Avoid ICD-10 Claims Denials

Wellmark offers environment for end-to-end testing

Date of Publication (July 28, 2015)

Providers everywhere are preparing for the introduction of the International Classification of Diseases, 10th Revision (ICD-10) codes. That includes taking steps to minimize business disruption that could result from denied ICD-10 claims.

To ensure a smooth transition to the new diagnosis codes, Wellmark Blue Cross and Blue Shield has set up an electronic testing environment for providers in Iowa and South Dakota. All the information you need to help avoid claim denials and payment delays is listed on the Wellmark ICD-10 Testing Instructions page.

Ensure end-to-end testing 

Providers and payers learned a valuable lesson with the introduction of the HIPAA 5010 from a few years ago. We discovered that some clearinghouses employed more robust testing than others, which caused unnecessary delays in payment for a number of providers. If you work with a clearinghouse, please: 
  • Confirm that your vendor will conduct end-to-end testing of your ICD-10 claims. (Provider ► Clearinghouse ► Wellmark ► Clearinghouse ► Provider).
  • Make sure you receive an 835 output file for claim results. If you don’t use the 835 file, please make sure your vendor provides an acceptance or rejection report.
  • Ask your vendor to visit the Wellmark ICD-10 Testing Instructions page.

Early testing reveals patterns to avoid

Since providers began sending ICD-10 test claims through Wellmark’s electronic testing environment in mid-May, a number of problematic patterns have begun to emerge. To ensure successful testing, please:
  • Make sure the ICD indicator matches the ICD-9 or ICD-10 diagnosis code.
  • Remember that ICD-9 and ICD-10 diagnosis codes cannot appear on the same claim.

Recent CMS policy generates questions to Wellmark 

The Centers for Medicare and Medicaid Services recently announced a number of steps to ease the transition to ICD-10. Two of these bear mention as questions Wellmark providers may have.

Q: If I use the wrong ICD-10 code, will my claim be denied?
A: Wellmark will not deny provider claims based solely on the specificity of the ICD-10 diagnosis code as long as the provider uses a valid code. However, a valid ICD-10 code will be required on all claims starting on October 1, 2015. It is possible a claim could be chosen for review for reasons other than the specificity of the ICD-10 code.

Q: What is advanced payment and how can I access this if needed?
A: Wellmark is ready. However, if Wellmark is unable to process claims within established time limits because of the ICD-10 implementation, an advance payment may be available. An advance payment is a conditional partial payment, which requires repayment. If advance payment becomes necessary, additional information will be distributed at that time. Wellmark will not make advance payments in the case where a provider is unable to submit a valid ICD-10 claim.

Related Documents

CMS ICD-10 Guidance
(Adobe PDF File)