Provider Manual
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Medicaid Managed Care
- Product Overview
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Benefit Information
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Clinical Trials and Related Routine ServicesDental and Oral SurgeryHome Health Care ServicesNever EventNon-covered ServicesNurse On-Call and Telemonitoring ProgramsPersonal Care ServicesSkilled Nursing FacilitySterilization - Hysterectomy CoverageSterilization - Tubal Ligation or Vasectomy CoverageTransportation ServicesUrgent Care & Emergency RoomVision care
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Care Management
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Additional ProgramsChronic Care ManagementHealth AssessmentNational Committee for Quality AssurancePotentially Preventable Readmission programPrenatal Care Coordination ServicesPreventive Service GuidelinesPrograms for membersQuality Improvement - Utilization Management Program Overview Security Health Plan ProtocolsWellness and Health Promotion
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Claims Processing Policies and Procedures
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Anatomical Modifier Requirement PolicyBilling claims for dates that span a change of enrollmentClaims Coding ResourcesClaims Payment CalendarClean Claim and InterestCMS 1500 InstructionsCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityDrug Wastage PoliciesElectronic ClaimsElectronic File Submission ProcessGenetic and Molecular Lab TestingLimitation of LiabilityModifier InformationNational Drug Code RequirementsOutput ReportsProvider Appeal and Grievance PolicyProvider Validation for Claims ProcessingProvider Remittance Advice StatementReimbursement for Inappropriate Discharge and ReadmissionReimbursement Recovery ProcessReference outside Laboratory Billing ProtocolSubrogationSurgery InformationTesting ProceduresTimely Filing for Claim SubmissionTrading Partner for Electronic DataTransaction TermsTransmissionUB 04 Instructions and Sample Claim FormUnlisted CodesWorkers' Compensation
- Clinical Practice Guidelines
- Contact Information
- Documentation Requirements
- ForwardHealth
- Fraud, Waste and Abuse
- HealthCheck
- Health Equity and Cultural Sensitivity Awareness
- Important Disclosures
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Rights and Responsibilities
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Access StandardsDHS Subcontract requirementsImproper billing of Medicaid Managed Care membersMedical PoliciesPrimary Care - Specialty Care Provider RoleProvider Credentialing ProcessProvider Reporting of Member ComplaintsProvider Response Requirements for Member ComplaintsProvider System Outages and or Material BreachProviders' Expectations of Security Health PlanSecurity Health Plans Expectations of Providers
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Utilization Management
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Continuity and Care CoordinationeviCoreHigh End Imaging - Cardiac studies and elective heart catheterizationHigh end imaging - radiation servicesHome HealthHospital admissions - Pre-certificationHospital Urgent/Observation AdmissionInappropriate Discharge and ReadmissionInpatient Acute Rehabilitation/Long Term Acute CareMedical NecessityMusculoskeletal proceduresNavihealth-Skilled Nursing Facility CareNorthwood DMENursing Facility Care/Skilled Nursing Facility CarePhysical, Speech and Occupational Therapy - OutpatientPre-certification Notification and Concurrent Review GuidePrior authorizationPrior Authorization for Non-affiliated ProvidersProvider Appeal and Grievance PolicySecond OpinionServices related to oral appliances - for treatment of obstructive sleep apneaSleep managementSterilization: Hysterectomy CoverageTechnology AssessmentUtilization management general informationUtilization management for behavior healthUtilization management for timeliness standards
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Family Health Center
- Program Overview
- Benefit Information
- Care Management
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Claims Processing and Policies and Procedures
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Anatomical Modifier Requirement PolicyClaims Coding ResourceClaims Payment CalendarClean Claim and InterestCMS 1500 InstructionsCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityDrug Wastage PoliciesElectronic ClaimsElectronic File Submission ProcessLimitation of LiabilityModifier InformationNational Drug Code RequirementsOutput ReportsProvider Appeal and Grievance PolicyProvider Remittance Advice StatementReference Outside Laboratory Billing ProtocolReimbursement Recovery ProcessSubrogationTesting ProceduresTimely Filing for Claim SubmissionTrading Partner for Electronic DataTransaction TermsTransmissionUB 04 Instructions and Sample Claim FormUnlisted CodesWorkers Compensation
- Clinical Practice Guidelines
- Contact Information
- Documentation Requirements
- Fraud, Waste and Abuse
- Health Equity and Cultural Sensitivity Awareness
- Important Disclosures
- Member Information
- Pharmacy
- Rights and Responsibilities
- Utilization Management
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Group & Direct Pay
- Product Overview
- Benefit Information
- Care Management
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Claims Processing Policies and Procedures
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Anatomical Modifier Requirement PolicyClaims Coding ResourcesClaims Payment CalendarClean Claim and InterestCMS 1500 InstructionsCoding Quick ReferenceCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityDrug Wastage PoliciesElectronic ClaimsElectronic File Submission ProcessGenetic and Molecular Lab TestingLimitation of LiabilityModifier InformationNational Drug Code RequirementsNew Code PricingNon-covered Services and Experimental/InvestigativeOffice Infusion ProtocolOutput ReportsPrior Authorization Required for Office Based Procedures in ASC or Hospital Outpatient SettingProvider Appeal and Grievance PolicyProvider Reimbursement NotesProvider Remittance Advice StatementReference (Outside) Laboratory Billing ProtocolReimbursement for Inappropriate Discharge and ReadmissionReimbursement Recovery ProcessSubrogationSurgery InformationTesting ProceduresTimely Filing for Claim SubmissionTrading Partner for Electronic DataTransaction TermsTransmissionUB-04 InstructionsUnlisted CodesWorkers' Compensation
- Clinical Practice Guidelines
- Contact Information
- Documentation Requirements
- Fraud, Waste and Abuse
- HCC - Risk Adjustment/Government Programs
- Health Equity and Cultural Sensitivity Awareness
- Important Disclosures
- Member Information
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Pharmacy
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Claims ProcessingDrug FormularyFormulary Exception RequestsGeneral ExclusionsGeneric SubstitutionOffice/Medical Setting Administered Medications that require prior authorization Over-the-Counter Medication CoveragePharmacy Utilization ManagementPrior AuthorizationSpecialty pharmacyStep TherapyTobacco Cessation Coverage
- Provider Directory
- Rights and Responsibilities
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Utilization Management
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Continuity and Care CoordinationDurable Medical Equipment and Home Respiratory EquipmenteviCoreHigh End Imaging - Cardiac studies and elective heart catheterizationHigh End Imaging - Radiation ServicesHome HealthHome IV Drug TherapiesHospice ProtocolsHospital Urgent/Observation AdmissionInappropriate Discharge and ReadmissionInpatient Acute Rehabilitation/Long Term Acute CareMedical NecessityMusculoskeletal proceduresNorthwood DMEOutpatient Therapy Treatment ConcurrentPharmaceuticals - Specialty Medications (Magellan)Physical, Speech and Occupational Therapy - OutpatientPre-Certification Notification and Concurrent Review GuidePrior authorizationsProvider appeal and grievance policyRadiation Oncology ServicesSecond OpinionServices related to oral appliances - for treatment of obstructive sleep apneaSkilled Nursing Facility AdmissionSleep managementTechnology AssessmentUtilization management general informationUtilization management for Behavior HealthUtilization management for Timeliness Standards
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Medicare Advantage
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Product Overview D-SNP
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Ally Rx D-SNP BasicsAlly Rx D-SNP Model of CareBilling Ally Rx D-SNP MembersDiscussion of Disenrollment from Medicare AdvantageEncounter Data PolicyMedicare Advantage Part D Data SubmissionsMedicare Advantage Part D Reporting RequirementsMedicare Advantage Reporting RequirementsRecipient of Federal Funds PolicyWhat are Medicare Advantage Plans
- Product Overview HMO and D-SNP
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Benefit Information
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Acupuncture for chronic low back painContinuity and Coordination of CareDental BenefitsEmergency and Non-emergency TransportationEmergency and Urgently Needed Care CoverageHearing Services and Hearing AidsHome Health Care ServicesHome INR MonitoringMacular Degeneration Eye InjectionsPlan OverviewsPreventive Care CoverageRenal DialysisSkilled Nursing FacilityVision and Hardware Coverage
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Care Management
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Additional ProgramsAdvance Directive PolicyChronic Care ManagementCoverage DeterminationEnd Stage Renal Disease (ESRD) Care CoordinationHealth Risk AssessmentHospice Care CoordinationNational Committee for Quality AssuranceNotice of Medicare NoncoverageOutpatient Observation Frequently Asked QuestionsPreventive Service GuidelinesPrograms for MembersQuality Improvement/Utilization Management Program OverviewSecurity Health Plan ProtocolsTwo Midnight RuleWellness and Health Promotion
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Claims Processing Policies and Procedures
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Anatomical Modifier Requirement PolicyBilling and ReportingClaims Coding ResourcesClaims Payment CalendarClean Claim and InterestCMS 1500 InstructionsCoding Quick ReferenceCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityDrug Wastage PoliciesElectronic ClaimsElectronic File Submission ProcessGenetic and Molecular Lab TestingLimitation of LiabilityNational Drug Code RequirementsModifier InformationOffice Infusion ProtocolOutput ReportsPayment IssuesProvider Appeal and Grievance PolicyProvider Remittance Advice StatementRate Letters from CMS for CAH, RHC & Swing BedsReference (Outside) Laboratory Billing ProtocolReimbursement for Inappropriate Discharge and ReadmissionReimbursement Recovery ProcessSkilled Nursing Facility (SNF) and Consolidated Billing SubrogationTesting ProceduresTimely Filing for Claim SubmissionTrading Partner for Electronic DataTransaction TermsTransmissionUB-04 Instructions and Sample Claim FormUnlisted CodesWorkers' Compensation
- Clinical Practice Guidelines
- Contact Information
- Documentation Requirements
- Fraud, Waste and Abuse
- HCC - Risk Adjustment
- Health Equity and Cultural Sensitivity Awareness
- Important Disclosures
- Member Information
- Pharmacy
- Primary Care Provider
- Provider Directory
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Rights and Responsibilities
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Access StandardsMedical policiesProhibition of Interference with Health Care Professionals Advice to Medicare Advantage MembersProvider ContractingProvider Credentialing ProcessProvider Reporting of Member ComplaintsProvider Response Requirements for Member ComplaintsProvider System Outages and or Material BreachProviders' Expectations of Security Health PlanSecurity Health Plan's Expectations of ProvidersSkilled Nursing Facility Denial of Medicare/Medicaid Payment
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Utilization Management
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Authorization of Inpatient CareContinuity and Care CoordinationeviCoreHigh End Imaging - Cardiac imaging and elective heart catheterizationHigh End Imaging - Radiation ServicesHome HealthHome IV Drug TherapiesHospice ProtocolsHospital Inpatient Utilization ReviewHospital Urgent/Observation AdmissionInappropriate Discharge and ReadmissionInpatient Acute Rehabilitation/Long Term Acute CareMedical NecessityMusculoskeletal proceduresNavihealth-Skilled Nursing Facility CareNorthwood DMEPharmaceuticals - Specialty Medications (Magellan)Physical, Speech and Occupational Therapy - OutpatientPre-Certification Notification and Concurrent Review GuidePrior authorizationsProvider appeal and grievance policyRadiation Oncology ServicesSecond OpinionServices related to oral appliances - for treatment of obstructive sleep apneaSkilled Nursing Facility AdmissionSleep managementTechnology AssessmentUtilization management general informationUtilization Management for behavior healthUtilization Management for timeliness standards
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Product Overview D-SNP
ICD-10 Implementation
Last Updated on October 06, 2026
As communicated, effective October 1, 2015, the ICD-9 code sets used to report medical diagnoses and inpatient procedures have been replaced by ICD-10 codes. If any issues are identified with the new coding we will use this website location to provide updates.
October 9, 2015 ICD-10 Update
Important information based on claim rejections we are seeing
Coding Claims: When to Use ICD-10 versus ICD-9
Use of ICD-10 versus ICD-9 on claims is based on dates of service—not on dates that claims are submitted.
- For dates of service before October 1, 2015, use ICD-9 codes.
- For dates of service on or after October 1, 2015, use ICD-10 codes.
For example, if you submit a claim for services provided on September 30, 2015, use ICD-9, even if you are submitting the claim in October 2015 or beyond.
For hospital inpatient claims, use date of discharge rather than date of service to determine whether to code in ICD-10 or ICD-9.
When billing electronically, send a “BK” indicator for ICD9 codes and an “ABK” indicator for ICD10 codes.
How do I indicate if I am using ICD-9 or ICD-10 on the paper claim forms (CMS-1500 and UB-04)?
Field 21 of the CMS1500 form gives providers the ability to indicate whether they are using ICD-9 or ICD-10 diagnosis codes on the form, using a single-digit numeric value in the top right of the field. The UB-04 form includes a space for the version indicator in field 66. For both forms, the valid values for these qualifiers are “0” and “9.” An indicator of "9" means that all diagnosis codes that follow are in ICD-9 and an indicator of "0" means that all diagnosis codes that follow are in ICD-10. There is only one ICD indicator per form, and providers cannot mix ICD-9 and ICD-10 codes on the same claim form.
ICD-10 qualifier Documentation
Electronic claims
Code Qualifiers: In the electronic claim, the ICD version indicator is in the HI – Health Care Diagnosis Code segment. Ø Professional Claim (837P) ICD Code Set Qualifiers: HI – Health Care Diagnosis Code segment / loop 2300 ABK = ICD-10-CM – Principal Diagnosis BK = ICD-9-CM – Principal Diagnosis ABF = ICD-10-CM – Diagnosis BF = ICD-9-CM – Diagnosis
Paper claims
Field 21 of the CMS1500 form gives providers the ability to indicate whether they are using ICD-9 or ICD-10 diagnosis codes on the form, using a single-digit numeric value in the top right of the field. The UB-04 form includes a space for the version indicator in field 66. For both forms, the valid values for these qualifiers are “0” and “9.” An indicator of "9" means that all diagnosis codes that follow are in ICD-9 and an indicator of "0" means that all diagnosis codes that follow are in ICD-10. There is only one ICD indicator per form, and providers cannot mix ICD-9 and ICD-10 codes on the same claim form.
We are always available to help with information and answers to your ICD-10 questions. Contact our Provider Relations and Contracting Department at 1-800-548-1224 or by email at shpprd-mfld@Sanfordhealth.org.
Common questions about ICD-10
Click here for a list of common questions to help you learn how the transition to ICD-10 will affect your organization and what you will need to do to comply with the new requirements.