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ICD-10 FAQs

ICD-10 coding went into effect October, 1st , 2015. Claims sent in with a date of service on or after October 1st, must be submitted with valid ICD-10 coding.



What is Health Net's program approach to implement ICD-10?

Health Net will be compliant by the ICD-10 implementation date of October 1, 2015. A cross-functional team of Health Net subject-matter experts is working on testing requirements for systems and business processes under a program approach. Health Net will enhance core enterprise systems to directly utilize ICD-10 data for processing.

What is Health Net's primary strategy for ICD-9 and ICD-10 claims processing after the ICD-10 implementation date?

Health Net will process ICD-10 claims based on, including, but not limited to, Centers for Medicare and Medicaid Services (CMS) guidelines, regulations, dates of service, and discharge dates. This translates to Health Net accepting ICD-10 claims with dates of service and discharge dates on and after October 1, 2015, and ICD-9 claims received after October 1, 2015, with dates of service and discharge dates prior to October 1, 2015.

Is Health Net planning to accept ICD-9 after the compliance date?

Health Net will only accept claims with ICD-9 codes received after October 1, 2015, with dates of service and discharge dates prior to October 1, 2015, according to the HIPAA ICD-10 final rule mandate.

Is Health Net planning to accept ICD-10 before the compliance date?

No. Health Net will only accept ICD-10 claims with dates of service and discharge dates on and after October 1, 2015.

How long will Health Net provide support for both ICD-9 and ICD-10?

Health Net will remain compliant with existing Provider Participation Agreement (PPA) language, and state, federal and regulatory requirements related to claims processing timelines.

What are Health Net's processing guidelines for paper claims on and after October 1, 2015?

The use of these ICD-10 code sets is not predicated on how the claim is submitted. Paper claims will be subject to the same rules as electronic claims, in accordance with CMS guidelines.

Does Health Net have plans to update its medical policies to be consistent with ICD-10 prior to the implementation
date?

Health Net will update all medical policies in accordance with ICD-10 coding, as needed, and communicate these changes to providers prior to the ICD-10 implementation date of October 1, 2015.

Will Health Net require or support interim billing?

Providers with inpatient members admitted prior to October 1, 2015, and discharged after October 1, 2015, need to submit the final interim bill using ICD-10 codes.

What if a bill is received with mixed ICD-9 and ICD-10 codes?

Health Net will not accept claims with mixed ICD-9 and ICD-10 coding.

How does Health Net intend to handle prior authorizations surrounding the transition date?

ICD-9 codes must be used for authorizations with dates of service prior to October 1, 2015. ICD-10 codes must be used for authorizations with dates of service on or after October 1, 2015.

When does Health Net intend to begin and complete testing for ICD-10?

Health Net has planned external testing for Q3 2015. Health Net will conduct regular testing with providers who submit encounters directly to Health Net, repricing vendors and clearinghouses. Health Net is not planning to test on an individual provider level unless the provider submits encounter data. Health Net encourages each provider to work with his or her clearinghouse to ensure the ability to send and receive data with the clearinghouse prior to the ICD-10 implementation date.

What resources are available for providers who need assistance with ICD-10 implementation?

Health Net encourages providers to work with their claims vendors to prepare for ICD-10 implementation.

The Workgroup for Electronic Data Interchange (WEDI) offers an online resource directory which lists vendors that offer products and services available to assist providers in preparing for ICD-10.

Visit the WEDI website

The CMS website offers resources for providers on the implementation for ICD-10.

Visit the CMS.gov website – Provider Services

Contact Health Net Provider Services Centers

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Important Notice

General Purpose
Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service, or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the Member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether, under the facts and circumstances of a particular case, the proposed procedure, drug, service, or supply is medically necessary. The conclusion that a procedure, drug, service, or supply is medically necessary does not constitute coverage. The Member's contract defines which procedure, drug, service, or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net's National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment and services. In order to be eligible, all services must be medically necessary and otherwise defined in the Member's benefits contract as described in this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the Member's benefits, nor is it intended to dictate to providers how to practice medicine.


Policy Effective Date and Defined Terms.
The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. In some states, prior notice or posting on the website is required before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative.


Policy Amendment without Notice.
Health Net reserves the right to amend the Policies without notice to providers or Members. In some states, prior notice or website posting is required before an amendment is deemed effective.


No Medical Advice.
The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to Members. Members should consult with their treating physician in connection with diagnosis and treatment decisions.


No Authorization or Guarantee of Coverage.
The Policies do not constitute authorization or guarantee of coverage of any particular procedure, drug, service, or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations and dollar caps apply to a particular procedure, drug, service, or supply.


Policy Limitation: Member's Contract Controls Coverage Determinations.
Statutory Notice to Members: The materials provided to you are guidelines used by this plan to authorize, modify or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract. The determination of coverage for a particular procedure, drug, service, or supply is not based upon the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the Member's contract, and requirements of applicable laws and regulations. The contract language contains specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. In the event the Member's contract (also known as the benefit contract, coverage document, or evidence of coverage) conflicts with the Policies, the Member's contract shall govern. The Policies do not replace or amend the Member contract.


Policy Limitation: Legal and Regulatory Mandates and Requirements
The determinations of coverage for a particular procedure, drug, service, or supply is subject to applicable legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern.


Reconstructive Surgery
California Health and Safety Code 1367.63 requires health care service plans to cover reconstructive surgery. "Reconstructive surgery" means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following:


1. To improve function; or
2. To create a normal appearance, to the extent possible.


Reconstructive surgery does not mean "cosmetic surgery," which is surgery performed to alter or reshape normal structures of the body in order to improve appearance.


Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery.


Reconstructive Surgery after Mastectomy
California Health and Safety Code 1367.6 requires treatment for breast cancer to cover prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. Coverage for prosthetic devices and reconstructive surgery shall be subject to the copayment, or deductible and coinsurance conditions, that are applicable to the mastectomy and all other terms and conditions applicable to other benefits. "Mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon.


Policy Limitations: Medicare and Medicaid
Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service, or supply for Medicare or Medicaid Members shall not be construed to apply to any other Health Net plans and Members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid Members by law and regulation.

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I have elected to upload a zipped folder of care coordination documents in a pdf format using the specified file naming convention as set forth below. I understand the importance of ensuring that the file names are accurate and that they accurately identify the member(s) that the care coordination document(s) is/are associated with. I have elect to upload of the attached documents and confirm submission using the review option. I certify that the files will be carefully audited and confirmed to be accurately named before confirming my upload. By confirming my upload, I am representing that the file(s) is/are named accurately.


Document Type - File naming convention
PPG Care Plans - careplan_hnsubidpersonid_yyyymmdd.pdf
CBAS Care Plan - cbascp_hnsubidpersonid_yyyymmdd.pdf
CBAS Assessment - cbasa_hnsubidpersonid_yyyymmdd.pdf
MSSP Assessment - msspa_hnsubidpersonid_yyyymmdd.pdf
MSSP Care Plan - msspcp_hnsubidpersonid_yyyymmdd.pdf
MSSP Connect the Needs Assessment - mctna_hnsubidpersonid_yyyymmdd.pdf
MSSP Connect the Needs Care Plan - mctncp_hnsubidpersonid_yyyymmdd.pdf
SNF MDS Form - snfmds_hnsubidpersonid_yyyymmdd.pdf
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