Claim Submission
Q1. When will Wellmark begin accepting ICD-10 codes on our claims?
A1. On October 1, 2014, Wellmark will accept ICD- 10 codes on claims for services provided on or after October 1, 2014. ICD-10 codes cannot be used to bill services provided before that date.
Q2. Will there be a transition or grace period during which Wellmark will accept either an ICD-9 or ICD‑10 code on our claims regardless of the date of service?
A2. Per the mandate, claims with service dates on or after October 1, 2014, must process using ICD-10 codes, while service dates prior to October 1, 2014, must process using ICD-9 codes. Wellmark will deny claims submitted with inappropriate codes as determined by the date of service.
Q3. How should we file a claim that includes services before and after October 1, 2014?
A3. Claims cannot be submitted with a mix of ICD-9 and ICD-10 codes. Claims submitted with both will be rejected. To determine how to file services, refer to the tables in CMS ruling (CR #7492). Wellmark will communicate any deviations from the CMS guidance in future Blue Ink newsletters or on our ICD‑10 website page.
Q4. When is the last date Wellmark will accept ICD‑9 codes?
A4. For most Wellmark members, you have 365 days from the date of service to file a claim for the first time. This means that services provided on September 30, 2014, must be filed by September 30, 2015, which will be the last date a new claim can be submitted with an ICD-9 code. Wellmark’s timely filing guideline includes a few exceptions, including Medicare supplement and BlueCard® claims (for members whose coverage is with a Blue Plan in another state). See the Claims filing section of our Wellmark Provider Guide for specific timely filing information.
Q5. Will both electronic and paper claims require ICD-10 coding?
A5. All claims need to be compliant.
Q6. If we transmit electronic claims, do we need to make any interface or other technical adjustments to assure complete and accurate transmissions?
A6. All electronic claims need to be in the HIPAA X12 Version 5010 format, which accommodates the ICD-10 code structure. The compliance deadline for HIPAA 5010 compliance was January 1, 2012.
Q7. Will you be using a standard map or a customized map to convert to ICD-10?
A7. Wellmark is not using a mapping system to crosswalk codes. A crosswalk document will not be available because Wellmark is converting to a system based on ICD-10 codes.
Claims Reimbursement
Q1. Will Wellmark renegotiate provider contracts that have diagnosis-based payment provisions?
A1. Wellmark is required to provide a 120-day notice prior to the effective date of any provider agreement change. At this point, we are evaluating the effect of the ICD-10 changes and will communicate information on this topic in the future.
Q2. Will DRG groupers (inpatient and outpatient facility) continue to be based on ICD-9 codes after the adoption of ICD-10 codes?
A2. Our groupers will be both ICD-9 and ICD- 10 compliant so that Wellmark can process services correctly based on the date of service (see question 2). Wellmark is currently working with 3M, our vendor, to determine which grouper versions will be used.
Q3. If ICD-10 codes are used, will the payer give the member a copy of the new grouper logic?
A3. Wellmark uses 3M grouping software which is proprietary.
Q4. How will you handle payment for diagnosis based reimbursement?
A4. Reimbursement for dates of service through September 30, 2014, will be based on ICD-9 diagnosis and procedure codes. Reimbursement for dates of service on and after October 1, 2014, will be based on ICD‑10 codes.
Q5. To what degree will the transition impact managed care rate schedules?
A. Wellmark is currently evaluating our approach and will communicate information in the future.
Q6. Do you intend to change medical-necessity requirements because of the more specific codes that will be available? A. Wellmark is currently evaluating our approach and will communicate information in the future.
Q7. How do you plan to manage capitation reconciliations? A. Wellmark is currently evaluating our approach and will communicate information in the future.
Transition Time Line
Q1. When will Wellmark be ready to accept test claims containing ICD-10 codes?
A1. Wellmark plans to target high-volume submitters to test with us early in the third quarter of 2014. We will contact those providers in advance.
Q2. Will Wellmark share its testing results?
A2. Wellmark is currently evaluating our approach and will communicate information in the future.
Q3. Do you intend to change medical-necessity requirements because of the more specific codes that will be available?
A3. Wellmark is still evaluating our approach. Any medical-necessity changes will be communicated in the future.
Q4. Because there will be a period where you will be simultaneously processing ICD-9 and ICD‑10 claims that will have very different IT processing requirements given the differences in amount of data, complexity, etc., what are your plans to manage potential problems related to network connectivity processing time and overall integration?
A4. The Wellmark systems and processes will be updated to handle the ICD-9 claims run out and ICD‑10 claims.
Q5. Where are you in your implementation/conversion cycle?
A5. Currently in produce phase with internal testing starting April 2013.
Q6. What system(s) of yours will need to be updated in order to be ICD-10 compliant?
A6. Claims processing and reporting systems will be updated.
Q7. Will you be required to fully upgrade your system(s) or will you only be installing a fix or patch?
A7. Wellmark is fully upgrading its systems for ICD-10
Q8. How does your organization plan to handle anticipated ICD-9 or ICD-10 reimbursement/adjudication delays?
A8. Wellmark is currently in process of identifying and developing mitigation plans for any potential reimbursement/adjudication delays.
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