2015 Survey of Payers' ICD-10
Transition Strategies
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
Questions (cont’d)
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
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,
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-10.
26.
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
Questions (cont’d)
providers? (A 999 and 277CA
will be returned for each 837 file
submitted.)
30.
Will the payer support
end-to-end testing with providers? (An
835, 999 and 277CA will be
returned for each 837 file
submitted.)
31.
If the payer responded “Yes” 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 “Yes” to
any one or number of the test
approaches, will the payer
accept fictitious or anonymized
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?
Completed Responses
Awaiting Response
Blue Cross Blue Shield Aetna Boston Medical Center HealthNet Plan Anthem
Harvard Pilgrim Health Care CeltiCare Health Health New England Cigna
MassHealth ConnectiCare Health Plan Tufts Health Plan / Network Health Fallon Health
Neighborhood Health Plan Senior Whole Health
Q1: Please
select your
organization.
Q2: When will the
Health Plan first
accept ICD-10
codes on claims?
Blue Cross Blue Shield October 1, 2015 Boston Medical Center HealthNet Plan October 1, 2015 Harvard Pilgrim Health Care October 1, 2015 Health New England October 1, 2015 MassHealth October 1, 2015 Tufts Health Plan / Network Health October 1, 2015
Q3: How should a
provider submit
inpatient claims
that span the
ICD-10 implementation
date?
Payer
Response
Blue Cross Blue Shield Claims for services provided prior to October 1, 2015 must be billed separately from services provided on or after October 1, 2015.
Boston Medical Center
HealthNet Plan Claims that span October 1, 2015 must be submitted with ICD-10 coding for the full admission period. Harvard Pilgrim Health
Care 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.
Health New England Claims for services provided prior to October 1, 2015 must be billed separately from services provided on or after October 1, 2015.
MassHealth 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.
Tufts Health Plan /
Q4: How should a
provider submit
outpatient claims
that span the
ICD-10 implementation
date?
Blue Cross Blue Shield
Claims for services provided prior to October 1, 2015 must be billed separately from services provided on or after October 1, 2015.
Boston Medical Center HealthNet Plan
Harvard Pilgrim Health Care
Health New England MassHealth
Tufts Health Plan / Network Health
Q5: Will the
payer support dual
submission of
ICD-9 and ICD-10
diagnosis and
procedure codes
after the
compliance date?
Payer
Response
If “Yes,” please elaborate
Blue Cross Blue Shield No Boston Medical Center
HealthNet Plan No Harvard Pilgrim Health
Care No
Health New England Yes Only 9 codes with Dates of Service prior to 10/1/15 and I-10 codes after I-10/1/15.
MassHealth Yes 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 Yes 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.
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?
Blue Cross Blue Shield Yes Boston Medical Center HealthNet Plan Yes Harvard Pilgrim Health Care Yes Health New England Yes
MassHealth Yes
Q7: What ICD-10
compatible grouper
will the payer use
as of October 1,
2015?
Payer
Response
Blue Cross Blue Shield APR-DRG Grouper v26.1 Boston Medical Center HealthNet Plan APR-DRG Grouper v30
Harvard Pilgrim Health Care The Grouper is based on provider contract.
Health New England Both APR-DRG v30 (or above) and MS-DRG v30 (or above)
MassHealth EAPG for out-patient claims
Tufts Health Plan / Network Health Commercial: APR-DRG Grouper v30
NH and TMP: MS-DRG Grouper v32 (Updated version once released in Fall)
Q8: What is the
payer’s approach to
Claims
Adjudication?
Blue Cross Blue Shield Native ICD-10 Adjudication
Boston Medical Center HealthNet Plan Native ICD-10 Adjudication. Reverse mapping is being performed for APR DRG Grouper V30 but natively within the grouper software.
Harvard Pilgrim Health Care Native ICD-10 Adjudication Health New England Native ICD-10 Adjudication MassHealth Native ICD-10 Adjudication Tufts Health Plan / Network Health Native ICD-10 Adjudication
Q9: Will claims that
do not comply with
ANSI 5010
specifications be
rejected at point of
receipt or will a
denial be issued?
Payer
Response
Blue Cross Blue Shield Same as current process. Rejections and denials will be routed through the same process as it is today for ICD-9 codes. Boston Medical Center HealthNet Plan Rejected at point of receipt
Harvard Pilgrim Health Care Rejected at point of receipt Health New England Rejected at point of receipt MassHealth Rejected at point of receipt Tufts Health Plan / Network Health Rejected at point of receipt
Q10: How long will
payer support
ICD-9 coding for
corrected
claims/appeals?
Blue Cross Blue Shield Not anticipating any change in policies for corrected claims/appeals
Boston Medical Center HealthNet Plan Greater than 90 days Harvard Pilgrim Health Care Greater than 90 days Health New England Greater than 90 days MassHealth Greater than 90 days
Tufts Health Plan / Network Health No time frame. Based on claims date of service, filing limits and appeal guidelines.
Q11: Will the payer
be requiring coding
that differs from, or
expands, ANSI
v5010?
Payer
Response
Blue Cross Blue Shield No Boston Medical Center HealthNet Plan No Harvard Pilgrim Health Care No Health New England No
MassHealth No
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?
Blue Cross Blue Shield No Boston Medical Center HealthNet Plan No Harvard Pilgrim Health Care No Health New England No
MassHealth No
Q13: Will the
payer's EOB/
remittance remarks
explicitly state
reason for denials if
related to no
coverage?
Payer
Response
Blue Cross Blue Shield No Boston Medical Center HealthNet Plan Yes Harvard Pilgrim Health Care No Health New England Yes
MassHealth
-Q14: What
restrictions, if any,
will the payer place
on the acceptance
of unspecified
codes for ICD-10?
Blue Cross Blue Shield Will follow current CMS guidelines Boston Medical Center HealthNet Plan Will follow current CMS guidelines
Harvard Pilgrim Health Care HPHC will handle unspecified codes for ICD-10 as we do today for ICD-9 unless otherwise specified in published policies.
Health New England Will follow current CMS guidelines MassHealth
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
Response
Blue Cross Blue Shield Yes Boston Medical Center HealthNet Plan Yes Harvard Pilgrim Health Care Yes Health New England Yes
MassHealth
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?
Blue Cross Blue Shield 10/1/2015 Boston Medical Center HealthNet Plan 8/17/2015 Harvard Pilgrim Health Care 8/1/2015 Health New England _
MassHealth
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
Response
Blue Cross Blue Shield 10/1/2015 Boston Medical Center HealthNet Plan 8/17/2015 Harvard Pilgrim Health Care 8/1/2015 Health New England _
MassHealth
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?
Blue Cross Blue Shield No 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 Yes Harvard Pilgrim Health
Care Yes
Health New England Yes 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 /
Q19: Is the payer
using InterQual®
SmartSheet™ for
prior
authorizations?
Payer
Response
Blue Cross Blue Shield Yes Boston Medical Center HealthNet Plan No Harvard Pilgrim Health Care No
Health New England Do not know
MassHealth No
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?
Blue Cross Blue Shield BCBS will incorporate ICD-10 and map from ICD-9 to ICD-10 Boston Medical Center HealthNet Plan NA
Harvard Pilgrim Health Care NA Health New England NA Senior Whole Health
Q21: If the payer
will be using
SmartSheet™, will
it be available
on-line to providers for
administrative
simplicity?
Payer
Response
Blue Cross Blue Shield Yes Boston Medical Center HealthNet Plan NA Harvard Pilgrim Health Care NA Health New England NA
MassHealth NA
Q22: Does the
payer expect
payment, medical
necessity and/or
medical policies to
change to support
ICD-10?
Blue Cross Blue Shield No Boston Medical Center
HealthNet Plan Yes Policies have been updated to reflect appropriate ICD-10 coding. Harvard Pilgrim Health
Care Yes Harvard Pilgrim Health Care will modify it's policies to reference the related ICD-10 codes applicable where an ICD-9 code is referenced. Health New England Do not know HNE is actively updating their policies
as needed. Senior Whole Health
Tufts Health Plan /
Q23: Has the payer
included, or will you
include, ICD-10
diagnosis and
procedure codes in
any policies?
Payer
Response
Comment
Blue Cross Blue Shield Yes Boston Medical Center HealthNet Plan Yes Harvard Pilgrim Health
Care Yes Harvard Pilgrim Health Care will modify it's policies to reference the related ICD-10 codes applicable where an ICD-9 code is referenced.
Health New England Do not know MassHealth
-Tufts Health Plan /
Q24: If not already
available, by when
will medical policies
amended for
ICD-10 be available?
Blue Cross Blue Shield -Boston Medical Center HealthNet Plan
-Harvard Pilgrim Health Care 8/1/2015 Health New England 9/1/2015
MassHealth
-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
Response
Blue Cross Blue Shield BCBSMA will reimburse claims as appropriate, based on how they were coded
Boston Medical Center
HealthNet Plan 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.
Harvard Pilgrim Health Care HPHC will update our policies posted on our external website to reflect ICD-10 codes where applicable.
Health New England Yes, all applicable codes will be approved for payment.
MassHealth No, each claim must provide unique, specific and documented ICD-10 diagnosis code(s).
Tufts Health Plan / Network Health
-Q26: Will the payer
be using CMS
GEMs as part of its
process?
Blue Cross Blue Shield Yes Boston Medical Center HealthNet Plan Yes Harvard Pilgrim Health Care Yes Health New England Yes
MassHealth Yes
Q27: Will the
payer provide the
mapping of ICD-9
to ICD-10 they will
be utilizing?
Payer
Response
Comment
Blue Cross Blue Shield Yes Maps already available via MHDC website. Boston Medical Center
HealthNet Plan No Harvard Pilgrim Health
Care NA HPHC published policies will delineate the mapping from ICD-9 to ICD-10. Health New England No
MassHealth No Tufts Health Plan /
Q28: Will the payer
support
acknowledgement
testing with
providers? (A Pass
or Fail response will
be returned for
each 837 file
submitted.)
Blue Cross Blue Shield Yes Boston Medical Center HealthNet Plan No Harvard Pilgrim Health Care Yes Health New England Yes
MassHealth Yes
Q29: Will the payer
support
validation testing
with providers? (A
999 and 277CA will
be returned for
each 837 file
submitted.)
Payer
Response
Comment
Blue Cross Blue Shield Yes 999 only. Boston Medical Center HealthNet Plan Yes 999 only. Harvard Pilgrim Health Care Yes
Health New England Yes
MassHealth Yes 999 only. Tufts Health Plan / Network Health Yes
Q30: Will the payer
support
end-to-end testing with
providers? (An 835,
999 and 277CA will
be returned for
each 837 file
submitted.)
Blue Cross Blue Shield No Completed end-to-end testing in 2014. Boston Medical Center HealthNet Plan Yes Providers will get a 999. 835 provided on a
limited basis, based on time and resource availability.
Harvard Pilgrim Health Care To be determined HPHC plans on supporting 835 but not yet able to do so.
Health New England Yes Only for selected hospitals and provider groups.
MassHealth Yes 835 and 999 will be issued, but
MassHealth does not support the 277CA. Tufts Health Plan / Network Health No Completed end-to-end testing in 2014.
Q31: If the payer
responded “Yes” to
any one or number
of the test
approaches, is
there a limit on the
number of
transactions that
can be submitted?
Payer
Response
Comment
Blue Cross Blue Shield Yes TBD
Boston Medical Center HealthNet Plan Yes Maximum of 25 claims or less in a batch file.
Harvard Pilgrim Health Care No
Health New England Yes Initial test cycles limited to fewer than 50 claims. Subsequent tests may allow for increased volume.
MassHealth Yes 25 from providers; 50 from vendors. Tufts Health Plan / Network Health No
Q32: If the payer
responded “Yes” to
any one or number
of the test
approaches, will
the payer accept
fictitious or
anonymized claims
data?
Blue Cross Blue Shield Yes Acknowledgement testing does not perform subscriber or member matching. Boston Medical Center HealthNet Plan No The Plan’s test environment is a subset of
production data and can accept current production active members/providers only.
Harvard Pilgrim Health Care No Health New England No MassHealth No Tufts Health Plan / Network Health No
Q33: If the payer
responded “Yes” to
any one or number
of the test
approaches, in
what format should
test claims be
submitted?
Payer
Response
Blue Cross Blue Shield ANSI 5010 Boston Medical Center HealthNet Plan ANSI 5010 Harvard Pilgrim Health Care ANSI 5010 Health New England ANSI 5010 MassHealth ANSI 5010 Tufts Health Plan / Network Health ANSI 5010
Q34: Has the payer
tested, or will the
payer be testing
with
clearinghouses
(e.g., SSI,
RelayHealth)?
Blue Cross Blue Shield Yes Boston Medical Center HealthNet Plan Yes Harvard Pilgrim Health Care Yes Health New England Yes
MassHealth Yes
Q35: How often will
the payer provide
ICD-10 status
updates?
Payer
Response
Blue Cross Blue Shield As-needed Boston Medical Center HealthNet Plan As-needed Harvard Pilgrim Health Care As-needed
Health New England Planning to complete a test cycle approximately every two weeks.
MassHealth Monthly
Q36: Can the
payer's provider
updates be found
online?
Blue Cross Blue Shield Yes Boston Medical Center HealthNet Plan Yes Harvard Pilgrim Health Care Yes Health New England No
MassHealth Yes
Q37: Does the
payer's companion
guide reflect ICD-10
updates?
Payer
Response
Blue Cross Blue Shield Yes Boston Medical Center HealthNet Plan Not yet
Harvard Pilgrim Health Care Currently being updated to be published by June 15, 2015. Health New England Yes
MassHealth No, the HIPAA modifications for ICD-10 are "required" data elements. Therefore, CG modifications are not required. Tufts Health Plan / Network Health No updates are needed as the
