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On Feb. 21, 2024, Change Healthcare experienced a cyber security incident. Any individuals impacted by this incident will receive a letter in the mail. Learn more about this from Change Healthcare, or reach out to the contact center at 1-866-262-5342.

Requirements for ICD-10 Claims and Authorization Processing

Date: 01/26/16

Superior HealthPlan successfully transitioned to ICD-10 on 10/1/2015 as mandated by CMS. Providers must submit claims in accordance with CMS and state guidelines:

Claims Processing

The following information applies to paper, web, and standard electronic (837 X12) claims.

  • Claims may not contain a combination of ICD-9 and ICD-10 codes.
  • Claims must be submitted with ICD-10 codes if the date of discharge / date of service is on or after the ICD-10 compliance date of 10/1/2015.
  • Claims must not be submitted with ICD-10 codes if the date of discharge / date of service is prior to the compliance date of 10/1/2015.
  • For some claims which span the ICD-10 compliance date, the admit date on the claim can be prior to the ICD-10 compliance date and the claim can still contain ICD-10 codes. For other claims which span the ICD-10 compliance date, a splitting of the claim into two separate claims is necessary. CMS has outlined guidance on which claims will need to be split in this claims processing document (SE1408).
  • CMS uses the “bill type” on an institutional claim for determining whether a claim that spans the compliance date should be split. In general, inpatient claims can have dates of service which span the compliance date and contain ICD-10 codes. Outpatient and professional claims cannot have dates of service which span the compliance date and have ICD-10 codes. For outpatient and professional claims, providers must split claims into two separate claims (one claim with a end date on 9/30/15 and another claim with a start date of 10/1/15).
  • Interim bills for long hospital stays (TOB: 112, 113, 114) are expected to follow the same rules as other claims. If a provider submits a replacement claim (TOB: 117) to cover all interim stays, it is expected that the provider must re-code all diagnoses / procedures to ICD-10 since the replacement claim will have a discharge / through date post-compliance.
  • All first-time claims and adjustments for pre-10/1/2015 service dates must include ICD-9 codes, even if claims are submitted post-10/1/2015. Claims with pre-10/1/2015 service dates can be submitted with ICD-9 codes for as long as contracts and provider manuals specify.
  • Reiteration: Claim submission date does not determine whether ICD-9/10 codes should be used. All ICD-9/10 claims submission rules outlined by CMS are based on patient discharge date, or date of service for outpatient/professional services.
  • Claims are reimbursed according to state reimbursement guidelines. Claims are adjudicated natively in ICD-9 for dates of service prior to 10/1/15 and natively in ICD-10 for dates of service on and after 10/1/2015, consistent with CMS requirements.

Authorization Processing

ICD-10 diagnosis codes are accepted on prior authorization requests for services with a start date on or after the ICD-10 compliance date of 10/1/15. ICD-9 codes will no longer be accepted on prior authorization requests submitted on the ICD-10 compliance date or later except in the case of retro authorizations for services with a start date on or before 9/30/15. ICD-9 procedure codes are not used on authorizations and ICD-10 procedure codes will not be used on authorizations.

Questions

Providers: For additional questions, please contact Provider Services at 1-877-391-5921.

Clearinghouses: For additional questions, please contact the EDI service desk at 1-800-225-2573, ext. 25525 or EDIBA@centene.com.