by Jared Staheli
June 25th, 2015
The CMS currently authorizes a limited number of providers to centrally bill for influenza virus and pneumococcal immunization claims. 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.
To qualify for centralized billing, a mass immunizer must be operating in at least three payment localities for which there are 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 and the contractor must verify this through the enrollment process.
Centralized billers must send all claims for influenza virus and pneumococcal immunizations to a single contractor 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. This process is only available for claims for the influenza virus and pneumococcal 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 virus and pneumococcal vaccinations and 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 bill for these claims to their regular carrier/AB MAC per the instructions in §10.3.1 of this chapter.
The claims processing instructions in this section apply only to the designated processing contractor. However, all carriers/AB MACs must follow the instructions in §10.3.1.1.J, below, “Provider Education Instructions for All Carriers/AB MACs.”
A. Processing Contractor
Trailblazers Health Enterprises is designated as the sole contractor for the payment of influenza virus and pneumococcal claims for centralized billers from October 1, 2000, through the length of the contract. The CMS central office will notify centralized billers of the appropriate contractor to bill when they receive their notification of acceptance into the centralized billing program.
B. Request for Approval
Approval to participate in the CMS centralized billing program is a two part approval process. Individuals and corporations who wish to enroll as a CMS mass immunizer centralized biller must send their request in writing. CMS will complete Part 1 of the approval process by reviewing preliminary demographic information included in the request for participation letter. Completion of Part 1 is not approval to set up vaccination clinics, vaccinate beneficiaries, and bill Medicare for reimbursement. All new participants must complete Part 2 of the approval process (Form CMS-855 Application) before they may set up vaccination clinics, vaccinate Medicare beneficiaries, and bill Medicare for reimbursement. If an individual or entity’s request is approved for centralized billing, the approval is limited to 12 months from September to August 31 of the next year. It is the responsibility of the centralized biller to reapply for approval each year. The designated contractor shall provide in writing to CMS and approved centralized billers notification of completion and approval of Part 2 of the approval process. The designated contractor may not process claims for any centralized biller who has not completed Parts 1 and 2 of the approval process. If claims are submitted by a provider who has not received approval of Parts 1 and 2 of the approval process to participate as a centralized biller, the contractor must return the claims to the provider to submit to the local carrier/AB MAC for payment.
C. Notification of Provider Participation to the Processing Contractor
Before September 1 of every year, CMS will provide the designated contractor with the names of the entities that are authorized to participate in centralized billing for the 12 month period beginning September 1 and ending August 31 of the next year.
Though centralized billers may already have a Medicare provider number, for purposes of centralized billing, they must also obtain a provider number from the processing contractor for centralized billing through completion of the Form CMS-855 (Provider Enrollment Application). Providers/suppliers are encouraged to apply to enroll as a centralized biller early as possible. Applicants who have not completed the entire enrollment process and received approval from CMS and the designated contractor to participate as a Medicare mass immunizer centralized biller will not be allowed to submit claims to Medicare for reimbursement.
Whether an entity enrolls as a provider type “Mass Immunization Roster Biller” or some other type of provider, all normal enrollment processes and procedures must be followed. Authorization from CMS to participate in centralized billing is dependent upon the entity’s ability to qualify as some type of Medicare provider. In addition, as under normal enrollment procedures, the contractor must verify that the entity is fully qualified and certified per State requirements in each State in which they plan to operate.
The contractor will activate the provider number for the 12-month period from September 1 through August 31 of the following year. If the provider is authorized to participate in the centralized billing program the next year, the contractor will extend the activation of the provider number for another year. The entity need not re-enroll with the contractor every year. However, should there be changes in the States in which the entity plans to operate, the contractor will need to verify that the entity meets all State certification and licensure requirements in those new States.
E. Electronic Submission of Claims on Roster Bills
Centralized billers must agree to submit their claims on roster bills in an Electronic Media Claims standard format using the appropriate version of American National Standards Institute (ANSI) format. Contractors should refer to the appropriate ANSI Implementation Guide to determine the correct location for this information on electronic claims. The processing contractor must provide instructions on acceptable roster billing formats to the approved centralized billers. Paper claims will not be accepted.
F. Required Information on Roster Bills for Centralized Billing
In addition to the roster billing instructions found in §10.3.1 of this chapter, centralized billers must complete on the electronic format the area that corresponds to Item 32 and 33 on Form CMS 1500 (08-05). The contractor must use the ZIP Code in Item 32 to determine the payment locality for the claim. Item 33 must be completed to report the provider of service/supplier’s billing name, address, ZIP Code, and telephone number. In addition, the NPI of the billing provider or group must be appropriately reported.
For electronic claims, the name, address, and ZIP Code of the facility are reported in:
• The HIPAA compliant ANSI X12N 837: Claim level loop 2310D NM101=FA. When implemented, the facility (e.g., hospitals) NPI will be captured in the loop 2310D NM109 (NM108=XX) if one is available. Prior to NPI, enter the tax information in loop 2310D NM109 (NM108=24 or 34) and enter the Medicare legacy facility identifier in loop 2310D REF02 (REF01=1C). Report the address, city, state, and ZIP Code in loop 2310D N301 and N401, N402, and N403. Facility data is not required to be reported at the line level for centralized billing.
G. Payment Rates and Mandatory Assignment
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 vary based on the geographic locality where the service was performed.
The HCPCS codes G0008 and G0009 for the administration of the vaccines are not paid on the MPFS. However, prior to March 1, 2003, they must be paid at the same rate as HCPCS code 90782, which is on the MPFS. The designated contractor must pay per the correct MPFS file for each calendar year based on the date of service of the claim. Beginning March 1, 2003, HCPCS codes G0008, G0009, and G0010 are to be reimbursed at the same rate as HCPCS code 90471.
In order to pay claims correctly for centralized billers, the designated contractor must have the correct name and address, including ZIP Code, of the entity 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 of influenza virus and pneumococcal vaccines must accept assignment for the vaccine. 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 virus and pneumococcal benefit, accepting assignment means that Medicare beneficiaries cannot be charged for the vaccination.
H. 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.
I. Provider Education Instructions for the Processing Contractor
The processing contractor must fully educate the centralized billers on the processes for centralized billing as well as for roster billing. General information on influenza virus and pneumococcal coverage and billing instructions is available on the CMS Web site for providers.
J. Provider Education Instructions for All Carriers/AB MACs
By April 1 of every year, all carriers/AB MACs must publish in their bulletins and put on their Web sites the following notification to providers. Questions from interested providers should be forwarded to the central office address below. Carriers/AB MACs 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 locality 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 available 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 centralized billing must contact CMS central office, in writing, at the following address by June 1 of the year they wish to begin centrally billing.
Center for Medicare & Medicaid Services
Division of Practitioner Claims Processing
Provider Billing and Education Group
7500 Security Boulevard
Mail Stop C4-10-07
Baltimore, Maryland 21244
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 immunization services for influenza virus and pneumococcal 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). Since there is no coinsurance or deductible for the influenza virus and pneumococcal benefit, 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 Security 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, userfriendly 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 Media Claims standard format. Paper claims will not be accepted.
• Centralized billers must obtain certain information for each beneficiary including name, health insurance number, date of birth, sex, and signature. [Fill in name of contractor] must be contacted prior to the season for exact requirements. The responsibility lies with the centralized biller to submit correct beneficiary Medicare information (including the beneficiary’s 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 contractor. Beneficiaries are sometimes confused when they receive an MSN from a contractor other than the contractor that normally processes their claims which results in unnecessary beneficiary inquiries to the Medicare contractor. Therefore, centralized billers must provide every beneficiary receiving an influenza virus or pneumococcal vaccination with the name of the processing contractor. 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. [Fill in name of contractor] 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 [Fill in name of contractor]. This can be done by completing the Form CMS- 855 (Provider Enrollment Application), which can be obtained from [Fill in name of contractor].
• If an individual or entity’s request for centralized billing is approved, the approval is limited to the 12 month period from September 1 through August 31 of the following year. It is the responsibility of the centralized biller to reapply to CMS CO for approval each year by June 1. Claims will not be processed for any centralized biller without permission from CMS.
• Each year the centralized biller must contact [Fill in name of contractor] 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 entity’s 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. The approximate dates for when the vaccinations will be given;
4. A list of the States in which influenza virus and pneumococcal clinics will be held;
5. The type of services generally provided by the corporation (e.g., ambulance, home health, or visiting nurse);
6. Whether the nurses who will administer the influenza virus and pneumococcal vaccinations are employees of the corporation or will be hired by the corporation specifically for the purpose of administering influenza virus and pneumococcal vaccinations;
7. Names and addresses of all entities operating under the corporation’s application;
8. Contact information for designated contact person for centralized billing program.