ICD-10 Medical Policy is important not only for health plans that are undergoing the ICD-10 transition, but for health care providers who are doing proper forward planning on payor contracting. ICD-10 medical policy is a key component in a health plan strategy that will determine how ICD-10 claims are processed and how ICD-10 reimbursement to health care providers will be determined.
ICD-10 Medical Policy Management should include:
Guiding principals for Care Management
Improve wellness, cost savings, auto-adjudication, etc.
- Use of ICD-10 specificity will allow rules to enhance pre-auth and auto-adjudication, improve accuracy and consistency applying policies
- ICD-10 Education and Awareness will help the team develop a better strategy for proper ICD-10 medical policy management.
Develop Criteria for prioritization of Policies to remediate
Base on precise intent and services
Clearly define intent of policy (codable)
Requires increased $, time for policy reviews, expedited approval lack of staff could slow process
Configure Claims System to reflect intent
Testing adjudication results
Multiple scenarios with each policy
Maintenance of Configurations & Rules
Classify each code as include, exclude, review
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