Roster Claims Submitted to AB MACs for Mass Immunization (Rev. 3159, 02-02-15)

by  Jared Staheli
June 25th, 2015

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. Key information from the beneficiary roster list and the abbreviated Form CMS-1500 is used to process pneumococcal and influenza virus vaccination claims.

Separate Form CMS-1500 claim forms, along with separate roster bills, must be submitted for pneumococcal and influenza roster billing.

If other services are furnished to a beneficiary along with pneumococcal or influenza virus vaccine, individuals and entities must submit claims using normal billing procedures, e.g., submission of a Form CMS-1500 or electronic billing for each beneficiary.

Contractors 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. The contractor must replicate the claim for each beneficiary listed on the roster.

Contractors must provide Palmetto-Railroad Retirement Board (RRB) with local pricing files for pneumococcal and influenza virus vaccine and their administration. If PHCs or other individuals or entities inappropriately bill pneumococcal or influenza virus vaccinations using the roster billing method, contractors return the claim to the provider with a cover letter explaining why it is being returned and the criteria for the roster billing process. Contractors 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 claims to A/B MACs must complete the following blocks on a single modified Form CMS-1500, which serves as the cover document for the roster for each facility where services are furnished. In order for A/B MACs 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 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 1: Choose appropriate diagnosis code from §10.2.1

Item 24B: (Place of Service (POS)):

   Line 1: "60"

   Line 2: "60"

   NOTE: POS Code “60" must be used for roster billing.

Item 24D: (Procedures, Services or Supplies):

    Line 1: Pneumococcal vaccine: "90732"


    Influenza Virus vaccine: “Select appropriate influenza virus vaccine code”

    Line 2: Pneumococcal vaccine Administration: "G0009"


    Influenza Virus Vaccine Administration: "G0008"

Item 24E: (Diagnosis Code):

    Lines 1 and 2: "1"

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 system 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 as soon as it is available. The NPI may be reported on the Form CMS-1500 as early as October 1, 2006.

Item 33: (Physician's, Supplier's Billing Name): The entity must complete this item to include the Provider Identification Number (not the Unique Physician Identification Number) or NPI when required.

Item 33a: Effective May 23, 2007, and later, enter the NPI of the billing provider or group. (The NPI may be reported on the Form CMS-1500 as early as October 1, 2006.)

B. Format of Roster Claims

Qualifying individuals and entities must attach to the Form CMS-1500 claim form, a roster which contains the variable claims information regarding the supplier of the service and individual beneficiaries. While qualifying entities must use the modified Form CMS-1500 without deviation, contractors must work with these entities to develop a mutually suitable roster that contains the minimum data necessary to satisfy claims processing requirements for these claims. Contractors must key information from the beneficiary roster list and abbreviated Form CMS-1500 to process pneumococcal and influenza virus vaccination claims.

The roster must contain at a minimum the following information:

• Provider name and number;

• Date of service;

NOTE: Although physicians who provide pneumococcal or influenza virus vaccinations may roster bill if they vaccinate fewer than five beneficiaries per day, they must include the individual date of service for each beneficiary's vaccination on the roster form.

• Control number for contractor;

• Patient's health insurance claim 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 claim form 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.


Roster Claims Submitted to AB MACs for Mass Immunization (Rev. 3159, 02-02-15). (2015, June 25). Find-A-Code Articles. Retrieved from

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