ICD-10 overrides for prescription processing
Customize your policy alerts
Sign up for all kernfamilyhealthcare policy alerts
Know when kernfamilyhealthcare releases new policies or updates existing guidance.
Monitor payer policy activity
Defines specific ICD-10 diagnosis codes that will automatically allow point-of-sale claims for listed medications without prior authorization for Kern Family Health Care members; applies to providers submitting pharmacy claims to the plan.
No material clinical or coverage changes in this revision.
Point-of-Sale Coverage Rules
Point-of-sale ICD-10 overrides
Covered when ALL of the following are met
Clears without prior authorization at point-of-sale; plan quantity limits and DUR edits (member not active with plan, refill-too-soon, drug interactions, formulary strengths) may still apply
Clears without prior authorization at point-of-sale; documentation supporting the diagnosis should be available on hand
FDA dosing guidelines for H. pylori apply; clears without prior authorization at point-of-sale
Claims for the medications listed in this policy that meet the specified ICD-10 override conditions will still be processed through normal claims adjudication. In particular, claims remain subject to the plan's quantity limits and standard DUR edits (for example: member not active with plan, refill-too-soon, drug interactions, and formulary/strength restrictions), any of which can cause a claim to reject at point-of-sale.
Providers must submit the appropriate ICD-10 diagnosis code on the prescription claim to trigger the override and should enter only the alphanumeric characters (do not include the '.' in the data field). Documentation supporting the diagnosis should be available on hand in case of audit or review. For H. pylori indications, FDA dosing guidelines apply.
ICD-10 Code Mappings by Drug
| Y04.1 | Assault by animal bite |
| W53.01 | Bitten or struck by dog |
| W53.19 | Other bite or strike by dog |
| W53.21 | Bitten by other specified animal |
| W54.0 | Bitten or struck by rat |
| W55.01 | Contact with nonvenomous marine animal |
| W55.81 | Other contact with animal |
| Z88.0 | Allergy status to penicillin |
| B96.81 | Helicobacter pylori as the cause of diseases classified elsewhere |
Billing & Documentation Guidance
Point-of-sale ICD-10 overrides
Specified medications (Augmentin, cefdinir, amoxicillin, clarithromycin, omeprazole, pantoprazole) will clear at point-of-sale without prior authorization when billed with the listed ICD-10 diagnosis codes for each drug.
- Augmentin: Y04.1, W53.01, W53.19, W53.21, W54.0, W55.01, W55.81 (animal bites/contact)
- Cefdinir: Z88.0 (penicillin allergy)
- Amoxicillin, Clarithromycin, Omeprazole, Pantoprazole: B96.81 (H. pylori)
Claim submission: ICD-10 coding and dosing
Submit the appropriate ICD-10 diagnosis code on the pharmacy claim using only the alphanumeric characters (do not include the period) so the claim can process under the point-of-sale override.
- Enter the ICD-10 code without the '.' character (alpha-numeric only) on the claim.
- Follow FDA dosing guidelines for H. pylori where applicable.
Maintain supporting documentation
Documentation that supports the submitted diagnosis must be available on hand and accessible to support the point-of-sale override if requested.
- Keep clinical documentation that justifies the ICD-10 diagnosis (e.g., allergy history for Z88.0, bite/contact details for animal bite codes, H. pylori diagnosis for B96.81).
Claim rejection risks remain
Even when an ICD-10 override is used, claims may still reject for plan quantity limits, DUR edits, or other eligibility issues; providers should verify member eligibility and quantity/DUR constraints before dispensing.
- Common reject causes: member not active with plan, refill-too-soon, drug interactions, formulary strengths, or plan quantity limits.
- Confirm member eligibility and DUR/quantity rules at point-of-sale to reduce risk of rejection.
Policy Background
This notice maps specific ICD-10 diagnosis codes to certain medications so that, when billed together, those prescriptions will clear at point-of-sale without a separate prior authorization. Examples include Augmentin for animal bites (Y04.1, W53.01, W53.19, W53.21, W54.0, W55.01, W55.81), cefdinir for documented penicillin allergy (Z88.0), and amoxicillin, clarithromycin, omeprazole, or pantoprazole for H. pylori (B96.81). These overrides take effect January 1, 2020.
Key Definitions
Initial Therapy Point-of-Sale Overrides
Initial therapy overrides
Point-of-sale coverage when billed with specified ICD-10 codes
Providers must submit the ICD-10 without periods (alpha-numeric only) and have documentation supporting the diagnosis available on hand; plan quantity limits and DUR edits may still cause rejection
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.