Physical therapists who receive rejection codes H20203 and/or H45255 on claim forms will need to balance bill their patients' supplemental payers for any balances left after Medicare, according to recent instructions from the Centers for Medicare and Medicaid Services (CMS) that state that this issue is expected to affect a limited number of providers. (Scroll down to article titled "Providers who Receive Error Codes H20203 and H45255 Need to Balance Bill" for details.)

On February 29, CMS alerted Medicare providers and suppliers to 3 edits that they may see on special provider notification letters that they receive from their local Fiscal Intermediary (FI), Carrier, A/B Medicare Administrative Contractor (MAC), or Durable Medical Equipment MAC (DME MAC). These edits had resulted, or are still resulting, from defects within CMS' coordination of benefits (COB) HIPAA 837 compliance editing. The defects associated with edits H51108 and H20203 at the Coordination of Benefits Contractor (COBC) were resolved on January 16 and February 27, respectively.

CMS has released the following additional information regarding edits H20203 and H45255:

• H20203 (element CLM16 is present though marked ‘Not Used’)
Medicare repaired all affected 837 professional claims soon after February 27.  However, due to more highly critical HIPAA 5010 fixes that were needed to the version 5010 837 institutional COB/crossover claims process, the Fiscal Intermediary Shared System (FISS) was unable to resend 837 institutional claims that incorrectly rejected with error code H20203. The overall volume of affected claims was determined to be very low. Providers who received rejection code H20203 on their provider notification letters issued from their FI or A/B MAC will need to balance bill their patients’ supplemental payers for any balances left after Medicare.
• H45255 (the Other Subscriber Primary Identifier [2330A NM109] cannot be the same as the group or policy number [2320 SBR03])
COBC's translation routine will eliminate the duplicate identifier that is present in 2320 SBR03. The date for this fix to be completed is May 18. The current problem appears to only affect HIPAA 5010A1 837 professional claims billed to Medicare by providers and DMEPOS suppliers. The error is principally affecting crossover claims that would have been transferred to North Dakota Medicaid, due to its reporting of the Medicare Health Insurance Claim Number as the policy number for crossover claim purposes. 

Because certain Carriers, A/B MACs, and DME MACs have withheld provider notification letters tied to rejection code H45255 since February, CMS has determined that a system fix to with these claims would not be available after May 18. Therefore providers and suppliers may see error H45255 on their provider notification letters. If providers and supplier offices see this rejection code, they will need to balance bill their patients' supplemental payer for any balances remaining after Medicare.