driven by service code and not diagnosis code. Change related to implementation of ICD-10 is not anticipated. We will continue to assess. Asuris ICD codes and descriptions are not specified in our pre-authorization lists and we are not planning to add them. Cigna Any materials that health care professionals may need to reference will be available effective 10/1/2014. FCH Since ICD-specific information does not need to be supplied to us for any pre-authorization, our preauthorization and medical necessity guidelines/lists/processes will not be affected by the ICD10 implementation. As such, updated materials, tools and forms will not be required. For all procedures requiring a pre-authorization, providers should continue to supply the type of information, e.g. general diagnosis description, that they do now. If ICD9 or ICD10 information is supplied by the provider at the time of pre-authorization, it will be accepted regardless of date. GHC Pre-authorization and medical necessity guidelines/lists/processes currently do not include ICDspecific information and will not be impacted by the ICD10 implementation. As such, updated materials, tools and forms will not be required. For all procedures requiring a pre-authorization, providers should continue to supply the type of information that they do now. After October 1, 2014, we will only accept ICD10 codes if a diagnosis code is being provided on a request for authorization. HCA Any materials that health care professionals may need to reference will be available effective 10/1/2014. L&I Not Applicable Molina Our pre-auth requirements are based on services and not strictly based on diagnosis. We do not currently intend to change our pre-auth requirements overall the same types of services that need a pre-auth now will need them with ICD-10. Premera Sixty-90 days before compliance date for those few ICD-10 procedure codes that are on our pre- and post-service review lists. Regence ICD codes and descriptions are not specified in our pre-authorization lists and we are not planning to add them. United We don't publish a list at a code level; only categories are defined. Those are published annually as Page 4

5 part of the Administrative Guide (published on UHCOnline on or about 12/31, and is effective 1/1 or 4/1, depending on the contract. 3. When does your health plan intend to update and release your medical necessity lists/guidelines to include ICD-10 & related codes/descriptions? Please be as clear as possible about any revisions to medical lists/guidelines/policies that will be triggered by the transition to ICD10. Aetna We plan to update our medical policies on-line in July of CHPW Asuris Cigna FCH GHC HCA L&I CHPW medical policy is not driven by ICD coding. Changes are not anticipated Most of our medical policies which outline medical necessity do not contain ICD coding so will not need to be updated for ICD-10 implementation. The few medical policies that do have descriptions will be updated prior to ICD-10 implementation. The updates would occur at least 90 days prior to implementation. Internally our staff refers to industry standard ICD tables published by Milliman to identify an estimated length of stay when hospitalized or if case management services will be required. Our internal tables with ICD codes will be updated and ready for staff by 10/1/2014. Our plan is to support updates or changes to our coverage, medical, or medical- necessity policies as part of the normal annual update process. ICD- 10 codes have been added to the policies along with the corresponding ICD- 9 codes. All of our policies are currently available on our public website as well as the secure Cigna for Health Care Professionals website ( We also will provide information about major policy updates in our quarterly newsletter to our network health care professionals, Network News. Since ICD-specific information does not need to be supplied to us for any pre-authorization, our preauthorization and medical necessity guidelines/lists/processes will not be affected by the ICD10 implementation. As such, updated materials, tools and forms will not be required. For all procedures requiring a pre-authorization, providers should continue to supply the type of information, e.g. general diagnosis description, that they do now. If ICD9 or ICD10 information is supplied by the provider at the time of pre-authorization, it will be accepted regardless of date. Pre-authorization and medical necessity guidelines/lists/processes currently do not include ICDspecific information and will not be impacted by the ICD10 implementation. As such, updated materials, tools and forms will not be required. For all procedures requiring a pre-authorization, providers should continue to supply the type of information that they do now. After October 1, 2014, we will only accept ICD10 codes if a diagnosis code is being provided on a request for authorization. We anticipate this happening in early to mid 2014, but we are still finalizing our plans. Not Applicable Page 5

6 Molina Premera Regence United At this time we do not anticipate any significant change to our medical necessity policies. At least 90 days prior to compliance date. Most of our medical policies which outline medical necessity do not contain ICD coding so will not need to be updated for ICD-10 implementation. The few medical policies that do have descriptions will be updated prior to ICD-10 implementation. The updates would occur at least 90 days prior to implementation. The work to update the lists/guidelines is currently ongoing and a release date has not yet been determined. 4. If a pre-authorization is currently required for a service associated with an ICD-9 diagnosis and that diagnosis crosswalks to multiple ICD-10 diagnoses, will all services with all of these ICD-10 diagnoses require pre-authorization after 10/1/2014? For example, when ICD-9 diagnosis XYZ maps to ICD-10 diagnoses AB7R and HY8T, will all services with diagnoses AB7R and HY8T require a pre-auth? Aetna Authorizations provided prior to the conversion will be carried over for services post 10/1/2014. Asuris CHPW Cigna FCH GHC HCA L&I Molina How we will handle this situation still needs to be determined. TBD This is still under review as we build our ICD 10 tables. Since ICD-specific information does not need to be supplied to us for any pre-authorization, our preauthorization and medical necessity guidelines/lists/processes will not be affected by the ICD10 implementation. As such, updated materials, tools and forms will not be required. For all procedures requiring a pre-authorization, providers should continue to supply the type of information, e.g. general diagnosis description, that they do now. If ICD9 or ICD10 information is supplied by the provider at the time of pre-authorization, it will be accepted regardless of date. Pre-authorization and medical necessity guidelines/lists/processes currently do not include ICDspecific information and will not be impacted by the ICD10 implementation. As such, updated materials, tools and forms will not be required. For all procedures requiring a pre-authorization, providers should continue to supply the type of information that they do now. After October 1, 2014, we will only accept ICD10 codes if a diagnosis code is being provided on a request for authorization. TBD Not Applicable As we do not pre-auth based solely on ICD-9 codes, we would consider an auth after the ICD-10 implementation in the same manner we do today. Exact details of our requirements are still under Page 6

7 consideration. Premera We do not require specific ICD-9 diagnosis codes for our prospective reviews at this time. Regence How we will handle this situation still needs to be determined. United These plans have not yet been finalized, but will be communicated when determined. 5. When will you update your online tool to be compliant with ICD10? When will you update your fax form? Will your updated fax form replace the current form (being a combined ICD9&10 form ) or will it be an additional form? If you will have two forms, are there timeline restrictions for the use of either form? Aetna We will be compliant prior to 10/1/2014 but detailed timing is not available at this time. Asuris We will have minor updates to our pre-authorization request online form and fax form and will update prior to the October 1, 2014 implementation date, most likely update and announce in our August 2014 provider newsletter. We will finalize a decision related to whether we use one or multiple forms in the near future. CHPW Our Care Management system is ICD-10 enabled. CHPW medical policy is not driven by ICD coding so changes to our fax form will not be necessary. Cigna Any changes to systems where ICD 10 codes are utilized is currently under revision and will be ready by 10/1/2014 FCH Since ICD-specific information does not need to be supplied to us for any pre-authorization, our preauthorization and medical necessity guidelines/lists/processes will not be affected by the ICD10 implementation. As such, updated tools and forms will not be required. For all procedures requiring a pre-authorization, providers should continue to supply the type of information, e.g. general diagnosis description, that they do now. If ICD9 or ICD10 information is supplied by the provider at the time of pre-authorization, it will be accepted regardless of date. GHC Unknown at this time. HCA Any changes to systems where ICD 10 codes are utilized is currently under revision and will be ready by 10/1/2014 L&I Forms will be updated Molina Dates of when forms and tools will be updated are still under consideration, as is our exact cutover process. Premera Fax forms will be updated at least 90 days before compliance date. We are still working on the forms and have not made a decision about whether we will have a combined form or two separate forms. Page 7

8 Crossing the 10/1/2014 boundary We are still planning the timeline for our online tools, but they will be updated by the compliance date. Regence We will have minor updates to our pre-authorization request online form and fax form and will update prior to the October 1, 2014 implementation date, most likely update and announce in our August 2014 provider newsletter. We will finalize a decision related to whether we use one or multiple forms in the near future. United By the October 1, 2014 implementation date. 6. How will authorizations for inpatient stays that cross the 10/1/14 implementation date be addressed? For example if a patient is scheduled to be admitted on Sept 30 with an expected length of stay of 5 days, will how many pre-authorizations be required and will ICD9 or ICD10 information need to be submitted with the pre-auth? Aetna Pre-authorization ICD codes should be based on the date of submission of the pre-authorization. The claim ICD codes should be based on date of service or discharge. Asuris Pre-authorization ICD codes should be based on the date of submission of the pre-authorization. The claim ICD codes should be based on date of service or discharge. How we will handle this situation internally still needs to be determined. CHPW No change: Pre-authorizations are based on submission of service codes vs ICD procedure codes Cigna Cigna uses CMS guidelines for dates of service that cross the compliance date. FCH Since ICD-specific information does not need to be supplied to us for any pre-authorization, our preauthorization and medical necessity guidelines/lists/processes will not be affected by the ICD10 implementation. As such, updated materials, tools and forms will not be required. For all procedures requiring a pre-authorization, providers should continue to supply the type of information, e.g. general diagnosis description, that they do now. If ICD9 or ICD10 information is supplied by the provider at the time of pre-authorization, it will be accepted regardless of date. GHC If an authorization for any service spans the implementation date, we will honor the ICD-9 code through the end of that authorization with the exception of outpatient authorizations for our Access PPO plan being offered in January We will evaluate how we will accommodate new authorizations with ICD10 diagnosis codes for our Access PPO plan as the implementation date gets closer. HCA Details are not available at this time, however, ICD9 should be used for pre-certs submitted prior to compliance date (10/01/2014); ICD 10 for pre-certs submitted post compliance date L&I To be determined Molina We are still evaluating our approach but do not believe this to be a significant issue as we don t auth Page 8

9 based solely on diagnosis/pcs code. Premera We will be evaluating our systems capabilities to determine our approach Regence Pre-authorization ICD codes should be based on the date of submission of the pre-authorization. The claim ICD codes should be based on date of service or discharge. How we will handle this situation internally still needs to be determined. United These plans have not yet been finalized. 7. How will you handle an authorization that covers multiple dates of service, some of which are prior to 10/1/2014 and some after? (e.g. Chemotherapy is authorized for 6 visits with 3 occurring before 10/1 and 3 occurring after) Will 2 different pre-authorization numbers be required? Aetna If this is certified before 10/1/2014 with ICD-9 codes, it will carry over even if the services are provided after 10/1/2014. Asuris The approach to this situation is still being analyzed. It is possible that a single pre-authorization will be sufficient CHPW Two pre-authorizations will not be required since the process is reliant on service codes vs ICD codes. Cigna Cigna uses CMS guidelines for dates of service that cross the compliance date. FCH No 2 different pre-authorizations will not be required. Since ICD-specific information does not need to be supplied to us for any pre-authorization, our pre-authorization and medical necessity guidelines/lists/processes will not be affected by the ICD10 implementation. As such, updated materials, tools and forms will not be required. For all procedures requiring a pre-authorization, providers should continue to supply the type of information, e.g. general diagnosis description, that they do now. If ICD9 or ICD10 information is supplied by the provider at the time of preauthorization, it will be accepted regardless of date. GHC If an authorization for any service spans the implementation date, we will honor the ICD-9 code through the end of that authorization with the exception of outpatient authorizations for our Access PPO plan being offered in January We will evaluate how we will accommodate new authorizations with ICD10 diagnosis codes for our Access PPO plan as the implementation date gets closer. HCA The approach to this situation is still being analyzed. It is possible that a single pre-authorization will be sufficient L&I Probably a single authorization Molina At this point we believe a single authorization will suffice. Premera No. We will accept the ICD-9 code for the entire approved range of services. Page 9

10 Regence The approach to this situation is still being analyzed. It is possible that a single pre-authorization will be sufficient United These plans have not yet been finalized. 8. What is the earliest date (prior to 10/1/2014) that your health plan will accept pre-auth requests with ICD-10 codes/descriptions? Aetna Exact timing is still being determined, however providers should plan to use ICD9 for pre-certs submitted prior to compliance date (10/01/2014); ICD 10 for pre-certs submitted post compliance date Asuris We accept pre-authorizations 60 days prior to service Our Pre-authorization Request Form allows entry of an ICD code or description; however our preference is the ICD code. We are currently considering if it will be feasible for us to allow ICD-9 or ICD-10 coding on the Pre-authorization Request Form 60 days prior to October 1, The situation may also change because we plan to upgrade our pre-authorization system. If it does, we will update this response with additional details CHPW These plans have not yet been finalized. Cigna Cigna uses CMS guidelines for dates of service that cross the compliance date. FCH Since ICD-specific information does not need to be supplied to us for any pre-authorization, our preauthorization and medical necessity guidelines/lists/processes will not be affected by the ICD10 implementation. As such, updated materials, tools and forms will not be required. For all procedures requiring a pre-authorization, providers should continue to supply the type of information, e.g. general diagnosis description, that they do now. If ICD9 or ICD10 information is supplied by the provider at the time of pre-authorization, it will be accepted regardless of date. GHC To be determined HCA Exact timing is still being determined, however providers should plan to use ICD9 for pre-certs submitted prior to compliance date (10/01/2014); ICD 10 for pre-certs submitted post compliance date L&I To be determined Molina We have not finalized our approach but the tentative plan is to begin accepting ICD-10 coded authorizations 9/1/14. Premera We will be evaluating our systems capabilities to determine our approach Regence We accept pre-authorizations 60 days prior to service Our Pre-authorization Request Form allows entry of an ICD code or description; however our preference is the ICD code. We are currently considering if it will be feasible for us to allow ICD-9 or ICD-10 coding on the Pre-authorization Request Form 60 days prior to October 1, The situation may also change because we plan to Page 10

11 upgrade our pre-authorization system. If it does, we will update this response with additional details United These plans have not yet been finalized. 9. How will you handle the situation when there is a conflict between the ICD code/description version that was authorized and the ICD code/description version that was used for the actual date of service? Aetna Asuris CHPW Cigna FCH GHC HCA L&I Molina Premera We do not anticipate changes in our process due to the conversion to ICD-10. Aetna will handle ICD9-ICD10 conflicts in the say way as it currently does when there is a conflict between the ICD9 code that was authorized and the ICD9 code that was billed? This is not an issue for our current claims system as we don t use the diagnosis codes in our matching logic between the claims system and our pre-authorization system. However this could change prior to the cutover if we upgrade our pre-authorization system. If it does, we will update this response with additional details. CHPW does not use diagnosis code in our matching logic. The process to match a pre-auth to a claim for payment edits against many other fields and will not reject a claim solely based on the ICD code version. Since ICD-specific information does not need to be supplied to us for any pre-authorization, our preauthorization and medical necessity guidelines/lists/processes will not be affected by the ICD10 implementation. As such, updated materials, tools and forms will not be required. For all procedures requiring a pre-authorization, providers should continue to supply the type of information, e.g. general diagnosis description, that they do now. If ICD9 or ICD10 information is supplied by the provider at the time of pre-authorization, it will be accepted regardless of date. If an authorization for any service spans the implementation date, we will honor the ICD-9 code through the end of that authorization with the exception of outpatient authorizations for our Access PPO plan being offered in January We will evaluate how we will accommodate new authorizations with ICD10 diagnosis codes for our Access PPO plan as the implementation date gets closer. TBD To be determined We do not believe this will be an issue as we don t auth only based on the dx codes. We are evaluating our exact requirements but our objective is to avoid the need for revised/new authorizations where possible. We will look at the diagnosis and manually match the claim to the approved review if necessary to allow the claim to pay. Page 11

12 Regence United This is not an issue for our current claims system as we don t use the diagnosis codes in our matching logic between the claims system and our pre-authorization system. However this could change prior to the cutover if we upgrade our pre-authorization system. If it does, we will update this response with additional details. These plans have not yet been finalized. Page 12

13 ICD- 10 Claims Questions Claims Processing Questions & Answers 1. What steps have been/will be taken to prevent claims from being inappropriately denied due to ICD10 coding or mapping problems, causing cash flow interruptions? Aetna We have engaged the impacted areas of our company in business assessments and planning for the move from 18,000 ICD-9 codes to more than 140,000 ICD-10 codes. Our program incorporates remediation of our impacted systems and vendor tools, affected business processes and policies. We are not anticipating problems with claims handling but we have mitigation plans in place for any issues should they arise. Asuris If denial is due to the claim containing non-compliant ICD codes based on date of discharge, please follow our Corrected Claims process for resubmission of a corrected claim with the corrected diagnosis information. Our Corrected Claims process can be found the Claims & Billing section of our Provider Web Site. CHPW Cigna FCH If ICD codes on the claim are compliant but other problems related to mapping caused the denial, please contact your assigned provider consultant to report the issue and for appropriate steps for resolution. If you are unsure who that is, you can locate the information in the Contact Us section of the Provider Web Site at We will have in place an internal escalation process to quickly resolve issues related to mapping so that claims can process correctly. CHPW will develop and execute a detailed testing program long before the ICD-10 effective date. Partnering with our providers in the testing effort will be welcomed. We have been testing ICD-10 internally since 1Q2013 and will continue to test through 1Q2014 to ensure proper receipt and processing of claims. Testing included: Loading ICD-10 codes on all platforms Receipt of electronic, paper, and direct data entry transactions with new ICD-10 codes Processing of ICD-9 and ICD-10 codes concurrently based on dates of service or discharge Claim logic based on date of service or discharge date along with authorization match logic Claims coded from medical records in ICD-9 and 10 using HIMSS/WEDI industry data FCH has a dedicated ICD10 Implementation Team that has assessed systems, business processes, policies and procedures. These systems, policies and procedures have been remediated for ICD10 Page 13

14 GHC HCA L&I Molina Premera Regence implementation. FCH will also perform end to end testing by participating in the HIMSS/WEDI Testing Pilot Program. We will make every attempt to avoid claims being inappropriately denied or delayed. We will have a process identified to respond to providers claims inquiries and respond expeditiously. HCA has begun an impact assessment and system remediation project. ICD-10 will be done prior to the deadline and providers will be invited to test their system with the HCA Medicaid ProviderOne system. Providers should bill the most appropriate ICD-10 code. Adjustments should be submitted with correct code. L&I will prepare its processes to respond to ICD-10 questions. You can use the medical provider contacts listed here to get assistance. Molina is interested in coordinating with providers and facilities to help understand and mitigate potential impacts and is interested in obtaining ICD-10 coded claims for detailed testing and financial analysis prior to implementation We do not anticipate any significant issues. We will monitor claims closely to ensure any impacts are identified and resolved early in the process If denial is due to the claim containing non-compliant ICD codes based on date of discharge, please follow our Corrected Claims process for resubmission of a corrected claim with the corrected diagnosis information. Our Corrected Claims process can be found the Claims & Billing section of our Provider Web Site. If ICD codes on the claim are compliant but other problems related to mapping caused the denial, please contact your assigned provider consultant to report the issue and for appropriate steps for resolution. If you are unsure who that is, you can locate the information in the Contact Us section of the Provider Web Site at We will have in place an internal escalation process to quickly resolve issues related to mapping so that claims can process correctly. United We will not be mapping ICD-9 codes to ICD-10 codes. ICD-10 codes will be loaded into our system. If there are inappropriate denials, providers can contact our Customer Care area for resolution, as they do today. 2. If claims are denied en masse due to ICD10 coding or mapping problems, what will be the notification and resolution process? How should providers engage in the process? Aetna While we do not anticipate this type of problem, appropriate communication plans will be in place to notify submitters should we encounter this situation Page 14

15 Asuris CHPW Cigna FCH GHC HCA L&I Molina Premera Regence If ICD10 coding is denied en masse due to coding or mapping issues that are due to system issues at Asuris, please contact your assigned provider consultant to report the issue and for appropriate steps for resolution. If you are unsure who that is, you can locate the information in the Contact Us section of the Provider Web Site at We will have in place an internal escalation process to quickly resolve issues related to coding and mapping so that claims can process correctly and will work directly with individual providers to resolve any payment issues. We will use our Provider Web Site, newsletter, and other available communication vehicles, as necessary to communicate issues and resolutions for en masse issues affecting large numbers of providers. Detailed processes for error notification and resolution will be developed in collaboration with our providers in early Multiple communications mechanisms will be employed. The notification and resolution process that occurs today will not be changing. An ICD-10 code is defined as a code that has been coded to its highest level of specificity and Cigna will follow the CMS General Claims Submission Information Guidelines for accepting and rejecting both paper and electronic claims, which includes those services that cross the compliance date. FCH has communication mechanisms in place including Provider Bulletins, FCH website, Provider Webinars and Blasts (for provider for whom we have their addresses.) Providers should engage us through their Provider Relations contact who can elevate issues to the ICD10 implementation team for resolution. We will identify a process to remediate any denials and communicate that process to our providers. Our extensive testing process is designed to identify any such en masse issues prior to the implementation deadline. HCA is striving to have as little disruption as possible. If unforeseen outcomes occur, HCA will use its normal provider communications processes to communicate and mitigate the resolution. L&I will be preparing its processes to respond to ICD-10 issues. If unforeseen generalized issues occur, information on the response, and ways to engage the process will be communicated through the Provider Web Although Molina strives for minimal disruption in operations, we acknowledge that with any implementation there is a potential for an unforeseen event to occur. Molina will institute proven strategies to any area requiring it. A contingency plan will be developed if needed. We will follow our current process for resolving claims payment issues. If ICD10 coding is denied en masse due to coding or mapping issues that are due to system issues at Page 15

16 Regence, please contact your assigned provider consultant to report the issue and for appropriate steps for resolution. If you are unsure who that is, you can locate the information in the Contact Us section of the Provider Web Site at We will have in place an internal escalation process to quickly resolve issues related to coding and mapping so that claims can process correctly and will work directly with individual providers to resolve any payment issues. We will use our Provider Web Site, newsletter, and other available communication vehicles, as necessary to communicate issues and resolutions for en masse issues affecting large numbers of providers. United 3. When claims are adjudicated under ICD-10, do you expect to maintain the ICD-9 levels of timeliness in adjudication, i.e. for a similar clinical encounter, will the ICD-10 claim be adjudicated in the same timeframe as was the ICD-9 claim? If not, what differences do you expect? Will timeliness of adjudication be part of your testing? Aetna We do not anticipate delays in claims processing. Asruis Yes, it is our intent that the adjudication timeliness will remain the same. CHPW We are not anticipating changes in adjudication timeliness, but ICD-10 claims testing beginning Q will reveal potential issues and provide time for remediation. Cigna There are no changes on claim timeliness adjudication from ICD-9 to ICD-10. Yes, adjudication timeliness is part of the testing. FCH We are expecting that adjudication time will remain the same when implementing ICD10. We will also be tracking adjudication time during testing. GHC The adjudication timeframes are expected to remain the same and that will be part of our testing. HCA L&I If providers bill with valid ICD 10 codes, we don t anticipate any problems or differentiation from current timeframes. Timeliness will be part of our testing. Molina We expect to maintain the same timeliness standards as we do today. We will be evaluating all processes and impacts to our anticipated response times and will be putting together a plan to mitigate any impacts related to the ICD-10 transition. Premera Yes, It is the stated goal of Premera s ICD10 program not to affect timeliness of claim adjudication. Regence Yes, it is our intent that the adjudication timeliness will remain the same. United Yes, United s goal is not to affect timeliness of claim adjudication. 4. As of , will your system be able to accept ICD-9 codes for dates of service PRIOR to 10- Page 16

17 and ICD-10 codes for dates of service AFTER ? Aetna Yes, Aetna is prepared to support ICD-9 and ICD-10 codes after the 10/1/2014 implementation date for the appropriate dates of service. Asuris Yes, we will have a dual use period starting October 1, 2014 where we will accept and process valid ICD-9 (DOS before Oct ) and valid ICD-10 codes (DOS after Sept 30, 2014). We will follow CMS guidelines for how to process claims that span the ICD-10 implementation date. CHPW Yes, CHPW will be prepared to accept and process both ICD-9 and ICD-10 codes on electronic and paper claims after the 10/1/2014 effective date. The state of industry-wide and regional provider readiness in Q2, 2014 will be a major determinant. ICD-10 codes will not be accepted on production claims prior October 1, 2014, except for testing purposes. Cigna Cigna will support the processing of electronic and paper claims based either on the date of service for outpatient settings or the discharge date for inpatient facility settings. Claims submitted with a date of service or discharge date prior to the compliance date will be processed using ICD-9 codes. Those claims submitted with a date-of-service or discharge date on or after the compliance date will be processed using ICD-10 codes FCH FCH will follow CMS guidelines regarding which ICD version is applicable for which dates of service GHC Yes. Claims would process according to dates of services and would map to appropriate ICD codes. We will be following the CMS guidelines for how to process claims using the date of discharge and date of service parameters. HCA Yes, claims will process according to the dates of service using whichever code set is appropriate. L&I L&I will follow the CMS guidelines for how to process claims. In the L&I systems, ICD-9 codes will be accepted for dates of service through and will not be accepted for dates of service on or after In the L&I systems ICD-10 codes will be accepted for dates of service on and after and will not be accepted for dates prior to For claims that span the ICD-10 implementation date, our systems will follow the CMS guidelines indicated above. Molina Yes, Molina s systems are scalable and can accommodate the simultaneous processing of ICD-9 and ICD-10 coded claims based on date of service/discharge Premera Yes, we will be able to accept ICD-9 codes for dates of service/discharge 9/30/14 and earlier and ICD-10 codes for dates of service/discharge 10/1/14 and later; however, ICD-9 and ICD-10 codes cannot be combined on the same claim for any overlapping dates. Regence Yes, we will have a dual use period starting October 1, 2014 where we will accept and process valid Page 17

18 ICD-9 (DOS before Oct ) and valid ICD-10 codes (DOS after Sept 30, 2014). We will follow CMS guidelines for how to process claims that span the ICD-10 implementation date. United Yes 5. On claims submitted with codes from Chapter 19 of ICD-10-CM Injury, Poisoning and Certain Other Consequences of External Causes Diagnosis Codes, will the use of the secondary code from Chapter 20, External Causes of Morbidity be required? Will a claim submitted without the secondary code be denied? (Concerns have been raised related to the level of detail now provided in this section. Many times that detail is not known.) Aetna Our requirements for E-codes will not change with ICD-10 implementation. Asuris Our requirements for E-codes will not change with ICD-10 implementation. Currently we require hospitals to use E-codes to clarify circumstances for emergency room visits and also to enter up to three E-codes if an injury, poisoning or adverse effect is the cause for seeking medical treatment or occurred during the medical treatment. We do not require E-code use for professional claims CHPW Cigna FCH GHC HCA L&I Molina Premera Regence There is no regulation mandating the use of ICD-10-CM codes for External Causes of Morbidity (V00-Y99) as a condition of the ICD-10-CM implementation on October 1, Therefore Cigna has no specific requirements regarding the submission of External Causes of Morbidity. FCH requires that the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM and the International Classification of Diseases, 10th revision, Procedure Coding System (ICD-10-PCS) coding guidelines be followed as well as the AHIMA Standards of Ethical Coding Yes, external cause does require primary coding with ICD-9s now. Our assumption is that the ICD- 10 Final Ruling will have the same requirement. When ICD-10 is implemented and the guidelines require the external cause dx, then a code from Chapter 20 should be billed. External cause diagnosis cannot be billed alone. They always are a secondary diagnosis. Yes, a claim submitted without the secondary code will be denied. ICD-10 is not expected to have an impact on this type of processing. New rules will be applied similar to current ICD-9 processing which, in most cases, does not require a secondary code. Codes for External Causes of Morbidity are not currently required by our claims submittal process. Additional planning and requirement development is required to make that determination No Our requirements for E-codes will not change with ICD-10 implementation. Currently we require hospitals to use E-codes to clarify circumstances for emergency room visits and also to enter up to Page 18

19 three E-codes if an injury, poisoning or adverse effect is the cause for seeking medical treatment or occurred during the medical treatment. We do not require E-code use for professional claims United 6. Tables A-D in CMS s MLN 7492 ( Learning-Network-MLN/MLNMattersArticles/downloads/MM7492.pdf) give guidance to providers for billing claims that span the periods where ICD-9 and ICD-10 codes may both be applicable, e.g. visits prior to Oct. 1, 2014 and visits on or after Oct. 1, 2014 must be billed on separate claims. Does your organization fully implement all of the guideline in MLN 7492s? If not, under what conditions will providers need to follow a different guideline when billing claims to your organization? Aetna Aetna s ICD Claim Date Rules are in alignment with CMS as outlined in MLN 7492 Asuris We will follow CMS guidelines for how to process claims that span the ICD-10 implementation date. CHPW Cigna Cigna is following CMS guidelines FCH FCH will follow the MLN 7492 guidelines GHC Group Health will be following the MLN7492 guideline HCA L&I L&I is implementing its ICD-10 changes based on the guidelines in MLN 7492s Molina Molina will follow MLN 7492 Premera We will follow MLN 7492 guidelines. Regence We will follow CMS guidelines for how to process claims that span the ICD-10 implementation United date. United Healthcare's Medicare plans will follow MLN Though the other product lines have not yet been finalized, they will most likely follow the guidance in this MLN as well. Updates for these product lines will be posted when that information becomes available 7. In anticipation that some health plans, e.g. MediCal, will not be ICD10 ready by Oct 1, 2014, the processing of crossover/secondary claims will be problematic. For each of the scenarios outlined below, will you adjudicate the claim, will you deny that claim, or will take some other action? i. Scenario 1: You receive a crossover claim from a health plan that is not ICD10 ready (it is coded in ICD9). How will you process it? Page 19

20 ii. iii. Scenario 2: You will send a crossover claim to a health plan that is not ICD10 ready. In what ICD version will you send it? Scenario 3: A provider submits a claim to a health plan that is not ICD10 ready (it is coded in ICD9). After that health plan processes the claim, the provider sends you the secondary claim that is coded in ICD9. How will you process it? Note to Providers: Check with your practice management/information systems vendor to see if you can send a claim in both ICD9 & ICD10 formats. Some EMRs must have both fields in order to do this. Aetna Awaiting guidance from CMS Asuris Awaiting guidance from CMS CHPW Awaiting guidance from CMS Cigna Awaiting guidance from CMS FCH FCH will be ICD10 compliant and will not be accepting ICD9 codes for dates of service on or after the compliance date. GHC Awaiting guidance from CMS HCA Awaiting guidance from CMS L&I Awaiting guidance from CMS Molina Awaiting guidance from CMS Premera Awaiting guidance from CMS Regence Awaiting guidance from CMS United Awaiting guidance from CMS 8. Will your acceptance of Not Otherwise Specified (NOS) codes change from ICD9 to ICD10? If so, how? Aetna No, our handling of Not Otherwise Specified codes will not change from ICD-9 to ICD-10. Asuris No, we do not anticipate any changes at this time. CHPW CHPW will accept an ICD-10 NOS code if it is the only code the documentation supports. For ICD-9 NOS codes that are mapped to an ICD-10 code, CHPW requirements for the ICD-10 code will be the same as those for ICD-9, as long as the description of the code does not change. Cigna As long as it is still a valid ICD code, there will be no change. FCH FCH acceptance of Not Otherwise Specific NOS is not anticipated to change. FCH requires coding to follow the ICD-10-CM book Official Guidelines for Coding and Reporting. Following the Page 20

21 GHC HCA L&I guidelines is required under HIPAA. There will be NOS ICD10 codes. If there is no specific ICD 10 code then it is appropriate to use a NOS code. However there may be more specific codes in the ICD10 code set that weren t in the ICD9 code set. L&I has no plans to treat ICD-10 NOS codes different from ICD-09 NOS codes. L&I will implement ICD-10 with minimal changes and slowly add any policy changes if they are warranted. Molina No. We expect claims to be coded to the most specific level possible based on the known condition, as we do today. Premera Acceptance of Not Otherwise Specific (NOS) codes will not change from ICD9 to ICD10. We will continue to require claims to be coded to the most specific level possible. Regence No, we do not anticipate any changes at this time. United Currently, there are no changes, though we cannot rule out changes in the future. 9. During and after the transition to ICD10, do you anticipate any changes to your current policy regarding adjudicating paper claims for primary and secondary billing (CMS 1450 aka UB04 - for inpatient and CMS1500 for outpatient)? Do you anticipate any changes to your policy of sending paper vouchers/ remittance advices and checks? If so, what will be the policy changes? Aetna Asuris No, we do not anticipate any changes for either of these In Washington, we are in the process of moving to the requirement of only accepting electronically submitted medical claims. This requirement is not related to the ICD-10 implementation, however, once the requirement is in place, we won t accept paper claims. The requirement will occur in 2014, however we have not yet set an effective date. CHPW We do not send paper vouchers or checks to participating providers and do not anticipate any changes to this existing process. CHPW will continue to accept paper claims from providers when billing the health plan as a primary payer or as a secondary payer. CHPW currently offers both 835 electronic RA remittance and paper RA s, as well as EFT and paper checks. There is a push with CORE III (a federally mandated operating rule) for EFT for CMS payers to have most every provider on EFT the first of this year. We re working on that project right now. So basically CHPW won t drive the change necessarily in moving from a paper RA/check to an electronic version. But we will follow CMS and State guidance. Page 21

22 Cigna FCH GHC HCA L&I Molina Premera Regence No changes are anticipated to either policy. We do not anticipate any changes to our current policy regarding adjudicating paper claims for primary and secondary billing (CMS 1450 aka UB04 - for inpatient and CMS1500 for outpatient). We do not anticipate any changes to our current policy of sending paper vouchers/ remittance advices and checks. There are no immediate changes planned for our processes. HCA does not expect any policy changes related to paper claims, remittance advices or checks as a consequence or byproduct of the change to ICD-10 codes. At this time the Department will not making any changes to our paper claim policies. In addition we will not be making any changes to our paper vouchers or remittances. There are no policy changes at this time We do not anticipate changes to our policy. In Washington, we are in the process of moving to the requirement of only accepting electronically submitted medical claims. This requirement is not related to the ICD-10 implementation, however, once the requirement is in place, we won t accept paper claims. The requirement will occur in 2014, however we have not yet set an effective date. Contract Implications We do not send paper vouchers or checks to participating providers and do not anticipate any changes to this existing process. United 10. Will my interactions with your organization change because of ICD-10? Aetna No, The normal providers service operations will be utilized for assistance related to ICD-10. Asuris No CHPW CHPW does not anticipate any changes in its interactions with its providers as a result of ICD10. As we proceed through our transition, we will communicate any changes we believe will improve our responsiveness to provider claims issues after the effective date. Cigna No, Cigna does not anticipate any changes in its interactions with its providers as a result of ICD-10 FCH No, our goal is to make this transition as seamless as possible. GHC Nothing will change. Our first line access will remain Provider Assistance Unit. HCA No. Normal provider support processes be utilized for assistance related to ICD-10. Page 22