CDC Billables Project

Evaluation Report

December 2017

CS287194-A
Rosemary Corriero, MPH, CHES®

Centers for Disease Control and Prevention

National Center for Immunization and Respiratory Diseases

Immunization Services Division

Communication and Education Branch

Atlanta, GA
Table of 

CONTENTS

List of Acronyms...........................................................................................................................................................................................................................................................................................................................................2

Glossary.........................................................................................................................................................................................................................................................................................................................................................................2

Executive Summary..............................................................................................................................................................................................................................................................................................................................4

Introduction.........................................................................................................................................................................................................................................................................................................................................................5

Background..................................................................................................................................................................................................................................................................................................................................................5

Program Description and Goals...........................................................................................................................................................................................................................................................................5

Funding and Budget...........................................................................................................................................................................................................................................................................................................................7

Planning ............................................................................................................................................................................................................................................................................................................................................................9

Implementation...................................................................................................................................................................................................................................................................................................................................9

Evaluation Description..................................................................................................................................................................................................................................................................................................................8

Evaluation Questions................................................................................................................................................................................................................................................................................................................8

Evaluation Tools...................................................................................................................................................................................................................................................................................................................................8

Data Collection and Sources.........................................................................................................................................................................................................................................................................................10

Final Reports..........................................................................................................................................................................................................................................................................................................................................10

Questionnaires..................................................................................................................................................................................................................................................................................................................................10

Monthly Reports and Calls........................................................................................................................................................................................................................................................................................10

Program Staff.......................................................................................................................................................................................................................................................................................................................................10

Methods...................................................................................................................................................................................................................................................................................................................................................................11

Design ............................................................................................................................................................................................................................................................................................................................................................11

Limitations ................................................................................................................................................................................................................................................................................................................................................11

Fidelity and Potential Bias.........................................................................................................................................................................................................................................................................................................................................11

Findings....................................................................................................................................................................................................................................................................................................................................................................11

Final Reports....................................................................................................................................................................................................................................................................................................................................................11

Activities, Resources, and Stakeholders.........................................................................................................................................................................................................................................12

Sustainability........................................................................................................................................................................................................................................................................................................................................13

Barriers.............................................................................................................................................................................................................................................................................................................................................................13

Questionnaires..................................................................................................................................................................................................................................................................................................................................16

Activities and Billing Practices...........................................................................................................................................................................................................................................................................22

Qualitative Results.....................................................................................................................................................................................................................................................................................................................22

Discussion............................................................................................................................................................................................................................................................................................................................................................24

Lessons Learned.....................................................................................................................................................................................................................................................................................................................................24

References...........................................................................................................................................................................................................................................................................................................................................................25

Appendix A: CDC Billables Project Awardees...........................................................................................................................................................................................................................26

Appendix B: Project Timeline......................................................................................................................................................................................................................................................................................27

Appendix C: Figures........................................................................................................................................................................................................................................................................................................................28

Appendix D: Selected Billing Resources and Manuals...........................................................................................................................................................................................29
2 

Acroynms

ACA Affordable Care Act

ARRA American Recovery and Reinvestment Act

BCBS Blue Cross Blue Shield

CDC Centers for Disease Control and Prevention

CEB Communication and Education Branch

CHIP Children’s Health Insurance Plan

ISD Immunization Services Division

LHDs Local Health Departments 

NCIRD National Center for Immunization 

and Respiratory Diseases

NIH National Institutes of Health

PPHF Prevention and Public Health Fund

UHC United Health Care

US United States

Glossary*

Awardee – CDC recognizes 64 immunization programs (awardees), which include the 50 states, six large urban 

areas, and eight US territories and freely associated states eligible to receive CDC funding 

(see https://www.cdc.gov/vaccines/imz-managers/guides-pubs/qa-317-funds.html). 

Balance billing – the practice of a provider billing you for all charges not paid by your insurance plan.

Claim – a payment request to the health plan for covered services provided to an individual enrolled in 

the health plan.

Clinical coding – the process of translating a doctor’s notes from a patient visit into the appropriate ICD-10 codes 

for diagnosis and Current Procedural Terminology (CPT) billing codes for medical treatment or services.

Contract – an agreement between parties that sets out each party’s rights and obligations (including financial 

obligations).

Cooperative agreement – an agreement between a federal awarding agency and a non-federal entity that 

provides for substantial involvement between the two parties in carrying out the activities described under the 

award.

Credentialing – the process by which an insurance plan or third-party payer reviews a health care professional’s 

credentials to determine whether the professional meets the requirements to participate in a payer’s provider 

network.

Fee schedule – a list of costs associated with each medical treatment or service that corresponds with a CPT 

billing code.
3 

Hardship policy – a policy specifying how to work with an individual whose intention is to pay for necessary 

medical services received, but who doesn’t have the financial capability to do so, in whole or in part.

Health care insurance – insurance to cover the cost of preventive services and medical care needed to prevent, 

diagnose, or treat illness or injury. May be an individual policy or family policy that also covers the beneficiary’s 

family members. Specific benefits provided differ by insurance plan. 

Health plan – written promise of health insurance coverage given to an individual, family, or group of covered 

individuals.

Health care provider – typically a physician, hospital, nursing facility, or laboratory that provides medical care 

services (not an insurance provider or organization that provides insurance coverage).

In-network provider – health care provider that has contracted with an insurance company to accept certain 

negotiated rates for providing treatment or services to that insurer’s beneficiaries.

Medicaid – a federal-state program that provides health coverage to low-income Americans, including eligible 

adults <65 years old, children, pregnant women, elderly adults, and people with disabilities. Each state administers 

its own Medicaid program within broad federal parameters regarding eligibility and benefits.

Medicare – a federal health insurance program for people who are 65 or older, certain younger people with 

disabilities, and people with End-Stage Renal Disease.

Out-of-network provider – health care provider that has not contracted with an insurance company for 

reimbursement at a negotiated rate.

Private payer – a health insurance plan provided through an employer or union; a plan purchased by an 

individual from an insurance company; or military health coverage (including plans purchased through the 

ACA-established Health Insurance Marketplace).

Public payer – includes Medicare, Medicaid, and other medical assistance programs; 

Veterans Affairs Health Care; the Children’s Health Insurance Program (CHIP); and individual state health plans.

Sliding scale – a written approach to adjusting fees for medical services for individuals who are unable to pay, 

in whole or in part, for the services they will or have received. Based on the individuals’ ability to pay, the scale 

provides for the reduction or possible waiver of fees. 

Typically requires some form of financial evaluation, a signed acknowledgment, and 

acceptance of the adjustment.

Third-party payer – any public or private payer billed for health care services.

*Some definitions are from: http://www.naic.org/consumer_glossary.htm; 

http://myhealthplan.guide/category/glossary/; https://www.cigna.com/glossary; 

https://www2.census.gov/programs-surveys/acs/tech_docs/subject_definitions/2015_ACSSubjectDefinitions.pdf; 

https://blog.grants.gov/2016/07/19/what-is-a-cooperative-agreement/; https://www.cms.gov/apps/glossary/
4 

Executive Summary

The Centers for Disease Control and Prevention (CDC) Billables Project was a response to the fact that even though 

a proportion of patients seeking immunization services at local health departments (LHDs) were insured, most 

LHDs were not requesting and receiving reimbursement for providing services to those patients. The project was 

designed to provide resources and technical assistance to assist LHDs in billing public and private third-party 

payers for immunization services provided to insured patients.

The Billables Project objectives were as follows:

1. Increase the ability of LHDs to begin, expand, or continue collection of reimbursements for in-network 

immunization services.

2. Increase the number of LHDs that have self-sustaining billing programs and immunization services.

3. Increase the capacity of LHDs to provide immunization services to the entire community—not just to those 

without insurance.

The objectives of this evaluation were to assess whether the Billables Project strengthened the capacity of LHDs 

to effectively bill third-party payers for immunization services; to identify activities, resources, and stakeholder 

partnerships that helped or hindered LHDs’ ability to bill; to describe the steps taken by LHDs to plan and 

implement a billing program and the barriers they encountered; and to describe trends seen in awardees’ 

billing programs.

Awardees took part in a variety of activities to facilitate planning and/or implementation of their billing programs. 

Many of the activities were related to training staff in insurance processes, clinical coding, reimbursements, 

and other major billing subject areas. Awardees encountered and were able to overcome a variety of barriers 

throughout the planning and implementation phases of their 

billing programs. The experiences of predecessors and stakeholders helped awardees to overcome barriers 

they encountered. 

Of the 11 implementation awardees funded in 2014, five awardees reported

that more than 50% of their immunization visits were being billed to a 

third-party payer compared to four at the beginning of data collection. 

Three awardees reported increases in the percentage of insured patients 

and three awardees reported decreases in the percentage of uninsured 

patients seen at LHDs. The percentage of immunization visits billed to 

public vs. private payers varied by awardee. However, over time, awardees 

reported an increase in the overall number of payers being billed.

The Billables Project has shown how important it is to work with partners, 

including third-party payers and community stakeholders, to improve 

capacity to provide services to the community and sustain immunization 

programs. The Billables Project has also shown how the landscape of 

immunization billing in public health settings is changing and evolving. 

Knowledge gained through this evaluation can be used to inform future 

immunization billing policies and efforts by state health departments and 

LHDs. Lessons learned through billing for immunization services have 

already been used to inform and expand programs to bill for other covered 

services (e.g., HIV screening and counseling, family planning, and laboratory 

services) offered by LHDs to insured patients. 
5 

Introduction

Background

Immunization is one of the most effective ways to prevent serious diseases.1 There are currently more than 

75 vaccines licensed for use in the United States that protect against 23 diseases.2, 3 Vaccination coverage varies 

by state due to differing state vaccination requirements for school entry and exemptions allowed, physician 

communication/recommendation, and socioeconomic status of individuals seeking vaccination.4-7 With passage 

of the Affordable Care Act (ACA) in 2010, recommended immunizations became available at little to 

no cost*

 for those covered by non-grandfathered health insurance plans.8

Because vaccines are available in many different locations including doctors’ offices, school-based clinics, 

pharmacies and worksite clinics, the U.S. has been able to achieve high vaccination levels, resulting in low 

vaccine-preventable disease prevalence nationwide. Though many health care locations provide immunization 

services, this evaluation focuses on local health departments (LHDs). LHDs are an important source of 

immunization and other health care services for the communities they serve. While they are often perceived as a 

place to receive free or low-cost services,9

 LHDs operate and employ health care professionals just as any private 

health care facility does. The number of staff at LHDs is determined by budgets, population data, and, in some 

cases, revenue collected from charges for services.10 Reimbursement from health insurance plans (also known as 

“third-party payers”) for services provided to covered patients can be an important source of revenue to sustain the 

services that LHDs offer. However, planning and implementing a program to enable billing for immunization and 

other services can often require a significant investment of time and money up front, in addition to being fraught 

with obstacles that LHDs must overcome. To bill third-party payers for immunization services, LHDs must negotiate 

and establish a contract with each payer and staff must be credentialed according to each payer’s standards.†

 The 

processes for contracting and credentialing can be long and complex, taking weeks or months. 

Program Description and Goals

CDC’s Billables Project was a response to the fact that even though a proportion of patients seeking immunization 

services at LHDs were insured, most LHDs were not requesting and receiving reimbursement for providing services 

to those patients.11, 12 The project was designed to provide resources and technical assistance to 

assist LHDs in billing public and private payers for immunization services provided to insured patients. 

To plan and implement a billing program, state immunization programs (referred to as “awardees”) needed to 

develop relationships with third-party payers, establish, update, or maintain systems for claims processing, add 

new or train existing staff to handle billing tasks, and communicate new billing policies to patients. These awardees 

were eligible through a competitive selection process to receive funding for billing activities through the Billables 

Project. Awardees used funding provided through the Billables Project to facilitate establishing contracts with 

third-party payers, complete the required credentialing of health care professionals, update or gain access to 

systems that support claims processing, and train LHD staff. By establishing and implementing a sustainable 

billing program, it was expected that state health departments and LHDs would have an increased capacity to 

begin or expand programs for collecting reimbursements in the short term, and greater reach and sustainability of 

immunization services in the long term.

*Grandfathered plans that were created or purchased prior to March 23, 2010 are exempt from changes required under the ACA 

(https://www.healthcare.gov/glossary/grandfathered-health-plan/). According to Kaiser Family Foundation’s 2016 Employer Health 

Benefit Survey, 23% of employers offer at least one grandfathered plan and 23% of covered workers are enrolled in a grandfathered 

plan (http://kff.org/report-section/ehbs-2016-summary-of-findings/).

†

Each third-party payer has its own requirements for credentialing.
6 

The Billables Project objectives were as follows (also see Figure 1):

1. Increase the ability of LHDs to begin, expand, or continue collection of reimbursements for in-network 

immunization services.

2. Increase the number of LHDs that have self-sustaining billing programs and immunization services.

3. Increase the capacity of LHDs to provide immunization services to the entire community—not just to those 

without insurance.

CDC’s National Center for Immunization and Respiratory Diseases (NCIRD) assembled a team to provide guidance 

and technical assistance to awardees as they sought to plan, implement, and/or sustain improvements to their 

billing programs. This report contains findings from an evaluation of the Billables Project conducted by staff in 

the Communication and Education Branch (CEB) in NCIRD’s Immunization Services Division (ISD). The project 

evaluation was conducted between September 2016 and January 2017 with the following objectives:

1. Assess whether the Billables Project strengthened the capacity of LHDs to effectively bill third-party payers for 

immunization services. 

2. Identify activities, resources, and stakeholder partnerships that helped or hindered LHDs’ ability to bill.

3. Describe the steps taken by LHDs to plan and implement a billing program and the barriers they encountered.

4. Describe immunization billing trends seen in LHDs’ billing programs.

Figure1: Simplified logic model for CDC Billables Project

CDC Inputs

Short-Time 

Outcomes

Long-Time 

Activities Outcomes

÷Authority

÷Funding

÷Program guidance

÷Technical assistance

÷Evaluation

÷Monthy Phone Calls

÷Monthy Reports

÷Final Project Reports

÷Public health 

departments 

begin, expand, or 

continue to capture 

reimbursements 

for immunization 

services

÷Increased knowledge 

of billing activities 

and processes

÷Increased ability and 

capacity to immunize 

communities

÷Increased selfsustainability at LHDs

÷Improved vaccine 

supply management 

at LHDs
7 

Funding and Budget

Since 2009, CDC has awarded more than $32.9 million to 38 

state immunization programs to plan and implement billing

for immunization services (see Table 1 and Appendix A and 

B).*

 Funding from CDC for the Billables Project was provided 

through the federally legislated American Recovery and 

Reinvestment Act of 2009 (ARRA) and the Prevention and 

Public Health Fund (PPHF), which was established through 

the ACA.13, 14 All funding awards were made through 

cooperative agreements that allowed CDC program staff 

and awardees to interact more directly, including regular 

communications and technical assistance for awardees 

when requested.

Planning

In 2009, the initial 14 awardees received more than $6.6 

million in funding from CDC. In 2011, a second round of 

funds, totaling more than $6.3 million, was awarded to 

14 additional awardees. In 2012, seven additional awardees 

received more than $2.8 million.

Implementation

In 2011, seven of the initial awardees received a total of 

more than $6.6 million to implement their strategic billing 

plans. In 2012, seven implementation awardees received 

more than $5.4 million for implementation.

In 2014, 11 awardees, all of which had previously been awarded planning grants, received a total of more than $5 million 

for implementation. One of the final 11 awardees completed its project at the end of 2016, while the remaining 10 have 

expected completion dates throughout 2017.

Table 1 : FY16 Achievements vs Targets:

* As displayed in Table 1 and Appendix B, awardees were funded during separate funding waves to participate in CDC’s Billables Project.

2009 2011 2012 2014 Total

Planning $6,653,680 n=14 $6,319,225 n=14 $2,852,607 n=7 $0 n=0 $15,825,512

 Implementation $0 n=0 $6,672,308 n=7 $5,414,765 n=7 $5,002,104 n=11 $17,089,177

 Total $6,653,680 n=14 $2,991,533 n=21 $8,267,372 n=14 $5,002,104 n=11 $32,914,689
8 

Evaluation Description

The project evaluation was undertaken to examine Billables Project processes and outcomes. The evaluation was 

designed to assist CDC in assessing and determining the extent to which awardee programs operated as intended 

and the extent to which LHDs were impacted by the Billables Project. Findings of this evaluation can be used to 

inform future decisions related to planning or implementing billing programs at LHDs.

Evaluation Questions

This evaluation was guided by the following questions: 

1. Planning Awardee Evaluation Questions 

a. What activities, resources, and stakeholders were involved in developing strategic billing plans and to what extent? 

Identify activities, resources, and stakeholder partnerships that helped or hindered LHDs’ ability to bill.

b. What activities, resources, and stakeholders were involved in developing strategic billing plans and to what extent? 

Identify activities, resources, and stakeholder partnerships that helped or hindered LHDs’ ability to bill.

3. Implementation Awardee Evaluation Questions

a. What activities, resources, and stakeholders were employed to increase capacity for billing and to what extent?

b. What barriers and facilitators to billing were identified by awardees?

c. To what extent did awardees increase rates of reimbursement throughout the program period?

d. To what extent did number of immunization visits change throughout the program period?

e. How did patient demographics change throughout the program period?

Evaluation Tools

A variety of methods, including content analysis, document review, a mixed-methods questionnaire, and a 

quantitative survey,*

 were used to evaluate both the planning and implementation projects. Methods and data 

sources used to answer evaluation questions are detailed in Table 2.

*Quantitative surveys were only distributed to the 11 implementation awardees funded in 2014 due to changes in award requirements.
9 

Table 2: Evaluation questions for planning and implementation

Evaluation Question Indicator Data Sources Analysis Methods

Planning Awardee Evaluation

What activities, resources, or 

stakeholders were involved 

in developing strategic billing

plans and to what extent?

Descriptions of activities, 

third-party relationships, and 

payer contracts 

Final reports and monthly 

reports and calls 

Quantitative analysis, 

qualitative analysis, and 

document review

What barriers and facilitators 

to billing were identified 

by awardees?

Descriptions of successes 

and challenges during the 

program period

Final reports, monthly reports 

and calls, and program staff 

Content analysis and 

telephone follow-up 

(if needed)

Implementation Awardee Evaluation

What activities, resources, or 

stakeholders were employed 

to increase capacity for billing 

and to what extent?

Descriptions of activities, thirdparty relationships, and payer 

contracts

Final reports and monthly 

reports and calls

Quantitative analysis, 

qualitative analysis, and 

document review

What barriers and facilitators 

to billing were identified 

by awardees?

Descriptions of successes 

and challenges during the 

program period

Final reports, monthly 

reports, program staff, and 

questionnaires

Content analysis and 

telephone follow-up 

(if needed)

To what extent did 

awardees increase rates of 

reimbursement throughout 

the program period?

Net collection rate and claims 

processing data

Questionnaires, program staff, 

and monthly reports

Quantitative analysis and 

qualitative analysis

To what extent did number 

of immunization visits 

change throughout the 

program period?

Total immunization visits data, 

payer and claims data

Questionnaires Quantitative analysis

How did patient 

demographics change 

throughout the 

program period?

Insurance status data Questionnaires Quantitative analysis
10 

Data Collection and Sources

Final Reports

All awardees that completed planning or implementation projects submitted written final reports to CDC program 

staff. These reports included information on project barriers, facilitators, third-party payers, and other topics related 

to planning or implementation. As of January 2017, all 35 planning awardees have completed the planning phase 

and submitted final reports. Of the 25 implementation awardees, 15 have completed the implementation phase 

and submitted final reports. 

Awardees were given a broad set of guidelines and questions to aid in writing final reports. The guidelines and 

questions varied based on project type(s) – planning, implementation or both – or year(s) in which the awardee 

participated. Questions were reviewed by CDC project leaders and refined throughout the course of the project. 

Final reports were reviewed for accuracy and completion. Data collected included total number of LHDs, training 

needed, stakeholders, insurance companies, barriers, benefits of billing, and other information specific to an 

awardee’s project. Data were independently coded by one evaluator and a spreadsheet of emergent themes 

and topics was created for analysis. Once main themes were established, subthemes and supporting data were 

categorized in order to best answer evaluation questions.*

 Themes, subthemes and supporting data were reviewed 

for accuracy and consensus by three CDC project leaders.

Questionnaires

The Billables Project receives ongoing evaluation updates from awardees who are still currently in the 

implementation phase of their projects.†

 These include monthly reports and calls, which monitor awardee progress 

toward goals, as well as questionnaires, which requested more detailed information on insurance claims, number 

of health plans the LHDs work with, and number of LHDs sending and collecting data. Questionnaires were 

collected for the following time periods‡

:

1. October 1, 2014 – March 31, 2015 (Q1)

2. April 1, 2015 – September 30, 2015 (Q2)

3. October 1, 2015 – March 31, 2016 (Q3)

4. April 1, 2016 – September 30, 2016 (Q4)

Qualitative and quantitative data were taken from responses to questionnaires that were completed by seven 

of the final 11 Billables Project awardees. Quantitative data were analyzed using an Access database (Microsoft 

Corp., Redmond, Washington) and SAS statistical software (version 9.4; SAS Institute Inc., Cary, North Carolina) for 

descriptive statistical analyses. 

Monthly Reports and Calls

For the duration of their projects, awardees submitted monthly reports and participated in monthly calls. The 

reports and calls gave CDC project leaders updates on awardee project status, as well as any other issues or 

project related topics that may have occurred. Reports and calls often included some specific details that were not 

included in the final reports.

Program Staff

Awardee program staff were contacted, by phone or email, as needed to gain further explanations of project 

details or updates presented in reports or on monthly calls.

*Monthly reports and call notes were used to gain further insight and details related to specific themes or topics if needed throughout 

the report findings.

†

These awardees are set to finish their implementation projects in 2017. 

‡

For simplicity, the data collection periods will be referred to as Q1, Q2, Q3, and Q4 in tables and graphs describing results.
11 

Methods

Design

A non-experimental, retrospective, descriptive evaluation design was used to analyze data. Descriptive evaluation 

designs are used to explore and describe experiences and outcomes, as well as compare outcomes achieved 

to planned outcomes.15 Non-experimental designs have several noted limitations, one of which is the lack of a 

comparison or control group.16 However, non-experimental designs offer an easy and inexpensive way to conduct 

useful evaluations of longitudinal studies.

Limitations

Although all awardees who completed a project submitted a final report, these reports did not include the same 

types or amounts of information. For some sections of data analysis and evaluation, some awardees were excluded 

due to missing information in final reports.

Data from questionnaires were requested only from the final 11 implementation awardees. Eight of the 11 

awardees returned questionnaires. This limited the amount and type of analysis that could be conducted 

for evaluation questions examined with questionnaire data. Questionnaire data collected by awardees were 

sometimes taken from LHD data, which could have led to inconsistencies and errors in data reporting due to 

varying data collection procedures at each LHD. In addition, since questionnaires were only required of the final 

11 Billables Project awardees,*

 the data collected cannot be generalized and compared to those of awardees who 

participated previously.

Fidelity and Potential Bias

CDC program staff maintained program fidelity through regularly scheduled all-awardee meetings, conference 

calls, and webinars. These provided effective channels of communication to discuss new and revised vaccine 

recommendations and policies and their impact on billing. All members of the CDC Billables Project staff 

participated in these activities to ensure reliability of data discussed. 

Findings

Data and findings from final reports (planning and implementation) and questionnaires (implementation) 

were reported separately due to differences in data required for submission by awardees participating in the 

planning vs. the implementation phase. In addition, only the final 11 implementation awardees collected data for 

questionnaires.

Final Reports

Final reports from 35 awardees in the planning phase and 15 awardees in the implementation phase were 

reviewed and analyzed. Data from final reports for this evaluation included information on activities, resources, 

stakeholders, and barriers.

*Some awardees were not able to respond with all data that was requested in the questionnaires due to the structure of 

their state health department and LHDs.
12 

Activities, Resources, and Stakeholders

Awardees took part in a variety of activities to facilitate planning and/or implementation of their billing programs. 

Many of the activities related to training staff on insurance processes, coding, reimbursements, and other major 

billing topics. Other activities included:

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Working and meeting with local organizations, immunization coalitions, or other health agencies 

Detailing and outlining billing procedures for development of guides/manuals

Developing communication plans and strategies for establishing billing of third-party payers

Negotiating new contracts and establishing partnerships with payers

Developing materials (e.g., claim submission tools and sample forms) for LHD staff 

Creating plans and processes for streamlining data and record-keeping

Working with IT departments to develop or implement billing software systems

Resources from internal and external sources, such as funding, software, and personnel, were an important part 

of planning and implementing a billing program. CDC funding from the Billables Project enabled many LHDs to 

purchase software or equipment they were lacking, as well as pay for additional staff needed to aid in the billing 

process. Software helped many awardees improve their billing processes by reducing the number of claims 

that were miscoded and denied. Some awardees used funding to pay for claim submission services provided 

by clearinghouses (e.g., vendors such as Health-e-Web, TransactRx, Upp Technology, Emdeon One, VaxCare, and 

Availity*

), which offered staff and expertise to improve reimbursement rates and reduce the number of denied and 

rejected claims. LHD staff also benefited from coding and claims processing guidance provided by billing training 

manuals and personnel.†

Strong partnerships with local stakeholders were one of the most important elements identified by awardees in 

building a strong, self-sustaining billing program. Types of stakeholders varied by state and included:

Immunization coalitions

Governor’s offices

State insurance commissioners

Attorneys general

State and local public health officials

Public health boards and medical associations (e.g., the American Academy of Pediatrics)

Hospitals

Vaccine manufacturers and pharmaceutical company representatives

State Medicaid and managed care programs

Medicare

Third-party payers

Universities

Some stakeholders participated in monthly calls and other meetings with awardees throughout the planning and 

implementation processes and assisted awardees with building relationships with third-party payers; negotiating 

contracts or creating contract templates; developing strategic plans; credentialing; covering costs of clearinghouse 

services; analyzing fees; selecting software; and developing training resources such as guides and manuals.

 *Clearinghouses listed are selected examples. The listing does not constitute CDC endorsement of a particular company. 

†

Selected resources are listed in Appendix C.
13 

Sustainability

Many awardees discussed the impact the Billables Project had on long-term infrastructure of their LHDs billing 

abilities, as well as the ability to increase immunization offerings to the community.

When discussing program sustainability, one awardee stated, “The CDC Billing Implementation grant gave [the 

state immunization coalition] the ability to provide support for all health care organizations in order to strengthen 

the overall vaccine delivery system, decreasing the potential cost to public health safety net service programs 

by keeping disease rates down and immunization rates high.” Another awardee discussed their increased 

ability to train and update policies related to billing, stating “We are now prepared to bill 3rd party payers for 

immunizations...We have updated policies and procedures as needed and trained new staff that may be involved 

in the billing process.”

Barriers

Barriers encountered by awardees and solutions to overcoming those barriers were described extensively in final 

reports (see Tables 3 and 4). 

Barriers were noted in six categories: (1) funding and costs, (2) staff, (3) health department characteristics, (4) thirdparty payers and insurance plans, (5) software, and (6) patient insurance status. Solutions for overcoming those 

barriers included: (1) using supplemental funds (e.g., grants) and clearinghouse services to overcome funding and 

cost barriers; (2) creating billing guides and modules to aid in staff training and ensuring all staff had sufficient 

knowledge of billing processes; (3) subcontracting work or using clearinghouse services if staffing levels were 

not adequate; (4) creating consistent, streamlined workflow processes at LHDs to bill accurately for immunization 

services; (5) establishing strong relationships with third-party payers to ensure open communication; (6) requesting 

assistance with contracting from state insurance commissioners and attorneys general; (7) modifying, developing, 

or purchasing new software to accommodate billing practices; and (8) capturing the patient data needed to bill by 

updating and modifying current clinic workflows/processes and patient/medical record systems.

Table 3: Most commonly reported barriers

Most commonly reported barriers by project phase

Planning Implementation

Credentialing and contracting Credentialing and contracting

Lack of or limited knowledge and understanding of processes 

for billing

Cost to acquire private stock of vaccines

Gaps in current software system Lack of or limited training/resources

Staff levels/turnover Structure of state health department system

Cost to acquire private stock of vaccines Payments for vaccine doses/reimbursement

Lack of or limited training/resources Gaps in current software system
14 

Table 4: Barriers identified by awardees in final reports for planning and implementation

Barrier 

Topic Supporting Themes Examples of Possible Solutions 

Given by Awardees Planning (N) Implementation

(N)

Funding and Costs

Large start-up funding costs 

(including clearinghouse 

costs and software and 

equipment needs)

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3⁄4

3⁄4

3⁄4

3⁄4

Use grant funds to purchase equipment 

and software

Negotiate with companies for discounts

8 3

Cost to acquire private stock 

of vaccines

Use revenue from billing to purchase

Work with manufacturers

11 5

Staff

Lack of or limited knowledge 

and understanding of processes 

for billing

Create a billing guide

Training modules

Contact subject matter experts 

for assistance

15 3

Leadership resistance Repeated messages regarding benefits 

of billing to leadership

4 3

Clinical coding errors Have a staff contact in finance department

Attend training on coding

4 3

Staff levels/turnover Use subcontractors 14 —

Lack of or limited 

training/resources

Create billing manuals

Have mentors from LHDs assist in training

11 5

No on-site physician/provider Educate third-party payers on the role 

of public health nurses in providing 

immunization services

3 —

Large time requirements Use billing clearinghouses to help 

streamline processes

7 2

Health Department Characteristics

Structure of state health 

department system

Centralize operations if possible 7 4

Inadequate volume/needs for 

establishing a billing protocol

Conduct a cost-benefit analysis

Partner with other LHDs to bill

5 1

Fees for services applied 

inconsistently/changes to fees

Establish policies and procedures to 

simplify application of fees for services for 

an efficient, consistent implementation of 

billing practices

3 —

Liability insurance coverage Increase coverage amount 2 —

Claim submission issues Create more consistent processes for 

submission

Training in accurate submission

8 3

Varied front-end processes Modify and streamline processes to 

accommodate billing

9 1
15 

Barrier 

Topic Supporting Themes Examples of Possible Solutions 

Given by Awardees Planning (N) Implementation

(N)

Third-Party Payers and Health Plans

Payments for vaccine doses/

reimbursement

3⁄4

3⁄4

3⁄4

3⁄4

3⁄4

3⁄4

3⁄4

3⁄4

3⁄4

3⁄4

3⁄4

Try to renegotiate fees or rates 4 4

Credentialing and contracting Seek help from immunization coalitions 

or partners

Develop contract templates

Ask attorneys general for assistance 

23 7

Difficulty with Medicare 

credentialing and 

application process

Seek state assistance with Medicare 

application fees

5 2

Difficulty negotiating 

or communicating

Be persistent in working to develop 

relationships and lines of communication

6 3

Lack of recognition of public 

health model

State legislation to support recognition 

of public health model

3 1

Software

Gaps in current system Change workflow to accommodate new 

billing mechanisms

Modify current system to fill gaps

15 4

Patient Insurance Status

Insurance information/status 

unavailable at time of service

Immunization coalition developed 

independent insurance verification 

process

Infrastructure and technology changes to 

capture insurance information

8 3
Questionnaires

As previously mentioned, questionnaire analyses were limited as only eight of the 11 awardees returned the 

questionnaire with required data. Findings for this section are discussed as Q1 vs. Q4, unless otherwise noted.*

Quantitative Results

The number of LHDs reported by each awardee remained the same throughout the project for all awardees except 

Mississippi (MS) and New Mexico (NM). MS reported a decline of 11 LHDs (-11%) and NM reported a decline of two 

LHDs (-4%) due to closures. 

Immunization Visits

The number of immunization visits varied across time (see Figure 2). Overall, Tennessee (TN) and Virginia (VA) had 

the highest average number of immunization visits during the data collection period. NM, TN, and VA experienced 

a decline in total immunization visits in Q2 and Q4. The specific reason for those declines (Figure 2) is not known, 

but could be related to the seasons that correspond with the data collection period or natural flow of patients 

visiting LHDs (i.e., there are increases in visits to LHDs during back-to-school and flu season). In Q3, VA reported 100% 

of immunization visits were being billed. Illinois (IL), MS, and TN billed for 100% of immunization visits in all data 

collection periods (see Figure 3).

Other notable trends included:

3⁄4 Kansas’ (KS) (Q1 vs. Q3) and IL’s (Q2 vs. Q4) number of immunization visits more than doubled. 

3⁄4 From Q1 to Q4, Nevada’s (NV) total number of immunization visits increased by 7,615 (+27 percentage points) from 28,215.

3⁄4 From Q1 to Q4, MS’ total number of immunization visits decreased by 7,488 (-14 percentage points) from 52,045.

Figure 2: Total number of immunization visits 

(note: IL did not provide data for Q1, KS and MS did not provide data for Q2, NV did not provide data for Q2 and Q3, 

and MO did not provide any data on total number of immunization visits)

120,000

80,000

60,000

40,000

20,000

0

100,00

5,315

102,453

80,710

7,379

56,952

55,860

5,579

44,557

91,508

37,577

42,447

41,354

85,599

92,323

7,380

28,215

56,596

43,991

5,039

35,830

29,455

52,045

IL

KS

MS

NV

NM

TN

VA

Q1 Q2 Q3 Q4

 *Questionnaire time periods: October 1, 2014 – March 31, 2015 (Q1), April 1, 2015 – September 30, 2015 (Q2), October 1, 2015 – March 31, 2016 

(Q3), April 1, 2016 – September 30, 2016 (Q4).
17 

Figure 3: Percentage of immunization visits that were billed

(total immunization visits billed/total immunization visits)

100%

90%

70%

60%

50%

40%

30%

20%

10%

0

80%

100%

94%

100%

37%

92%

100%

34%

100%

100%

100%

100%

100%

100%

37%

88%

100%

55%

44%

54%

100%

IL

KS

MS

NV

NM

TN

VA

Q1 Q2 Q3 Q4

Patient Insurance Status

Patient insurance status data were collected from each awardee to determine to some degree the demographics of 

those receiving services at state or LHDs. An insured patient is defined as “anyone with insurance that covers the cost of 

vaccination even if the insurance plan has a high deductible or co-pay.” An uninsured patient is defined as one without 

health insurance. An underinsured patient is defined as one with health insurance but has health insurance, but it doesn’t 

cover vaccines, or doesn’t cover certain vaccines, or covers vaccines but has a fixed dollar limit or cap for vaccines.*† 

The percentages of insured and uninsured patients seen at awardee health departments are shown in Figures 

4 and 5:

3⁄4

3⁄4

3⁄4

3⁄4

3⁄4

3⁄4

For five awardees, 50% of patients or more were insured.

IL had a 22 percentage point decrease in insured patients (Q2 vs. Q3), but the percentage of insured patients increased again in Q4.

NV had an increase in insured (+16 percentage points) and uninsured (+7 percentage points) patients.

NM had a decrease (-4 percentage points) in the percentage of insured patients and a decrease (-8 percentage points) in the 

percentage of uninsured patients. 

TN had an increase (+20 percentage points) in insured patients and a decrease (-19 percentage points) in uninsured patients.

VA had a decrease (-26 percentage points) in insured patients and an increase (+33 percentage points) in uninsured patients.

Missouri (MO) and KS reported data for only one reporting period; thus, trends for patient insurance status were not captured.

 *Definitions for “insured”, “uninsured” and “underinsured” were adapted from the definitions created for the Vaccines for Children program 

(https://www.cdc.gov/vaccines/programs/vfc/parents/qa-detailed.html and https://www.cdc.gov/vaccines/imz-managers/guides-pubs/qa-317-funds.html).

† Underinsured individuals are not depicted in the figures below.
18 

Figure 4: Percentage of patients who were insured 

(note: KS only provided data for Q1 and MO only provided data for Q4)

100%

90%

70%

60%

50%

40%

30%

20%

10%

0

80%

Q1 Q2 Q3 Q4

IL

KS

MS

MO

NV

NM

TN

VA

97% 75%

72% 66%

55%

94%

54%

43%

53%

45%

64%

65%

46%

57%

37%

62%

38%

65%

54%

57%

39%

74%

27%

61%

Figure 5: Percentage of patients who were uninsured 

(note: KS only provided data for Q1 and MO only provided data for Q4)

100%

90%

70%

60%

50%

40%

30%

20%

10%

0

80%

Q1 Q2 Q3 Q4

IL

KS

MS

MO

NV

NM

TN

VA

3% 7%

27% 32%

19%

6%

45%

57%

37%

25%

16%

34%

50%

35%

38%

63% 63%

34%

38%

35%

49%

26%

70%

32%
19 

Public, Private, and Patient Billing for Immunization Visits

By Q4, eight of the final 11 implementation awardees reported more than 50% of LHDs in their state were billing 

third-party payers for immunization visits. Of those eight, five awardees reported 100% of LHDs in their state were 

billing third-party payers for immunization visits.

In addition to general information on immunization visits billed, awardees were asked to give further details on 

the percentage of visits billed to private and public insurance (see Figures 6 and 7). Awardees also reported on the 

number of immunization visits for which the patient was billed directly (data not displayed due to low response 

rates on questionnaires). IL (+3 percentage points) and VA (+10 percentage points) reported an increase in the 

percentage of patients billed, while MS (-2 percentage points) and TN (-22 percentage points) reported decreases 

in the percentage of patients billed.

Findings from Figures 6 and 7 include:

3⁄4 I

3⁄4

3⁄4 I

3⁄4

3⁄4

3⁄4

3⁄4

L and KS billed more than 50% of immunization visits to private insurance. 

MS, MO, NV, NM, and TN billed 50% or more of immunization visits to public insurance. 

L had a decrease (-22 percentage points) in immunization visits billed to private insurance and an increase (+32 

percentage points) in immunization visits billed to public insurance (Q2 vs. Q4).

MS had an increase (+12 percentage points) in immunization visits billed to private insurance.

NM billed 100% of immunization visits to public insurance.

TN had an increase (+43 percentage points) in immunization visits billed to private insurance.

VA had a decrease (-8 percentage points) in immunization visits billed to private insurance.

Figure 6: Percentage of immunization visits billed to private insurance 

(note: KS only provided data for Q1 and MO only provided data for Q4)

100%

90%

70%

60%

50%

40%

30%

20%

10%

0%

80%

Q1 Q2 Q3 Q4

IL

KS

MS

MO

NV

NM

TN

VA

81% 60%

12% 12%

29%

59%

5%

0%

37%

73%

8%

27%

26%

12%

0% 0%

15%

36%

26%

0%

48%

29%

24%
20 

Figure 7: Percentage of immunization visits billed to private insurance 

(note: KS only provided data for Q1 and MO only provided data for Q4)

100%

90%

70%

60%

50%

40%

30%

20%

10%

0%

80%

Q1 Q2 Q3 Q4

IL

KS

MS

MO

NV

NM

TN

VA

3% 7%

68% 61%

61%

35%

50%

100%

26%

43%

63%

24%

74%

50%

100% 100%

50%

27%

74%

100%

51%

25%

76%

Claim and Payer Data

Of the four awardees that reported data for claim acceptance rates, all reported an acceptance rate of 90% or greater in 

all data collection periods. Other claim data, such as denials, were requested, but response rates for those data on our 

questionnaire were too low to present and compare.

Over time, there were three awardees that reported an increase in the number of payers being billed. The largest of 

those increases occurred in IL, with an increase from 10 to 38 payers being billed (see Table 5).

Two awardees indicated a decrease in the number of payers being billed (see Table 5).

The payers most commonly billed as of Q4, as well as the number of LHDs billing each payer, are listed in Table 6.
21 

Table 5: Number of payers currently being billed as of Q4, by awardee

Q1 Q4

# of 

Payers

# 

Public

# 

Private

# of InNetwork 

Payers

# of 

Out-ofNetwork 

Payers

# of 

Payers

# 

Public

# 

Private

# of InNetwork 

Payers

# of 

Out-ofNetwork 

Payers

Illinois 10 3 7 10 0 38 4 34 38 0

Kansas 10 3 7 10 0 10 3 7 10 0

Mississippi 76 12 64 13 63 76 12 64 13 63

Missouri 18 2 16 18 0 14 2 12 11 —d

Nevada 37 6a 32a 31b 10b 43 6a 38a 31b 16b

New 

Mexico

4 UNK UNK 4 0 5 5 0 5 0

Tennessee 10 6 4 9 1 9 6 3 7 2

Virginia 10 4 6 9c 6c 10 4 6 9c 6c

a: 1 payer listed as both public and private

b: 4 payers listed as both in-network and out-of-network

c: 5 payers listed as both in-network and out-of-network

d: 3 payers not listed as in-network or out-of-network

UNK: Unknown

Table 6: Top 5 payers most commonly billed as of Q4 by awardee

(number of health department clinics billing payer in parentheses)

1 2 3 4 5

Illinois IL Medicaid (79) Medicare (73) BCBS of IL (51) Health Alliance 

Medical Plans (41)

Coventry (39)

Kansas UHC (100) Sunflower (100) Amerigroup (100) BCBS KS (87) UHC – Private (87)

Mississippi MS Medicaid (87) MS CAN (87) CHIP (87) Medicare (87) UHC – Commercial 

(87)

Missouri MO Healthnet (107) Medicare (82) UHC (14) Humana (13) Aetna (11)/Cigna 

(11)

Nevada Cigna (22) Anthem BCBS (22) Medicaid (22) Medicare (22) NV Checkup (22)

New Mexico BCBS Medicaid (36) Presbyterian 

Medicaid (36)

United Health 

Group (36)

Molina Health Plan 

(36)

Medicare (36)

Tennessee UHC – Tenncare 

(101)

Amerigroup (101) BCBS – Tenncare 

(101)

BCBS – Private 

(101)

Cigna (101)

Virginia State Medicaid 

(131)

Medicaid MCOs 

(131) Anthem (131) Medicare (126) UHC (126)

BCBS: Blue Cross Blue Shield

CHIP: Children’s Health Insurance Program

MCOs: Managed Care Organizations

MS CAN: Mississippi Coordinated Access Network (includes United Health Care Community 

plan and Magnolia Health plan)

UHC: United Health Care
22 

Activities and Billing Practices

Awardees reported a variety of billing activities and practices within LHDs. An increase in billing activities and 

practices was expected for all awardees to indicate program growth and trends toward sustainability. Billing 

activities included training in billing and coding, hiring staff, developing new contracts with payers, developing 

new partnerships with health care providers, holding stakeholder and/or advisory board meetings, attending 

and/or presenting at professional meetings, and improving health information systems. Billing practices included 

balance billing, sliding scales, hardship policies, fee schedules, and administration fees. More than half of awardees 

reported that sliding scales, hardship policies, fee schedules, and administration fees were used in all or some 

clinics. From Q1 to Q4, there was an increase in the number of awardees indicating that all or some LHDs had 

sliding scales and hardship policies in place.

Qualitative Results

Free-response questions related to each billing project were important to show situations and barriers that 

quantitative data could not capture. These questions were also designed to capture how barriers encountered 

were overcome and gave each awardee an opportunity to discuss milestones for its projects. 

Awardees were also given the opportunity to further explain responses to questions on tracking and managing 

claims, claims rejection, barriers, and other issues. A sample of responses to each free-response question is listed 

below each corresponding topic (see Table 7).
23 

Table 7: Summary of open responses from questionnaires

3⁄4

3⁄4

3⁄4

3⁄4

3⁄4

Topic Question Selected Response(s)

Tracking and 

managing claims

What methods or systems do the local 

health department clinics in your 

service area use to track or manage 

claim submissions, claim denials, or 

other billing activities?

“For the 23 LHDs utilizing CDP* as of this reporting 

period, the billing team at ezEMRx†

 is responsible for 

tracking and managing all claim submissions and 

denials. Those that are not contracted with CDP, or 

another billing provider, are tracking and managing 

billing activities in-house via spreadsheets and 

clearinghouse reports.”

“Billing is done at each local health district, and the 

total number of invoices is reported on the billing 

event summary report. These data are not collected 

from the districts at this time, and it would have to 

be a manual reporting process. Claims denials are 

not tracked in our system, but we are looking at 

modifications to implement a tracking process that 

would be initiated as staffs are posting payments. We 

plan to use the standard CARCs and RARCs‡ if system 

modifications are possible.”

Claims rejection

To what extent do local health 

department clinics in your city or state 

follow up on claims rejections, and 

how?

“Each health department receives their payments 

directly and posts those payments to the clients’ 

accounts. The remittance that comes with the 

payments is reviewed for denials or other issues, 

and these claims are researched, corrected and 

resubmitted if appropriate. The guideline we have 

issued to the local health districts is to turn these 

claims around in 10 business days or less.”

Barriers

Describe barriers to reporting patients, 

visits, and claims processing data 

in this section. What factors, if any, 

will make it easier to capture this 

information in the future?

“Providing the claims processing data is difficult. While 

we can provide the number of immunization claims 

submitted, we do not capture the breakdown of the 

number of claims accepted, denied, rejected, pending, 

and unsubmitted. Our claims are submitted in multiple 

ways – commercial claims through Navicure, Blue 

Cross through Relay Health, Medicaid directly to 

Medicaid, Medicare directly to Medicare, and MS CAN, 

CHIP, and some Medicare Advantage plans through 

Availity. The claims processing data (accepted, denied, 

and rejected) is not available from all of these sources. 

Also, we are unsure if these numbers are for what 

occurred throughout the reporting period or for the 

status at the end of the reporting period.”

Other (activities, 

successes, 

challenges, 

or information)

What important information about 

your billing program or activities 

during this reporting period would you 

like to share?

“Implemented patient registration forms to capture 

current/accurate patient demographics; placed 

scanners and dual screens at clerical workstations to 

allow proficiency in workflow; and implemented a 

Superbill.”§

*CDP provides data management systems and services to public health clients.

†

ezEMRx provides products such as electronic medical record and practice management systems, as well as claims cleaning and 

management services.

‡CARCs (claim adjustment reason codes) and RARCs (remittance advice remark codes) are used to explain financial adjustments to payment.

§A superbill is an itemized list of services used to create and submit a health care claim.
24 

Discussion

Through CDC’s Billables Project, state and local health departments received funding and technical assistance 

that have allowed them to set up billing programs and begin billing insurance plans for immunization services 

provided to insured patients. Revenue collected from reimbursement for covered services has enabled LHDs 

to hire nurses and health educators, begin billing for other services (e.g., screening and testing for sexually 

transmitted infections), and become self-sustaining. In a few cases, the revenue from billing actually helped to 

prevent clinics from closing. 

The number of awardees that encountered barriers to billing decreased during the implementation phase, 

which was expected since awardees were able to overcome many of those barriers during the planning phase. 

It is possible that some barriers were not encountered in implementation because awardees were able to 

benefit from the experiences and knowledge of other awardees with billing programs already up and running. 

One barrier that remains for some awardees—and is difficult to overcome—is health department structure (i.e., 

centralized vs. decentralized).17 Throughout the Billables Project, many awardees in states with a decentralized 

structure noted how difficult it was to have everyone “on the same page” when each LHD has its own authority. 

The Billables Project has shown how important it is to work with partners, such as third-party payers and 

community stakeholders, to improve capacity to provide services to the community and sustain immunization 

programs. Knowledge gained through this evaluation report can be used to inform future immunization billing 

policies and efforts by state and LHDs. Lessons learned through billing for immunization services have already 

been used to inform and expand programs to bill for other covered services offered by LHDs to insured patients 

(e.g., HIV screening and counseling, family planning, and laboratory services).

Lessons Learned

1. Billing for immunization services provided to insured patients is feasible for local health departments and can be 

integrated as a standard practice.

2. Planning for contracting and communication with a variety of payers and organizations may be helpful to state and 

local health departments. Open communication with third-party payers helped reduce the number of issues and 

delays when developing contracts for Billables Project awardees.

3. State and LHDs may wish to develop specific plans for implementing or increasing billing. Taking steps to plan 

and specify billing expectations and processes helped decrease the number of mistakes made for Billables Project 

awardees and can help ensure all LHDs within an area are following the same procedures.

4. State and LHDs may utilize revenue generated through billing to increase vaccine supply and add billing staff, 

which can help to increase vaccination rates and reduce the impact of vaccine-preventable diseases.
25 

References

1. World Health Organization. Immunization. 2016 [cited 2016 December 14]; Available from: 

http://www.who.int/topics/immunization/en/.

2. Centers for Disease Control and Prevention. List of Vaccines Used in the United States. 2016 [cited 2016 

December 5]; Available from: http://www.cdc.gov/vaccines/vpd/vaccines-list.html.

3. U.S. Food and Drug Administration. Vaccines Licensed for Use in the United States. 2016 [cited 2016 December 5]; 

Available from: http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM093833.

4. Bradford, W.D. and A. Mandich, Some state vaccination laws contribute to greater exemption rates and disease 

outbreaks in the United States. Health Affairs, 2015. 34(8): p. 1383-1390.

5. Esposito, S., et al., Barriers to the vaccination of children and adolescents and possible solutions. Clinical 

Microbiology and Infection, 2014. 20: p. 25-31.

6. Lieu, T.A., T.G. McGuire, and A.R. Hinman, Overcoming Economic Barriers To The Optimal Use Of Vaccines. Health 

Affairs, 2005. 24(3): p. 666-679.

7. Centers for Disease Control and Prevention. Vaccination Coverage Among Children Aged 19–35 Months — 

United States, 2016. 2017 November 3, 2017; Available from: https://www.cdc.gov/mmwr/volumes/66/wr/

mm6643a3.htm.

8. U.S. Department of Health and Human Services. The Affordable Care Act and Immunization. 2012 [cited 

2016 December 14]; Available from: https://www.hhs.gov/healthcare/facts-and-features/fact-sheets/aca-andimmunization/index.html.

9. National Association of County & City Health Officials Billing for Clinical Services: Health Department Strategies 

for Overcoming Barriers. 2014.

10. National Association of County & City Health Officials The Changing Public Health Landscape. 2015.Esposito, S., et a

11. Santoli, J.M., et al., Health department clinics as pediatric immunization providers: a national survey. Am J Prev 

Med, 2001. 20(4): p. 266-71.

12. Kilgus, C.D. and G.S. Redmon, Enabling reimbursement to health departments for immunization services. Journal 

of Public Health Management and Practice, 2014. 20(4): p. 453-455. 

13. U.S. Department of Health and Human Services. Prevention and Public Health Fund. 2016 [cited 2016 December 

15]; Available from: https://www.hhs.gov/open/prevention/index.html. 

14. Centers for Disease Control and Prevention. Prevention and Public Health Fund. 2016 [cited 2016 December 15]; 

Available from: https://www.cdc.gov/funding/PPHF/index.html.

15. Belli, G., Research Essentials: An Introduction to Designs and Practices. 2008. p. 59-77. 

16. Little, P.M.D. Selected Evaluation Terms. 2002 [cited 2016 December 30]; Available from: 

http://www.hfrp.org/publications-resources/browse-our-publications/selected-evaluation-terms.

17. Association of State and Territorial Health Officials State Public Health Agency Classification: Understanding the 

Relationship Between State and Local Public Health. 2012. 
26 

Appendix A: CDC Billables Project Awardees*

Chicago Chicago

Houston

Phase Participation Implementation Only

Planning Only

Planning and Implementation

New York

*

City awardees were as follows: Chicago – planning and implementation; Houston – planning only; New York City – planning only.

CDC Billables Project Awardees. Map of project awardees. Massachusetts, North Dakota, and Oregon 

participated only in the implementation phase of the Billables Project. Alabama, Connecticut, Houston, Indiana, 

Louisiana, Maryland, Minnesota, Nebraska, New York City, South Carolina, Texas, Wisconsin, and Wyoming 

participated only in the planning phase of the Billables Project. Arizona, Arkansas, California, Colorado, 

Chicago, Georgia, Illinois, Iowa, Kansas, Massachusetts, Michigan, Mississippi, Missouri, Montana, Nevada, New 

Mexico, New York, North Dakota, Ohio, Oklahoma, Oregon, Tennessee, Virginia, Washington, and West Virginia 

participated in both the planning and implementation phases of the Billables Project.
27 

Appendix B: Project Timeline

2009 2010 2011 2012 2013 2014 2015 2016

Funding awarded 

to 14 states for 

planning and 

7 states for 

Implementation

Funding awarded 

to 7 states for 

planning and 

7 states for 

Implementation

Funding awarded 

to 11 states for 

Implementation

Extensions 

awarded to 11 

Implementation 

awardees

Funding awarded 

to 14 states for 

planning projects

Project Timeline. In 2009, funding was awarded to 14 states for planning projects. In 2011, funding was 

awarded to 14 states for planning and to 7 states for implementation. In 2012, funding was awarded to 7 

states for planning and to 7 states for implementation. In 2014, funding was awarded to 

11 states for implementation. In 2016, extensions were awarded to 11 implementation awardees.
28 

Appendix C: Figures

3⁄4 Figure 1: Simplified logic model for CDC Billables Project. CDC provided authority, funding, program guidance, 

technical assistance, and evaluation throughout the Billables Project. CDC’s inputs helped with activities such as monthly 

phone calls, monthly reports, and final project reports. The short-term outcomes for the Billables Project were that 

public health departments began, expanded, or continued capture of reimbursements for immunization services and 

increased knowledge of billing activities and processes. The long-term outcomes for the Billables Project were increased 

ability and capacity to immunize communities, increased self-sustainability at LHDs, and improved vaccine supply 

management at LHDs. 

3⁄4 Figure 2: Total number of immunization visits. Illinois did not provide data for Q1 (questionnaire 1), Kansas and 

Mississippi did not provide data for Q2 (questionnaire 2), Nevada did not provide data for Q2 and Q3 (questionnaire 3), 

and Missouri did not provide any data on total number of immunization visits. Illinois reported 5,315 immunization visits 

on questionnaire 2; 37,577 immunization visits on questionnaire 3; and 41,354 immunization visits on questionnaire 

4. Kansas reported 29,455 immunization visits on questionnaire 1 and 91,508 immunization visits on questionnaire 3. 

Mississippi reported 52,045 immunization visits on questionnaire 1; 44,557 immunization visits on questionnaire 3; and 

42,447 immunization visits on questionnaire 4. Nevada reported 28,215 immunization visits on questionnaire 1 and 

35,830 immunization visits on questionnaire 4. New Mexico reported 7,379 immunization visits on questionnaire 1; 

5,579 immunization visits on questionnaire 2; 7,380 immunization visits on questionnaire 3; and 5,039 immunization 

visits on questionnaire 4. Tennessee reported 80,710 immunization visits on questionnaire 1; 55,860 immunization visits 

on questionnaire 2; 92,323 immunization visits on questionnaire 3; and 43,991 immunization visits on questionnaire 4. 

Virginia reported 102,453 immunization visits on questionnaire 1; 56,952 immunization visits on questionnaire 2; 85,599 

immunization visits on questionnaire 3; and 56, 596 immunization visits on questionnaire 4.

3⁄4 Figure 3: Percentage of immunization visits that were billed (total immunization visits billed divided by 

total immunization visits). Illinois reported 100% of immunization visits billed on questionnaires 2-4. Kansas reported 

54% of immunization visits billed on questionnaire 1. Mississippi reported 100% of immunization visits billed on 

questionnaires 1, 3, and 4. Nevada reported 44% of immunization visits billed on questionnaire 4. New Mexico reported 

37% of immunization visits billed on questionnaire 1; 34% on questionnaire 2; 37% on questionnaire 3; and 55% on 

questionnaire 4. Tennessee reported 100% of immunization visits billed on questionnaires 1–4. Virginia reported 

94% of immunization visits billed on questionnaire 1; 92% on questionnaire 2; 100% on questionnaire 3; and 88% on 

questionnaire 4.

3⁄4 Figure 4: Percentage of patients who were insured. Kansas only provided data for Q1 (questionnaire 1) 

and Missouri only provided data for Q4 (questionnaire 4). Illinois reported 97% of patients were insured on 

questionnaire 2; 75% on questionnaire 3; and 94% on questionnaire 4. Kansas reported 64% of patients were insured 

on questionnaire 1. Mississippi reported 65% of patients were insured on questionnaire 1; 72% on questionnaire 3; and 

66% on questionnaire 4. Missouri reported 55% of patients were insured on questionnaire 4. Nevada reported 45% of 

patients were insured on questionnaire 1; 57% on questionnaires 2 and 3; and 61% on questionnaire 4. New Mexico 

reported 43% of patients were insured on questionnaire 1; 37% on questionnaire 2; 38% on questionnaire 3; and 39% on 

questionnaire 4. Tennessee reported 54% of patients were insured on questionnaire 1; 62% on questionnaire 2; 65% on 

questionnaire 3; and 74% on questionnaire 4. Virginia reported 53% of patients were insured on questionnaire 1; 46% on 

questionnaire 2; 54% on questionnaire 3; and 27% on questionnaire 4.
29 

3⁄4 Figure 5: Percentage of patients who were uninsured. Kansas only provided data for Q1 (questionnaire 1) and 

Missouri only provided data for Q4 (questionnaire 4). Illinois reported 3% of patients were uninsured on questionnaire 2; 

7% on questionnaire 3; and 6% on questionnaire 4. Kansas reported 16% of patients were uninsured on questionnaire 

1. Mississippi reported 34% of patients were uninsured on questionnaire 1; 27% on questionnaire 3; and 32% on 

questionnaire 4. Missouri reported 19% of patients were uninsured on questionnaire 4. Nevada reported 25% of patients 

were uninsured on questionnaire 1; 35% on questionnaires 2 and 3; and 32% on questionnaire 4. New Mexico reported 

43% of patients were uninsured on questionnaire 1; 37% on questionnaire 2; 38% on questionnaire 3; and 39% on 

questionnaire 4. Tennessee reported 54% of patients were uninsured on questionnaire 1; 62% on questionnaire 2; 65% 

on questionnaire 3; and 74% on questionnaire 4. Virginia reported 53% of patients were uninsured on questionnaire 1; 

46% on questionnaire 2; 54% on questionnaire 3; and 27% on questionnaire 4.

3⁄4 Figure 6: Percentage of immunization visits billed to private insurance. Kansas only provided data for Q1 

(questionnaire 1) and Missouri only provided data for Q4 (questionnaire 4). Illinois reported 81% of immunization visits 

were billed to private insurance on questionnaire 2; 60% on questionnaire 3; and 59% on questionnaire 4. Kansas 

reported 73% of immunization visits were billed to private insurance on questionnaire 1. Mississippi reported 8% of 

immunization visits were billed to private insurance on questionnaire 1 and 12% on questionnaires 3 and 4. Missouri 

reported 29% of immunization visits were billed to private insurance on questionnaire 4. Nevada reported 26% of 

immunization visits were billed to private insurance on questionnaires 2 and 3 and 24% on questionnaire 4. New Mexico 

reported 0% of immunization visits were billed to private insurance on questionnaires 1–4. Tennessee reported 5% of 

immunization visits were billed to private insurance on questionnaire 1; 12% on questionnaire 2; 15% on questionnaire 

3; and 48% on questionnaire 4. Virginia reported 37% of immunization visits were billed to private insurance on 

questionnaire 1; 27% on questionnaire 2; 36% on questionnaire 3; and 29% on questionnaire 4. 

3⁄4 Figure 7: Percentage of immunization visits billed to public insurance. Kansas only provided data for Q1 

(questionnaire 1) and Missouri only provided data for Q4 (questionnaire 4). Illinois reported 3% of immunization visits 

were billed to public insurance on questionnaire 2; 7% on questionnaire 3; and 35% on questionnaire 4. Kansas reported 

43% of immunization visits were billed to public insurance on questionnaire 1. Mississippi reported 63% of immunization 

visits were billed to public insurance on questionnaire 1; 68% on questionnaire 3; and 61% on questionnaire 4. Missouri 

reported 61% of immunization visits were billed to public insurance on questionnaire 4. Nevada reported 74% of 

immunization visits were billed to public insurance on questionnaires 2 and 3 and 76% on questionnaire 4. New Mexico 

reported 100% of immunization visits were billed to public insurance on questionnaires 1–4. Tennessee reported 50% 

of immunization visits were billed to public insurance on questionnaires 1–3 and 51% on questionnaire 4. Virginia 

reported 26% of immunization visits were billed to public insurance on questionnaire 1; 24% on questionnaire 2; 27% on 

questionnaire 3; and 25% on questionnaire 4.
30 

Appendix D: Selected Billing Resources and Manuals

3⁄4 American College of Physicians. Billing and Coding Adult Immunizations. Available at 

https://www.acponline.org/system/files/documents/running_practice/payment_coding/coding/billvaccines.pdf

3⁄4 Local Health Department Vaccination Billing Manual, Pomperaug (Connecticut) Health District, 

Part 2–Billing Manual, How to Bill for Vaccinations. Available at 

http://www.ct.gov/dph/lib/dph/infectious_diseases/immunization/vax_billing_part_2_complete.pdf 

3⁄4 Georgia Department of Public Health. Billing Resource Manual. Available at 

http://dph.georgia.gov/sites/dph.georgia.gov/files/Georgia%20DPH%20Billing%20Resource%20Manual%20

December%202013.pdf 

3⁄4 Illinois Public Health Association. Immunization Billing for Public Health. Available at https://ipha.com/content/uploads/

Immunization%20Billing%20for%20Public%20Health.pdf

3⁄4 Kansas Local Health Department Clinical Services Coding Resource Guide. Available at 

http://www.kalhd.org/wp-content/uploads/2016/09/KS-Billing-Resource-Guide-Updated-June-2017.pdf

3⁄4 Centers for Medicare and Medicaid Services. Medicare Part B Immunization Billing. Available at 

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/qr_

immun_bill.pdf

3⁄4 Missouri Department of Health and Senior Services, Bureau of Immunization Assessment and Assurance. Missouri’s Billing 

Plan Toolkit for Local Public Health Agencies. Available at 

http://health.mo.gov/living/wellness/immunizations/pdf/BillingPlanToolkitLPHA.pdf 

3⁄4 Oregon Health Authority (Oregon Immunization Program): Immunization Billing Resources. Available at http://www.

oregon.gov/oha/PH/PreventionWellness/VaccinesImmunization/ImmunizationProviderResources/Pages/Payor.aspx 

3⁄4 Wisconsin Department of Health Services. Wisconsin Immunization Program–Billing Manual for Local Health 

Departments. Available at https://www.dhs.wisconsin.gov/immunization/billingmanual.htm
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