Standard Stop Loss Disclosure Form
Disclosure required by most stop loss carriers and MGUs has grown in
sophistication and use. Today, most stop loss sources require
an employer disclosure before a new or renewal quote is offered.
Ideally, the Employer Disclosure lists all known high cost claims,
claims that have exceed a given dollar threshold, or
patient/employees with certain diagnoses. Failure to disclose these
individuals can later lead to claim denials.
Boards of the Self-Insurance Institute of American (www.SIIA.org), Society of Professional Benefits Administrators (www.SPBATPA.org)
and Health Care Administrators Association (www.HCAA.org) have endorsed the Employer Disclosure and its
accompanying codes set. The goal of the Standard Disclosure
Form is to improve the accuracy and timeliness of disclosure and
reporting of claims for partially self-funded health benefit programs.
Provided below is general background about the ICD, as well as the
specific process undertaken to develop the updated coding document.
Overview on the transition to ICD-10
The current clinical coding system in the United States (known as "ICD-9") -
used by healthcare providers and carriers to communicate types of clinical
patient conditions and treatments - is over 30 years old, and much of the
industry no longer considers it usable for today's treatment, reporting and
payment processes. As a result, Health and Human Services (HHS), under the
guidance of Centers for Medicare and Medicaid Services (CMS) lead the
implementation to a new coding system ("ICD-10") scheduled for October 1,
2015. The transition to the new coding system is a significant undertaking
for the insurance and self-insurance industry
What are clinical codes? What is ICD-10?
Clinical codes are sets of characters that represent clinical conditions,
diseases and procedures in a consumer's healthcare record. Clearly, these
clinical codes are critical for providers, health plans, third party
administrators, agencies and consumers. ICD-10 is the World Health
Organization's (WHO) 10th edition of its International Classification of
Diseases. CMS has adopted WHO's ICD-10 diagnosis codes and expanded ICD-10
implementation to inpatient procedure codes. With the upgrade to ICD-10 the
diagnosis codes are increasing from approximately 14,000 clinical language
possibilities to more than 68,000. If you add in alpha extensions the total
number of ICD-10 diagnosis codes is more than 91,000!
How does this impact the self-insurance industry?
Most self-insured health plans purchase stop loss insurance to protect the
Plan Sponsor from large claims. The insurers and MGUs that underwrite stop
loss use a disclosure statement to identify members that are potential large
claims. Part of the disclosure process is for TPAs to disclose members that
have had one or more claims with a diagnosis code that matches one of the
codes on a "trigger list" of diagnosis codes.
In the early 2000's a group of industry professionals collectively known as
the Industry Study Group ("ISG") created a Disclosure Notification form
along with a list of ICD-9 diagnosis codes that carriers and MGUs could
adopt to ease the burden of TPAs having to program their claim systems for
different trigger code lists for every carrier/MGU that wrote stop loss on
Plans the TPA administered. The Disclosure Notification and list of ICD-9
codes created by the ISG became known as the Industry Standard Disclosure
Notification and trigger list.
Now with the industry switching from the old ICD-9 coding system to the new
ICD-10 coding system the ISG once again undertook a project to develop a new
trigger list based on ICD-10 diagnosis codes. This document describes the
scope of that project, recognizes the numerous individuals that worked on or
provided input into the project, and describes the process the working group
went through to develop the new trigger list based on ICD-10 codes as well
as the reporting convention adopted so users understand exactly what codes
are included in the ranges of codes listed.
Scope of the project
The original trigger list contained 1,617 different ICD-9 codes. If one
converts just the codes that were on the original ICD-9 trigger list those
1,671 ICD-9 codes convert to 18,599 ICD-10 codes. The reason for the huge
increase was that the new ICD-10 codes contain much more detail than the
original ICD-9 codes so a single ICD-9 code can convert to multiple ICD-10
codes. For example ICD-9 code V5889 converts to 7,746 different ICD-10 codes
when alpha extensions are included.
Conversely multiple ICD-9 codes often convert to the same ICD-10 code. As an
example both ICD-9 codes 440.30 and 785.4 convert to ICD-10 code I70.362.
Removing these redundancies in the ICD-10 codes greatly reduced the number
of codes for trigger list reporting.
The total number of ICD-10 diagnosis codes, including those with alpha
extensions, numbers over 91,000! The total number of ICD-10 codes for
disclosure reporting (i.e. the ICD-10 trigger list), including those with
alpha extensions, numbers 11,808 codes. That number includes many new
diagnosis the group felt should be included that may not have been included
in the original ICD-9 trigger list.
People/Companies Contributing to this
This project could not have been completed without the painstakingly
detailed work performed by the following individuals who devoted countless
hours identifying ICD-10 codes that should be included in the list and by
reviewing the final list to make certain it contained codes that the
majority of participants felt important. Those individuals are:
- Karen Cunningham, Medical Risk Managers
- Lee Davidson, Berkley A&H
- Chris Haugan, Employee Benefit Management Services
- Ken Keefer, CareFirst BlueCross BlueShield
- Kathy Mitchell, Professional Benefits Administrators
- Ellen Motolo, Optum
- Darrin Napier, Spectrum Underwriting Managers
- Julaine Novak, Starline Group
- Jay Ritchie, HCC Life
A special thanks also to Bruce Carlson with CP
Consultants and Ernie Clevenger with CareHere/MyHealthGuide for keeping the
Industry Study Group focused on the importance of this
project for over 3 years, putting together a team of dedicated experts
knowledgeable about diagnosis coding, and providing the leadership to seeing
this project through to completion.
The process the group went through to develop the new trigger list was to
start by manually converting the existing 1,617 ICD-9 codes into 18,599
ICD-10 codes using the GEMS conversion list. Following that several more
codes were added, redundant codes removed, and the entire list of over
20,000 codes was sorted and broken down into subsets or Chapters based on
CMS Tabular listing of ICD-10 codes.
CMS has 21 Chapters of codes. Four (4) of those Chapters do not contain any
codes the group felt significant enough to include in the trigger list.
Those Chapters are:
- Chapter 7 - Diseases of the eye and adnexa (H00-H59)
- Chapter 8 - Diseases of the ear and mastoid process (H60-H95)
- Chapter 12 - Diseases of the skin and subcutaneous tissue (L00-L99)
- Chapter 20 - External causes of morbidity (V00-Y99)
The remaining 17 Chapters were then assigned to 8 reviewers to go through
and determine if any additional codes should be added or if some codes
should be deleted. The entire group or reviewers then reviewed the entire
list of codes for the remaining 17 Chapters.
The ranges included in the final trigger list may contain a few minor codes
that on their own are likely to not be serious enough to warrant inclusion.
This was done purposely where excluding those minor codes would have
resulted in breaking the ranges down into a much larger number of smaller
ranges separated by only 1 or 2 codes. While this may result, at time of
disclosure, in hits on some of those codes deemed minor the underwriter or
clinical reviewer can always ignore those hits if he/she feels the diagnosis
is not significant.
The group recognized that there will never be 100% consensus on which codes
to include in the list of trigger codes for disclosure reporting simply
because different reviewers likely have had different experience with
different diagnosis. When that happened we felt it better to err on the
conservative side by including the code instead of excluding the code.
ICD-10 diagnosis codes contain from 3-7 digits (alpha or numeric) the first
of which must be alpha, the second must be numeric, and digits 3-7 can be
either alpha or numeric. For reporting purposes we adopted the following
If a single code is reported it includes all codes with one or more digits
to the right of the rightmost digit in the reported code. For example code
F20 includes all codes from F20.0 through F20.9, code G82.5 includes all
codes from G82.50 through the last code with a prefix of G82.5, which is
G82.54. Similarly where a range of codes was described, such as C00-C96,
that range would include all codes up through and including the last code in
C96, which is C96.9.
Neither the ISG nor any other person/company that worked on this project
makes any representations or warranties regarding its accuracy. Moreover
this list may, from time to time, be updated to reflect code additions or
deletions made by CMS or some other governing body. Users are free to use
this list or to develop their own for disclosure reporting purposes.
Finally, while SIIA supports the work of the ISG, the ICD-10 document should
not be considered an official work product of the association. On July 30,
2015, the IRS released its second publication on the so-called
"Cadillac" tax, a non-deductible 40% excise tax on high-cost health
coverage that is scheduled to take effect in 2018.
About the Industry Study Group
The Industry Study Group is a group of TPAs, stop carriers and MGUs that have been meeting since the early 1990s. One of the purposes is to discuss and propose solutions to industry challenges.