by Jared Staheli
June 25th, 2015
The simplified roster billing process was developed to enable Medicare beneficiaries to participate in mass pneumococcal and influenza virus vaccination programs offered by PHCs and other individuals and entities that give the vaccine to a group of beneficiaries, e.g. at PHCs, shopping malls, grocery stores, senior citizen homes, and health fairs. Roster billing is not available for hepatitis B vaccinations.
Properly licensed individuals and entities conducting mass immunization programs may submit claims using a simplified claims filing procedure known as roster billing to bill for the influenza virus vaccine benefit for multiple beneficiaries if they agree to accept assignment for these claims. They may not collect any payment from the beneficiary. Effective November 1, 1996, roster billing is also available to individuals and entities billing for pneumococcal vaccinations.
Effective July 1, 1998, immunization of at least five beneficiaries on the same date is no longer required for any individual or entity to qualify for roster billing to carriers. However, the rosters should not be used for single patient claims and the date of service for each vaccination administered must be entered.
Entities that submit claims on roster claims must accept assignment and may not collect any “donation” or other cost sharing of any kind from Medicare beneficiaries for pneumococcal or influenza virus vaccinations. However, the entity may bill Medicare for the amount, which is not subsidized from its own budget. For example, an entity that incurs a cost of $7.50 per vaccination and pays $2.50 of the cost from its budget may bill Medicare the $5.00 cost which is not paid out of its budget.
A. Provider Enrollment Criteria for Mass Immunizers
Those entities and individuals that desire to provide mass immunization services, but may not otherwise be able to qualify as a Medicare provider, may be eligible to enroll as a provider type “Mass Immunization Roster Biller.”
These individuals and entities must enroll by completing the Provider/Supplier Enrollment Application, Form CMS-855. Individuals and entities that enroll as this provider type may not bill Medicare for any services other than pneumococcal and/or influenza virus vaccines and their administration. In addition, claims submitted by the provider type “Mass Immunization Roster Biller” are always reimbursed at the assigned payment rate.
B. Payment Floor for Roster Claims
Roster claims are considered paper claims and are not paid as quickly as electronic media claims (EMC). If available, offer electronic billing software free or at-cost to PHCs and other properly licensed individuals and entities. Contractors must ensure that the software is as user friendly as possible for the pneumococcal and influenza virus vaccine benefits.
C. Medicare Advantage Plans Processing Requirements
Medicare Advantage Plans may use roster billing only if vaccinations are the only Medicare-covered services furnished by the Medicare Advantage Plans to Medicare patients who are not members of the Medicare Advantage Plans. Medicare Advantage Plans must use Place of Service (POS) code 60 for processing roster claims.