Affinity Health Plan

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  • ICD-10: Making the transition

    This page includes resources to help Affinity’s provider community adopt ICD-10 code sets.

    ICD code conversion widget

    Use this handy widget to instantly convert disease classification codes from ICD-9 to ICD-10 (will also convert ICD-10 codes to ICD-9):

    Affinity has a formal initiative in place to remediate all non-ICD-10 compliant systems, policies and processes. Through the ICD-10 initiative, Affinity will:

    • Work with providers, suppliers and partners to implement the ICD-10-CM for diagnosis coding and/or ICD-10-PCS for procedure coding conversion
    • Ensure that Affinity can properly accept and adjudicate claims containing ICD-10 codes
    • Train Affinity’s internal staff to ensure continuity of current processes
    • Implement processes to help ensure that claims are not improperly rejected

    Affinity Health Plan will follow its current process, which is to issue authorizations based on request date. Affinity will begin accepting ICD-10 codes for authorization and referral requests from September 1, 2015 for date of service on or after October 1, 2015.

    • If an authorization is requested before the compliance date, and the date of service/date of discharge is before October 1, 2015, providers should submit an ICD-9 code
    • If an authorization is needed before the compliance date for a date of service/date of discharge on or after October 1, 2015, providers should submit an ICD-10 code any time after September 1, 2015
    • If an authorization is requested on or after the compliance date, and the date of service/date of discharge is on or after October 1, 2015, providers should submit an ICD-10 code
    • Services that spans the compliance date of October 1, 2015:
      • If an authorization is requested for an outpatient/professional service that begin prior to October 1, 2015, even if the service ends on or after October 1, 2015, providers should submit an ICD-9 code for entire service
      • If an authorization is requested for an inpatient service with date of discharge on or after Oct.1, 2015, even if the admission is prior to October 1, 2015, providers should submit an ICD-10 code

    Affinity Health Plan will adjudicate claims based on the following CMS rules:

    • Outpatient/Professional Services
      • Claims with a date of service of October 1, 2015 or later must use the ICD-10 code set
      • Claims with a date of service prior to October 1, 2015 should continue to use ICD-9 codes, this includes “Run-out” claims (those submitted to Affinity on or after October 1, 2015, but with a date of service of September 30, 2015 or earlier) should continue to use ICD-9 codes
      • Claims that span the date of service of October 1, 2015 must be split to separate ICD-9 claims (date of service prior to October 1, 2015) from ICD-10 claims (date of service on or after October 1, 2015)
    • Inpatient/Institutional Services
      • Claims with a discharge date prior to October 1, 2015 should continue to use ICD-9 codes
      • Claims with a discharge date/through date of October 1, 2015 or later must use the ICD-10 code set
      • Cross-over claims (i.e., claims where a patient is admitted prior to October 1, 2015, but discharged on or after October 1, 2015) must use the ICD-10 code set

    All claims submitted to Affinity must comply with the CMS rules outlined above. Affinity’s ICD-10 compliance rules apply to all claims regardless of claim type (for ex. HCFA 1500, UB04).

    For more information, click on this list of Frequently Asked Questions regarding ICD-10.

    Affinity ICD-10 Compliance Rules Quick Reference (PDF)

    Letter regarding ICD-10 from the Vice President, Network Operations (PDF)

    ICD-10 Provider Factsheet (PDF)

    Additional Resources

    The following web sites contain comprehensive information on ICD-10:
    Centers for Medicare & Medicaid Services (CMS)
    American Health Information Management Association (AHIMA)
    Workgroup for Electronic Data Interchange (WEDI)
    National Center for Health Statistics (NCHS)