evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Effective January 1 of the year following the year in which the PHE for COVID -19 ends, the payment rate for COVID -19 vaccine administration will be set at a rate to align with the payment rate for the administration of other Part B preventive vaccines.   In order to pay claims correctly for centralized billers, the designated contractor must have the correct name and address, including ZIP code, of where the service was provided.  The following remittance advice and Medicare Summary Notice (MSN) messages apply:   Claim adjustment reason code 16, Claim/service lacks information which is needed for adjudication.  At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code,   Remittance advice remark code MA114 , Missing/incomplete/invalid information on where the services were furnished.   MSN 9.4 -  This item or service was denied because information required to make payment was incorrect.   The payment rates for the vaccines must be determined by the standard method used by Medicare for reimbursement of drugs and biologicals.  (See chapter 17 for procedures for determining the payment rates for vaccines.)   Effective for claims with dates of service on or after February 1, 2001, 114, of the Benefits Improvement and Protection Act of 2000 mandated that all drugs and biologicals be paid based on mandatory assignment.  Therefore, all providers Medicare covered preventive must accept assignment for the vacc ine.  In addition, as a requirement for both centralized billing and roster billing, providers must agree to accept assignment for the administration of the vaccines as well.  This means that they must agree to accept the amount that Medicare pays for the vaccine and the administration.  Also, since there is no coinsurance or deductible for the influenza, pneumococcal, and COVID -19 vaccine benefits, accepting assignment means that Medicare beneficiaries cannot be charged for the vaccination.   G. Common Working File Information   To identify these claims and to enable central office data collection on the project, special processing number 39 has been assigned.  The number should be entered on the HUBC claim record to CWF in the field titled Demonstration Number.  H. Provider Education Instructions for the Designated Processing Part B MAC
(Medicare Claims Processing Manual)
The designated Part B MAC must fully educate the centralized billers on the processes for centralized billing as well as for roster billing.  General information on influenza, pneumococcal, and COVID -19 vaccine coverage and billing instructions is availabl e on the CMS Web site for providers.   I. Provider Education Instructions for All MACs (Part B)   By XXXX of every year, all MACs (Part B) must publish in their bulletins and put on their Web sites the following notification to providers.  Questions from interested providers should be forwarded to Novitas, the designated processing Part B MAC for the c entralized billing workload at the address below.  MACs (Part B) must enter the name of the assigned processing contractor where noted before sending.  NOTIFICATION TO PROVIDERS   Centralized billing is a process in which a provider, who provides mass immunization services for influenza virus and pneumococcal pneumonia virus (PPV) immunizations, can send all claims to a single contractor for payment regardless of the geographic loca lity 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.)  This process is only availabl e for claims for the influenza virus and pneumococcal vaccines and their administration.  The administration of the vaccinations is reimbursed at the assigned rate based on the Medicare physician fee schedule for the appropriate locality.  The vaccines are reimbursed at the assigned rate using the Medicare standard method for reimbursement of drugs and biologicals.  Individuals and entities interested in influenza and pneumococcal centralized billing must contact Novitas, to begin centrally billing for influenza and pneumococcal vaccines.    Applications to become a mass immunizer centralized biller for the COVID -19 vaccine is an ongoing enrollment. Individuals and entities can submit a request to become a centralized mass immunizer at any time. For more information on enrolling as a COVID -19 mass immunizer centralized biller go to: https://www.cms.gov/medicare/covid -19/enrollment -administering -covid -19-vaccine -shots  .      By agreeing to participate in the centralized billing program, providers agree to abide by the following criteria.   CRITERIA FOR CENTRALIZED BILLING
(Medicare Claims Processing Manual)
By agreeing to participate in the centralized billing program, providers agree to abide by the following criteria.   CRITERIA FOR CENTRALIZED BILLING    To qualify for centralized billing, an individual or entity providing mass vaccination services for influenza virus, pneumococcal, and COVID -19 vaccinations must provide these services in at least three payment localities for which there are at least three different contractors processing claims.   Individuals and entities providing the vaccine and administration must be properly licensed in the state in which the immunizations are given.    Centralized billers must agree to accept assignment (i.e., they must agree to accept the amount that Medicare pays for the vaccine and the administration).  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 vaccination and give the beneficiary a coupon for $10 to be used in the drugstore.   NOTE:   The practice of requiring a beneficiary to pay for the vaccination upfront and to file their own claim for reimbursement is inappropriate.  All Medicare providers are required to file claims on behalf of the beneficiary per 1848(g)(4)(A) of the Social S ecurity Act and centralized billers may not collect any payment.    The contractor assigned to process the claims for centralized billing is chosen at the discretion of CMS based on such considerations as workload, user -friendly software developed by the contractor for billing claims, and overall performance.  The assigned contractor for this year is [Fill in name of contractor.]    The payment rates for the administration of the vaccinations are based on the Medicare physician fee schedule (MPFS) for the appropriate year.  Payment made through the MPFS is based on geographic locality.  Therefore, payments received may vary based on the geographic locality where the service was performed.  Payment is made at the assigned rate.    The payment rates for the vaccines are determined by the standard method used by Medicare for reimbursement of drugs and biologicals.  Payment is made at the assigned rate.   Centralized billers must submit their claims on roster bills in an approved electronic format.  Paper claims will not be accepted.
(Medicare Claims Processing Manual)
 Centralized billers must submit their claims on roster bills in an approved electronic format.  Paper claims will not be accepted.    Centralized billers must obtain certain information for each beneficiary including name, MBI number, date of birth, sex, and signature.  [The designated Part B MAC] must be contacted prior to submitting claims for verification of billing requirements.  The  responsibility lies with the centralized biller to submit correct beneficiary Medicare information (including the beneficiarys Medicare Health Insurance Claim Number) as the contractor will not be able to process incomplete or incorrect claims.    Centralized billers must obtain an address for each beneficiary so that a Medicare Summary Notice (MSN) can be sent to the beneficiary by the Part B MAC.  Beneficiaries are sometimes confused when they receive an MSN from a Part B MAC other than the MAC that normally processes their claims which results in unnecessary beneficiary inquiries.  Therefore, centralized billers must provide every beneficiary receiving an influenza virus or pneumococcal vaccination with the name of the processing Part B MAC.  This  notification must be in writing, in the form of a brochure or handout, and must be provided to each beneficiary at the time he or she receives the vaccination.    Centralized billers must retain roster bills with beneficiary signatures at their permanent location for a time period consistent with Medicare regulations.  [ The designated Part B MAC ] can provide this information.   Though centralized billers may already have a Medicare provider number, for purposes of centralized billing, they must also obtain a provider number from [The designated Part B MAC].  This can be done by completing the Form CMS -855 (Provider Enrollment Application), which can be obtained from [ The designated Part B MAC].  NOTE:  Influenza/Pneumococcal Mass Immunizer Centralized Billers DO NOT  need to enroll separately as a COVID -19 Mass Immunizer Centralized Biller to administer COVID- 19 vaccine shots.   If an individual or entitys request for centralized billing of influenza, pneumococcal, and/or COVID -19 vaccines is approved, the approval is ongoing.  Claims will not be processed for any influenza, pneumococcal, or COVID -19 centralized biller without approval from the designated Part B MAC.
(Medicare Claims Processing Manual)
 Each year the centralized biller must contact the designated Part B MAC to verify understanding of the coverage policy for the administration of the pneumococcal vaccine, and for a copy of the warning language that is required on the roster bill.   The centralized biller is responsible for providing the beneficiary with a record of the pneumococcal vaccination.   The information in items 1 through 8 below must be included with the individual or entitys annual request to participate in centralized billing:   1.  Estimates for the number of beneficiaries who will receive influenza virus vaccinations;   2.  Estimates for the number of beneficiaries who will receive pneumococcal vaccinations;   3. Estimates for the number of beneficiaries who will receive COVID -19 vaccinations (if applicable);   4.  The approximate dates for when the vaccinations will be given;   5.  A list of the states in which influenza, pneumococcal, and COVID -19 vaccination clinics will be held;  6.  The type of services generally provided by the corporation (e.g., ambulance, home health, or visiting nurse);   7.  Whether the nurses who will administer the influenza, and pneumococcal, and COVID- 19 vaccinations are employees of the corporation or will be hired by the corporation specifically for the purpose of administering influenza, pneumococcal, and COVID -19 vaccinations;   8.  Names and addresses of all entities operating under the corporations application (not clinic locations);  9.  Contact information for designated contact person for centralized billing program.   10.3.2 - Claims Submitted to MACs (Part A) for Mass Immunizations of Influenza, Pneumococcal, and/or COVID- 19 Virus Vaccinations                                                            (Rev. 11355; Issued:04- 14-22; Effective:05 -16-22; Implementation:05 -16-22)
(Medicare Claims Processing Manual)
To increase the number of beneficiaries who obtain needed preventive vaccinations, simplified roster billing procedures are also available to mass immunizers that bill MACs (Part A).  The simplified roster claims filing procedure has been expanded from ava ilability for influenza and pneumococcal virus vaccinations to also include  COVID -19 virus vaccinations.  A mass immunizer is defined as any entity that gives the influenza, pneumococcal, or COVID -19 virus vaccinations to a group of beneficiaries, e.g., a t public health clinics, shopping malls, grocery stores, senior citizen homes, and health fairs.  To qualify for roster billing, immunizations of at least five beneficiaries on the same date are required.  (See 10.3.2.2 for an exception to this requirement for inpatient hospitals.)   The simplified roster billing claims filing procedure applies to providers other than RHCs and FQHCs that conduct mass immunizations.  Since independent and provider based RHCs and FQHCs do not submit individual Form CMS -1450s for the influenza virus vacci ne, they do not utilize the simplified billing process.  Instead, payment is made for the vaccine at the time of cost settlement.   The simplified roster billing process involves use of the provider billing form (Form CMS -1450) with preprinted standardized information relative to the provider and the benefit.  Mass immunizers attach a standard roster to a single pre- printed Form CMS -1450 that contains the variable claims information regarding the service provider and individual beneficiaries.   Qualifying individuals and entities must attach a roster, which contains the variable claims information regarding the supplier of the service and individual beneficiaries.  The roster must contain at a minimum the following information:   Provider name and NPI;    Date of service;    Patient name and address;    Patient date of birth;   Patient sex;    Patient  Medicare Beneficiary Identifier  (MBI) number; and    Beneficiary signature or stamped "signature on file."   In addition, for inpatient Part B services (12x and 22X) the following data elements are also needed:    Admission date;    Admission type;    Admission diagnosis;    Admission source code; and   Patient status code.
(Medicare Claims Processing Manual)
In addition, for inpatient Part B services (12x and 22X) the following data elements are also needed:    Admission date;    Admission type;    Admission diagnosis;    Admission source code; and   Patient status code.   NOTE:  A stamped "signature on file" can be used in place of the beneficiary's actual signature for all institutional providers that roster bill from an inpatient or outpatient department provided the provider has a signed authorization on file to bill Medicare f or services rendered.  In this situation, they are not required to obtain the patient signature on the roster.  However, the provider has the option of reporting "signature on file" in lieu of obtaining the patient's actual signature on the roster.   The pneumococcal vaccination roster must contain the following language to be used by providers as a precaution to alert beneficiaries prior to administering the pneumococcal vaccine.   Warning:  Beneficiaries must be asked if they have been vaccinated with the pneumococcal vaccine.    Rely on the patients' memory to determine prior vaccination status.    If patients are uncertain whether they have been vaccinated within the past 5 years, administer the vaccine,    If patients are certain that they have been vaccinated within the past 5 years, do not revaccinate.   For providers using the simplified billing procedure, the modified Form CMS -1450 shows the following preprinted information in the specific form locators (FLs). Information regarding the form locator numbers that correspond to the data element names below is found in Chapter 25:    The words "See Attached Roster" (Patient Name);    Patient Status code 01 (Patient Status);   Condition code M1 (Condition Code) (See NOTE below);    Condition code A6 (Condition Code);    Revenue code 636 (Revenue Code), along with the appropriate HCPCS code in FL 44 (HCPCS Code);    Revenue code 771 (Revenue Code), along with the appropriate "G" HCPCS code (HCPCS Code);    "Medicare" (Payer, line A);    The words "See Attached Roster" (Provider Number, line A); and    Diagnosis code     ICD- 10-CM - Use Z23 for an encounter for immunization effective with the implementation of ICD -10.
(Medicare Claims Processing Manual)
 The words "See Attached Roster" (Provider Number, line A); and    Diagnosis code     ICD- 10-CM - Use Z23 for an encounter for immunization effective with the implementation of ICD -10.   Influenza virus and COVID -19 vaccines require:     the providers own NPI to be reported in the NPI field for the attending physician on claims submitted on or after May 23, 2007.   Providers conducting mass immunizations are required to complete the following fields on the preprinted Form CMS -1450:    Type of Bill;    Total Charges;    Provider Representative; and    Date.   NOTE:  Medicare Secondary Payer (MSP) utilization editing is bypassed in CWF for all mass immunization roster bills.  However, if the provider knows that a particular group health plan covers the pneumococcal vaccine and all other MSP requirements for the Medicare beneficiary are met, the primary payer must be billed.  First claim development alerts from CWF are not generated for influenza, pneumococcal or COVID -19 vaccination claims.   Contractors use the beneficiary roster list to generate claim records to process the pneumococcal virus vaccination claims by mass immunizers indicating condition code M1 to avoid MSP editing.  Standard System Maintainers must develop the necessary softwar e to generate records that will process through their system.  Providers that do not mass immunize must continue to bill for the influenza, pneumococcal and COVID- 19 virus vaccinations using the normal billing method, (e.g., submission of a Form CMS -1450 or electronic billing for each beneficiary).    10.3.2.1 - Simplified Billing for Influenza, Pneumococcal and COVID -19 Virus Vaccination Services by HHAs                                                                            (Rev. 11355; Issued:04- 14-22; Effective:05 -16-22; Implementation:05 -16-22)  The following billing instructions apply to HHAs that roster bill for influenza virus and pneumococcal vaccines.
(Medicare Claims Processing Manual)
The following billing instructions apply to HHAs that roster bill for influenza virus and pneumococcal vaccines.    When an HHA provides the influenza virus vaccine or the pneumococcal vaccine in a mass immunization setting, it does not have the option to pick and choose whom to bill for this service.  If it is using employees from the certified portion, and as a result  will be reflecting these costs on the cost report, it must bill the A/B MAC (HHH) on the Form CMS -1450.    If the HHA is using employees from the noncertified portion of the agency (employees of another entity that are not certified as part of the HHA), and as a result, will not be reflecting these costs on the cost report, it must obtain a provider number and bill their A/B MAC (B) on the Form CMS -1500.   If employees from both certified and noncertified portions of the HHA furnish the vaccines at a single mass immunization site, they must prepare two separate rosters, e.g., one for employees of the certified portion to be submitted to the A/B MAC (HHH) and one roster for employees of the noncertified portion to be submitted to the A/B MAC (B).  10.3.2.2 - Hospital Inpatient Roster Billing  (Rev. 11355; Issued:04- 14-22; Effective:05 -16-22; Implementation:05 -16-22)   The following billing instructions apply to hospitals that roster bill for the influenza, pneumococcal and/or COVID -19 vaccinations provided to inpatients:    Hospitals do not have to wait until patients are discharged to provide the vaccine.  They may provide it anytime during the patients stay;    The roster should reflect the actual date of service;    The requirement to provide the vaccine to five or more patients at the same time to meet the requirements for mass immunizers is waived when vaccines are provided to hospital inpatients.  Therefore, the roster may contain fewer than five patients or fewer than five patients on the same day; and    The roster should contain information indicating that the vaccines were provided to inpatients to avoid questions regarding the number of patients or various dates.
(Medicare Claims Processing Manual)
 The roster should contain information indicating that the vaccines were provided to inpatients to avoid questions regarding the number of patients or various dates.   10.3.2.3 - Electronic Roster Claims  (Rev. 11355; Issued:04- 14-22; Effective:05 -16-22; Implementation:05 -16-22)  As for all other Medicare -covered services, MACs (Part A) pay electronic claims more quickly than paper claims.  For payment floor purposes, roster bills are paper bills and may not be paid as quickly as EMC.  (See Chapter 1.)  If available, MACs (Part A) must offer free, or at -cost, electronic billing software and ensure that the software is as user friendly as possible to roster bill for the influenza, pneumococcal and COVID -19 vaccinations.   10.4.1 - CWF Edits on MAC (Part A) Claims  (Rev. 11355; Issued:04- 14-22; Effective:05 -16-22; Implementation:05 -16-22)  In order to prevent duplicate payment by the same MAC (Part A), CWF edits by line item on the MAC (Part A) number, the Medicare Beneficiary Identifier (MBI) number, and the date of service, the influenza virus procedure codes 90630, 90653, 90654, 90655, 90656, 90657, 90658, 90660, 90661, 90662, 90672, 90673, 90674, 90682, 90685, 90686, 90687, 90688, 90694, or  90756 and the pneumococcal procedure codes 90670, 90671, 90677, or 90732, and the administration code, G0008 or G0009 .
(Medicare Claims Processing Manual)
1. If CWF receives a claim with either HCPCS codes 90630, 90653, 90654, 90655, 90656, 90657, 90658, 90660, 90661, 90662, 90672, 90673, 90674, 90685, 90686, 90687, 90688, 90694, or  90756 and it already has on record a claim with the same MBI number, same MAC (Part A) number, same date of service, and any one of those HCPCS codes, the second claim submitted to CWF rejects.  2. If CWF receives a claim with HCPCS codes 90670, 90671, 90677, or 90732 and it already has on record a claim with the same MBI number, same MAC (Part A) number, same date of service, and the same HCPCS code, the second claim submitted to CWF rejects when al l four items match.  3. If CWF receives a claim with HCPCS administration codes G0008 or G0009 and it already has on record a claim with the same MBI number, same MAC (Part A) number, same date of service, and same procedure code, CWF rejects the second claim submitted when all f our items match.    CWF returns to the MAC (Part A) a reject code 7262 for this edit. MACs (Part A) must deny the second claim and use the same messages they currently use for the denial of duplicate claims.   10.4.2 - CWF Edits on MAC (Part B) Claims  (Rev. 11355; Issued:04- 14-22; Effective:05 -16-22; Implementation:05 -16-22)
(Medicare Claims Processing Manual)
10.4.2 - CWF Edits on MAC (Part B) Claims  (Rev. 11355; Issued:04- 14-22; Effective:05 -16-22; Implementation:05 -16-22)  In order to prevent duplicate payment by the same MAC (Part B), CWF will edit by line item on the MAC (Part B) number, the  MBI number, the date of service, the influenza virus procedure codes 90630, 90653, 90654, 90655, 90656, 90657, 90658, 90660, 90661, 90662, 90672, 90673, 90674, 90682, 90685, 90686, 90687, 90688, 90694, or 90756; the pneumococcal procedure codes 90670, 90671, 90677, or 90732; and the administration code G0008 or G0009.    1. If CWF receives a claim with either HCPCS codes 90630, 90653, 90654, 90655, 90656,90657, 90658, 90660, 90661, 90662, 90672, 90673, 90674, 90682, 90685, 90686, 90687, 90688, 90694, or 90756 and it already has on record a claim with the same MBI number, same MAC (Part B) number, same date of service, and any one of those HCPCS codes, the second claim submitted to CWF will reject.   2. If CWF receives a claim with HCPCS codes 90670, 90671, 90677, or 90732 and it already has on record a claim with the same MBI number, same MAC (Part B) number, same date of service, and the same HCPCS code, the second claim submitted to CWF will reject when all four items match.