Electronic Solutions

HIPAA Information

The Health Insurance Portability and Accountability Act (HIPAA) mandates the standardization of EDI formats for health care data transmission, which includes claims, remittance, eligibility and claim status inquiries. HIPAA regulations replace the CMS 1500 and UB04 Claims formats with ASC X12N 837 Transactions.

The BCBSNC Companion Guide is available to assist trading partners in understanding Blue Cross and Blue Shield of North Carolina (BCBSNC) code and situation handling used in processing the ANSI ASC X12N Transactions. In October, 2010, two different versions of the Companion Guide will be available: one for x12 version 4010 and one for x12 version 5010.

ICD-10 Information

On October 1, 2014, the healthcare industry in the United States will begin using the ICD-10 code set when submitting claims. The current ICD-9 code set has no more room for growth and will be retired. This change will affect institutional and professional claims.

BCBSNC will be ready to process the ICD-10 codes on October 1, 2014 and will not accept ICD-10 codes before the October 1, 2014 implementation date. There will be no grace period or dual use period for ICD-9 codes after October 1, 2014. The following rules will be used:

    Professional claims:
      If the dates of service are greater than September 30, 2014, use ICD-10,
      If the dates of service are less than October 1, 2014, use ICD-9,
      If the dates of service span October 1, 2014, split the claim so that one claim covers the time before October 1, 2014 and the other claim covers the time from October 1, 2014 and later.

    Institutional claims:
      If the discharge date is greater than September 30, 2014 use ICD-10,
      If the discharge date is less than October 1, 2014, use ICD-9.

Business Impact:

    Providers not using the appropriate ICD-10 code after the October 1, 2014 implementation date will experience major business disruptions including claims payment issues. Providers still using the HIPAA 4010 version for their claims will have a rather difficult time since the 4010 version does not support using ICD-10 codes.

ICD-10 Testing:

    BCBSNC is not requiring testing for the ICD-10 codes. However, BCBSNC will have RampManager set up to facilitate ICD-10 testing for those EDI trading partners who wish to test. RampManager testing will be for HIPAA X12 syntax and structure only. It will not provide any end to end testing. RampManager will be set up for ICD-10 testing in the 4th quarter of 2013.

If you have any questions, please contact Guy Ferrari at (919) 765-7092 or Guy.Ferrari@BCBSNC.com.

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