ICD-10 Frequently Asked Questions Overview Is Harvard Pilgrim ready for the ICD-10 implementation? Yes. Harvard Pilgrim has completed systems work, and will be ready to implement ICD-10 codes by October 1, 2015, which is the compliance date set by the Centers for Medicare and Medicaid (CMS). We have also included ICD-10 coding on our medical and payment policies, which are located on the Providers section of our website. Will Harvard Pilgrim be using CMS General Equivalence Mappings (GEMs)? We do not use GEMs for transaction processing; however, we do use them as a conversion mapping base for our payment and medical policies. Submitting Claims When will Harvard Pilgrim first accept ICD-10 codes on claims? Harvard Pilgrim will accept ICD-10 codes on claims as of October 1, 2015 (the CMS compliance date). Is an ICD-10 procedure code required on a claim? An ICD procedure code is required on an inpatient claim when a procedure was performed. For inpatient claims with discharge date before October 1, 2015, an ICD-9 procedure code must be used. Inpatient claims with discharge date on or after October 1, 2015 must report an ICD-10 procedure code. ICD procedure codes are not required on outpatient surgical claims. FL 74 does not support submission of CPT procedure codes. ICD-10 Procedure codes are required in this field when billing inpatient procedures; ICD-9 code for dates before 10/1/2015 and ICD- 10 code for dates on or after 10/1/2015. How should providers submit inpatient claims that span the ICD-10 implementation date? Inpatient claims with date of discharge before October 1, 2015 must be billed with ICD-9 codes; those with date of discharge on or after October 1, 2015 must be billed with ICD-10 codes. Do not split inpatient claims by date of service. How should providers submit outpatient claims that span the ICD-10 implementation date? Page 1
We cannot accept claims containing both ICD-9 and ICD-10 codes. Therefore, services provided prior to October 1, 2015 must be billed separate (using ICD-9 codes) from services provided on or after October 1, 2015 (using ICD-10 codes). Will Harvard Pilgrim support dual submission of ICD-9 and ICD-10 diagnosis and procedure codes after the compliance date? No, each claim must contain either all ICD-9 codes or all ICD-10 codes based on date of service. Will Harvard Pilgrim accept 837 batches with both ICD-9 and ICD-10 claims spanning the conversion deadline? Yes, provided that that both ICD-9 and ICD-10 codes are not contained on the same claim, Harvard Pilgrim will accept 837 batches with ICD-9 and ICD-10 claims. What ICD-10 compatible grouper will Harvard Pilgrim use as of October 1, 2015? The DRG grouper will be based on the individual provider contract. What is Harvard Pilgrim s approach to claims adjudication? Harvard Pilgrim will use native ICD-10 adjudication and will not crosswalk ICD-10 codes to ICD- 9 codes. Will claims that do not comply with ANSI 5010 specifications be rejected at the point of receipt or will a denial be issued? Harvard Pilgrim will reject such claims at point of receipt. How long will Harvard Pilgrim support ICD-9 coding for corrected claims/appeals? No concrete time frame has been set; however, use of ICD-9 codes will be based on claim date of service, filing limits and appeal timeframes. Will Harvard Pilgrim require coding that differs from or expands ANSI V5010? No, Harvard Pilgrim will not require coding that differs from or expands ANSI V5010. Will Harvard Pilgrim implement a new appeal process related to ICD-10 code selection and/or DRG classifications used for reimbursement? No, Harvard Pilgrim will continue to use its current appeals process, which is outlined in our online Provider Manual. Page 2
What restrictions, if any, will Harvard Pilgrim place on the acceptance of unspecified codes for ICD-10? Unless otherwise specified in published policies, Harvard Pilgrim will handle unspecified codes for ICD-10 in the same manner as we currently handle unspecified codes for ICD-9. Notifications, Referrals, and Authorizations What codes will Harvard Pilgrim require for authorization of services? ICD-9 diagnosis codes will be required for referrals or authorizations of service with a requested start date prior to October 1, 2015, while ICD-10 diagnosis codes will be required for referrals or authorizations of service with a requested start date on or after October 1, 2015. Harvard Pilgrim does not require the use of ICD-10 procedure codes in referral or authorization requests; continue to use CPT, HCPHCS or revenue codes as appropriate. Will referrals or authorizations submitted before October 1, 2015 with services that extend beyond that date need to be split into two requests based on date of service? No. Any approved request that has a start date prior to October 1, 2015 (and, therefore, has been submitted with ICD-9 diagnosis codes) will also be valid for dates of service on or after October 1, 2015. When will Harvard Pilgrim begin accepting referral, prior authorization, and inpatient notifications for services with dates of service on or after October 1, 2015? Beginning August 1, 2015, Harvard Pilgrim will start accepting referrals, authorization requests, and inpatient notifications requiring ICD-10 codes for dates of service on or after the October 1, 2015 compliance date. Will Harvard Pilgrim support ICD-10 testing? Provider Self-Testing Yes, providers may choose to conduct ICD-10 self-testing to gain important knowledge about operational readiness for ICD-10 and identify any improvements that may be needed. Two forms of self-testing are available: validation self-testing and end-to-end self testing. What is the purpose of validation self-testing? Will a pass/fail response be returned for each 837 submitted file? ICD-10 validation self-testing can ensure that claims can be correctly submitted with ICD-10 codes. This form of testing uses the Edifecs Ramp Management application, supports testing of ICD-9 and ICD-10 claims, and allows providers to submit 837 claim files. Upon successful completion of Ramp testing, you will receive a pass/fail notification. This is not an end-to-end Page 3
test of claims and, therefore, you will not receive a claim acknowledgement or 835 electronic remittance advice. Will Harvard Pilgrim support provider validation testing with a 999 and 277 acknowledgement returned for each 837 file submitted? Yes, for each 837 claim submitted, a 999 and a 277 acknowledgement will be returned to ensure that the claim has been received and detail whether it has been accepted or rejected, and whether or not there are any errors. Will Harvard Pilgrim support provider end-to-end testing? Harvard Pilgrim will support a limited end-to-end testing. Following successful Ramp testing, Harvard Pilgrim will also support self-testing that allows providers to submit ICD-9 and ICD-10 claims through their existing provider test connection with Harvard Pilgrim. We will return an Excel file with claim adjudication results for claims submitted. For more details on end-to-end testing, please refer to ICD-10 Self Testing FAQ. How do I participate in testing? To get started with any self-testing, contact the EDI Team at EDI_Team@harvardpilgrim.org or call 800-708-4414 and select option 1, then option 3. Then submit your claims to the provider test system. Does Harvard Pilgrim limit the number of transactions that can be submitted for testing? No, Harvard Pilgrim does not place a limit on the number of transactions providers can submit for testing. Will fictitious or anonymized claims be accepted for testing? No fictitious or anonymized claims will be accepted for testing. In what format should test claims be submitted? Test claims should be submitted in ANSI 5010 professional or institutional format. Will Harvard Pilgrim test with clearinghouses? Yes, Harvard Pilgrim will test ICD-10 claims with provider clearinghouses. Additional Information/Resources Where can providers find additional information related to the ICD-10 transition? Page 4
Harvard Pilgrim s ICD-10 page for providers offers up-to-date information regarding the transition, including links to key ICD-10 resources and updated 837 professional and institutional claims companion guides, which include additional information on testing and setup of claims related electronic transactions. For any questions about the October 1, 2015 transition to ICD-10 coding, contact the Harvard Pilgrim EDI team at EDI_Team@harvardpilgrim.org, or call 800-708-4414 and select option 1, then press 3. Page 5