Providers who receive rejection codes H20203 and/or H45255 will need to balance
bill their patients' supplemental payers for any balances left after Medicare.
CMS deeply regrets that these error conditions have arisen.
On February 29, 2012, CMS alerted Medicare physicians/practitioners, providers,
and suppliers to three (3) edits that they may be seeing reflected 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 our coordination of benefits (COB) HIPAA 837
compliance editing. The defects associated with the firing of edits H51108 and
H20203 at the Coordination of Benefits Contractor (COBC) were resolved on
January 16 and February 27, respectively. CMS has the following additional
information updates to offer regarding edits H20203 and H45255:
* H20203: Element CLM16 is present though marked 'Not Used'
* Update: Medicare was able to repair all affected 837 professional
claims right after February 27, 2012. Unfortunately, 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. Fortunately, the overall volume of affected
claims was determined to be very low. Providers that 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)
* Resolution: COBC's translation routine will scrub the duplicate
identifier that is present in 2320 SBR03.
* Updated confirmed fix date: May 18, 2012
* Scope of Impact: The current problem seems to only be impacting HIPAA
5010A1 837 professional claims billed to Medicare by physicians/practitioners
and DMEPOS suppliers. The error is principally impacting crossover claims that
would have been transferred to North Dakota Medicaid. (Note: This is due to
its reporting of the Medicare Health Insurance Claim Number (HICN) as the
policy number for crossover claim purposes).
* Update: Because certain Carriers, A/B MACs, and DME MACs have been
holding generation of their provider notification letters tied to rejection
code H45255 since February 2012, CMS has determined that a future claim repair
action after May 18, 2012, would not be viable. Therefore,
physicians/practitioners and suppliers may be seeing error H45255 on their
provider notification letters. If physicians/practitioner and supplier offices
see this rejection code, they will need to balance bill their patients'
supplemental payer for any balances remaining after Medicare.
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