(Medicare Claims Processing Manual)

10.3.1 -  Roster Claims Submitted to A/B MACs (B) for Mass Immunization Roster Claims Submitted to AB MACs (B) for Mass Immunization  (Rev. 11355; Issued:04- 14-22; Effective:05 -16-22; Implementation:05 -16-22)  If the PHC or other individual or entity qualifies to submit roster claims, it may use a preprinted Form CMS -1500 that contains standardized information about the entity and the benefit.  See Pub. 100-04, Chapter 26, 10 for more information about the CMS -1500 claim form.  Key information from the beneficiary roster list and the abbreviated claim form is used to process pneumococcal, influenza, and COVID -19 vaccination claims.   Separate CMS -1500 claim forms, along with separate roster bills, must be submitted for influenza virus, pneumococcal, and COVID -19 roster billing.  If other services are furnished to a beneficiary along with pneumococcal, influenza, or COVID -19 vaccines, individuals and entities must submit claims using normal billing procedures, e.g., submission of a separate claim for each beneficiary.   MACs (Part B) must create and count one claim per beneficiary from roster bills.  They must split claims for each beneficiary if there are multiple beneficiaries included in a roster bill.  Providers must show the unit cost for one service on the claim.  T he MACs (Part B) must replicate the claim for each beneficiary listed on the roster.   MACs (Part B) must provide Palmetto -Railroad Retirement Board (RRB) with local pricing files for pneumococcal, influenza, and COVID -19 vaccines and their administration.  If PHCs or other individuals or entities inappropriately bill pneumococcal, influenza , or COVID -19 vaccinations using the roster billing method, MACs (Part B) shall return the claim as unprocessable with the appropriate rejection message. MACs (Part B) may not deny these claims.   Providers must retain roster bills with beneficiaries' signatures at their permanent location for a time period consistent with Medicare regulations.   A. Modified Form CMS -1500 for Cover Document   Entities submitting roster bills to MACs (Part B) must complete the following blocks on a single modified Form CMS -1500 claim form, which serves as the cover document for the roster for each facility where services are furnished.  In order for MACs (Part B ) to reimburse by correct payment locality, a separate Form CMS -1500 must be used for each different facility or physical location where services are furnished.   Item #  Instruction  Item 1:  An X in the Medicare block  Item 2:  (Patient's Name):  "SEE ATTACHED ROSTER"  Item 11:  (Insured's Policy Group or FECA Number):  "NONE"  Item 20:  (Outside Lab?): An "X" in the NO block  Item 21:  (Diagnosis or Nature of Illness):  Line A:  Choose appropriate diagnosis code from 10.2.1 ICD Ind. Block: Enter ICD -10-CM code.  Enter the indicator as a single digit between the vertical dotted lines.  Item 24B:  (Place of Service (POS)):  Line 1: "60"  Line 2: "60"  NOTE: POS Code 60" must be used for roster billing.   Item #  Instruction  Item 24D:  (Procedures, Services or Supplies):  Line 1:   Vaccine code   Line 2:  Vaccine Administration code   Item 24E:  (Diagnosis Pointer):  Lines 1 and 2: "A"  Item 24F: ($ Charges):  The entity must enter the charge for each listed service.  If the entity is not charging for the vaccine or its administration, it should enter 0.00 or "NC" (no charge) on the appropriate line for that item.  If your system is unable to accept a line item charge of 0.00 for an immunization service, do not key the line item.  Likewise, electronic media claim (EMC) billers should submit line items for free immunization services on EMC pneumococcal or influenza virus vaccine claims only if your s ystem is able to accept them.  Item 27:  (Accept Assignment): An "X" in the YES block.  Item 29:  (Amount Paid):  "$0.00"  Item 31:  (Signature of Physician or Supplier):  The entity's representative must sign the modified Form CMS -1500.  Item 32:  Enter the name, address, and ZIP code of the location where the service was provided (including centralized billers).  Item32a:  Enter the NPI of the service facility.  Item 33:  (Physician's, Supplier's Billing Name):  The entity must complete this item.  Item 33a:  Effective May 23, 2007, and later, enter the NPI of the billing provider or group.    B. Format of Roster Claims   Qualifying individuals and entities must attach to the CMS -1500 claim form, a roster bill which contains the claims information regarding the supplier of the service and individual beneficiaries.  While qualifying entities must use the modified Form CMS -1500 claim form without deviation, MACs (Part B) must work with these entities to develop a mutually suitable roster bill that contains the minimum data necessary to satisfy claims processing requirements for these claims.  MACs (Part B) must key information  from the beneficiary roster bill and abbreviated Form CMS -1500 claim form to process pneumococcal, influenza virus, and COVID -19 vaccination claims.  The roster must contain at a minimum the following information:   Provider name and number;    Date of service;   NOTE:  Providers must include the individual date of service for each beneficiary's vaccination on the roster bill.    Control number for MAC (Part B);    Patient's Medicare beneficiary identifier number;    Patient's name;    Patient's address;    Date of birth;    Patient's sex; and    Beneficiary's signature or stamped "signature on file.   NOTE:  A stamped "signature on file" qualifies as an actual signature on a roster bill   if the provider has a signed authorization on file to bill Medicare for services rendered.  In this situation, the provider is not required to obtain the patient signature on the roster, but instead has the option of reporting signature on file in lieu of obtaining the patient's actual signature.   The pneumococcal roster must contain the following language to be used by providers as a precaution to alert beneficiaries prior to administering the pneumococcal vaccination.   WARNING:  Beneficiaries must be asked if they have received a pneumococcal vaccination.    Rely on patients' memory to determine prior vaccination status.  MACs (Part B) shall use the data on the CMS -1500 claim form cover sheet and the roster bill to correct or add missing claims data and continue to process the claims for payment.  Contractors shall not return a claim as unprocessable if the following data fields on the CMS -1500 are not completed:   Item 1,  Item 2, or  Item 20.   The MAC (Part B) shall allow the roster claims to continue to process for payment. The MAC (Part B) shall complete the incomplete fields if the data is available on the attached roster bill.   The MAC (Part B) may fill in missing or incomplete information on the attached roster bill when the required data such as providers name and NPI is missing but is included on the abbreviated CMS -1500 claim form. The MAC shall fill in the missing informati on and continue to process the claim for payment.   10.3.1.1 - Centralized Billing for Influenza Virus and Pneumococcal Vaccines to A/B MACs (B)  (Rev. 11355; Issued:04- 14-22; Effective:05 -16-22; Implementation:05 -16-22)  The CMS currently authorizes providers to centrally bill for influenza, pneumococcal, and COVID -19 vaccination claims.  That is to say, they bill all of the claims for those vaccinations to one MAC, rather than to each of the MACs that service the location where the services are rendered.   Centralized billing is an optional program available to providers who qualify to enroll with Medicare as the provider type Mass Immunization Roster Biller, as well as to other individuals and entities that qualify to enroll as regular Medicare providers.  Centralized billers must roster bill, must accept assignment, and must bill electronically.   The contractor assigned to process the claims for centralized billing will be chosen at the discretion of The Centers for Medicare & Medicaid Services (CMS) based on such considerations as workload, user -friendly software developed by the contractor for bi lling claims, and overall performance.  Currently the specialty contractor for centralized billing is Novitas (JH).   To qualify for centralized billing, a mass immunizer must be operating in at least three payment localities for which there are three different MACs processing claims.  Individuals and entities providing the vaccine and administration must be properly lice nsed in the State in which the vaccinations are given and the MAC will verify this through the enrollment process.   As previously stated, centralized billers must send all claims for influenza, pneumococcal, and COVID- 19 vaccinations to a single MAC for payment, regardless of the jurisdiction in which the vaccination was administered.  (This does not include claims for the Railroad Retirement Board, United Mine Workers or Indian Health Services.  These claims must continue to go to the appropriate processing entity.)  Payment is made based on the payment locality where the service was provided.  Centralized billing is only available for claims for the influenza, pneumococcal, and COVID- 19 vaccines and their administration.  The general coverage and coding rules still apply to these claims.   This section applies only to those individuals and entities that provide mass immunization services for influenza, pneumococcal, and COVID -19 virus vaccinations that have been authorized by CMS to centrally bill.  All other providers, including those individuals and entities that provide mass immunization services that are not authorized to centrally bill, must continue to submit claims to their regular MAC (Part B) per the instructions in 10.3.1 of this chapter.   The claims processing instructions in this section apply only to claims submitted to the designated processing MAC.  However, all MACs (Part B) must follow the instructions in 10.3.1.1.J , below, Provider Education Instructions for All MACs (Part B).    A. Request for Approval   Centralized Billing for Influenza, Pneumococcal and COVID -19 Virus Vaccinations    A. Information for Providers Interested in Applying for Centralized Billing   In order to qualify as a centralized biller , a provider must be operating in at least three payment localities for which there are three different MACs processing claims.   Individuals and corporations who wish to enroll as a CMS centralized biller must send their request in writing to Novitas, (the current specialty contractor) at the address at the end of this section.      Providers must include the following information in their application to become a centralized biller.   1.  Providers must indicate that they agree to the following:    a) Centralized billers providing the vaccine and administration must be properly licensed in the States in which the vaccinations are given.   b) Centralized biller must agree to accept assignment (i.e., they must agree to accept the amount that Medicare pays for the vaccine and the administration).  Since there is no coinsurance or deductible for the influenza, pneumococcal and COVID -19 vaccination s, accepting assignment means that Medicare beneficiaries cannot be charged for the vaccination, i.e., beneficiaries may not incur any out -of-pocket expense.  For example, a drugstore may not charge a Medicare beneficiary $10 for an influenza virus vaccina tion and give the beneficiary a coupon for $10 to be used in the drugstore.  This practice is unacceptable.   c) Centralized billers must understand that beginning December 11, 2021 the payment rate for the administration of the COVID -19 vaccine is $40 and $30 for the other preventive vaccinations.  These payment amounts are geographically adjusted by locality.  Ther efore, the centralized biller must be willing to accept that payments received may vary based on the geographic locality where the service was performed.   d) Centralized billers must understand that the payment rates for the vaccines will be determined by the standard method used by Medicare for reimbursement of drugs and biologicals.   e) Centralized billers must agree to submit their claims in a CMS approved electronic media claims standard format.  Paper claims will not be accepted.   f) In addition to the elements required by regular roster billing, centralized billers must complete the service facility location in order for the MAC to be able to pay correctly by geographic locality. Centralized billers should contact the processing contr actor for specific information.   g) Centralized billers must obtain certain information for each beneficiary including name, Medicare Beneficiary Identifier, date of birth, sex, and signature.  Novitas must be contacted prior to the season for exact requirements.  The responsibility lies wit h the centralized biller to submit correct beneficiary Medicare information (including the correct MBI as Novitas will not be able to process incomplete or incorrect claims.