Wellmark plans to begin end to end testing for ICD-10 in collaboration with providers beginning early 2015. While we will not require testing, all electronic submitters are encouraged to test. Check out the benefits of ICD-10 on the ICD-10 Diagnosis and Procedure Codes page on Wellmark.com.
Wellmark will accept HIPAA 5010 837 electronic claims containing ICD-10 codes in our test environment. These claims will be processed using ICD-10 edits; reimbursements will be calculated with ICD-10 grouper software. 835 electronic remittance advice files will be returned through the test environment for test claims that are submitted electronically.
Purpose and Value of Testing ICD-10 Claims with Wellmark
ICD-10 testing with Wellmark will more than simply confirm that submitters can create electronic data in the correct format, it will allow you to exchange ICD-10 data on test claims while providing processing detail. If you rely on your vendor for format testing only, you will be missing out on opportunities to validate your organization’s readiness for exchanging actual ICD-10 data with Wellmark.
Determine if you are Operationally Ready by answering the following questions:
- Is your organization able to send and receive 837 claims with ICD-10 codes?
- Is your organization able to receive 835 remittance advices with ICD-10 codes?
- Do your test claims process through Wellmark’s ICD-10 business rules and edits as expected?
- Are the physicians within your organization trained to provide the necessary documentation (such as laterality and specificity) to support ICD-10 coding?
- Do your medical coders have a solid understanding of ICD-10 and as result, coding properly?
- Monitor test claims to determine how ICD-10 claims edit and price within Wellmark’s system.
ICD-10 Testing Coordination
If you use a clearinghouse or billing service to submit medical claims to Wellmark, you will need to work with them to coordinate all of your testing. Your clearinghouse or vendor will need to be able to send 837 claim records to our test environment and receive 835 remittance advice from our test environment. All test claim submissions will only be accepted from your vendor or clearinghouse; Wellmark is unable to accept direct test submissions.
Production Data Path
ISA15 = ‘P’ (Production)
Test Data Path
ISA15 = ‘T’ (Test)
Wellmark has provided an environment for testing and has added ICD-10 edits and vital processing information. This is the same Model Office test environment and processes as used for HIPAA 4010 and 5010 testing. We do not require a new submission connection.
- A separate Model Office user ID and password are used to access the test environment. Passwords expire after 30 days. If you need a user ID or a password reset, please contact 800-407-0267.
- You must be registered to receive our test 835 files. If you have not yet registered for an electronic remittance advice, please contact Wellmark’s EC Solutions Registration at WellmarkECSolutionsRegistration@hp.com.
- HIPAA X12 Version 5010 requirements will be evaluated during testing and any invalid claims will be rejected.
- Remittance responses will only be provided via 835 files. No paper reports will be mailed from our test environment.
- Our production environment only generates 835s remittances weekly on Fridays. Our test environment is configured to generate 835s nightly to speed up the testing process.
- You have the opportunity to send batches of ICD-9 along with batches of ICD-10 claims to allow for comparison of claim results for dual coded claims.
- A single claim cannot be submitted with a mix of ICD-9 and ICD-10 codes; claims submitted with both will be rejected.
- You will receive the same .TXN, .Z16, .999 reports in the test environment for both ICD-9 and ICD-10 These reports will look the same as the production version of each report.
- Our test system will accept all providers registered under each submitter. We do not need a separate test user ID or separate file for each provider.
Claims must contain valid Wellmark member and provider information as well as valid ICD-9 or ICD-10 codes to process through our test environment. We will reject data that is not present in our production environment. IMPORTANT: *** Please do not send masked test data. ***
For the purpose of testing, we’ve expanded the window of ICD-9 and ICD-10 effective and cancellation dates.
|Dates of Service prior to October 1, 2015
||Use ICD-9 codes only
|Dates of Service on or after October 1, 2015
||Use ICD-10 codes
Wellmark suggests converting a variety of recently submitted claims to ICD-10 and submitting those for testing. All electronic test claims must be clean and process first pass; test claims will not be manually worked in the test environment.
Wellmark's test environment will accept institutional, outpatient and professional claims for ICD-10 testing.
Wellmark Testing Constraints
- It is not Wellmark’s position to provide guidance or recommendations on how to code claims for ANY medical situation.
- Testing will be completed in our Model Office environment. This environment will be refreshed periodically to better mirror the Production environment. However, some differences are anticipated between the two environments.
- The only EDI transactions we are able to test as part of ICD-10 end to end testing are the 837 Claims and 835 Electronic Remittance Advices. We are not able to test the 27x series and will not create 276 Claim Status Response transactions.
- Please use Wellmark local members only. We are not able to pass along test claims to other commercial payers, Medicare, BlueCard or the Federal Employee Program (FEP).
- Claims must process through completion automatically. No claims will be manually worked in the test environment. As such, you may not receive an 835 on every claim submitted. (e.g. not a clean claim)
- Wellmark consistently monitors the Model Office environment to address benefits and edits tied to ICD-9 that have been implemented recently. As such, there may be some situations where ICD-9 claims may process or have different edits than ICD-10 edits.
APR-DRG Grouper Version
- Our Model Office environment will contain 3M's APR-DRG Grouper version 31 for testing in 2015 through early Q2.
- July 1, 2015 through June 30, 2016, Wellmark will upgrade to 3M's APR-DRG grouper version 32.
- 3M has stated there are no clinical changes between versions 30 and 31. However, grouping results may vary between version 31 and 32.
|July 1, 2014||October 1, 2014||July 1, 2015||October 1, 2015||July 1, 2016
Please direct ALL inquiries regarding testing to our ICD-10 e-mail box: ICD-10Testing@wellmark.com.