Medicare Compliance & Reimbursement

Every year, Medicare providers and suppliers administer preventive immunizations over the course of the designated flu season. With large numbers of beneficiaries being vaccinated around the same time, the Centers for Medicare & Medicaid Services (CMS) offers providers the option to utilize roster billing.

Details: If you’re giving shots en masse, you may be able to take advantage of roster billing. However, there is a process for becoming a mass immunizer that includes state licensure, Medicare provider enrollment, specific forms, and coordination with the A/B Medicare Administrative Contractor (MAC) in your jurisdiction. Read on for six steps to help get you started.

1. Determine if you can do mass immunizations. There are various types of mass immunizers, including physician practices, hospitals, and pharmacies. Here’s a list of the mass immunizer requirements to be able to submit roster billing, according to CMS guidance: Licensed in the state where you operate; enrolled as a Medicare provider; accept Medicare payment as is without deductibles or copays; bill a MAC; submit the appropriate but separate claims for the immunization your administering via roster billing; and bill only for COVID-19, flu, pneumococcal, and administration using the approved Medicare process.

2. See what vaccinations you can submit roster billing claims for. “Roster billing only applies to COVID-19 vaccines, monoclonal antibody (mAb) infusions, influenza and pneumococcal immunizations,” Part B Medicare Administrative Contractor (MAC) First Coast Services Options (FCSO) says in online guidance. You may not bill for hepatitis B vaccinations. Remember, you’ll need separate roster billing forms for the different immunization types.

3. Understand the Medicare provider enrollment details. To submit these claims, you must be enrolled in the Medicare program — even if you’re only enrolling to provide mass immunizations. During enrollment, you must choose the specialty type as 73 (Mass immunization roster biller) for the application to be accepted. Individual applicants like physicians or nonphysician practitioners (NPPs) must submit a CMS-855I form while group practices, clinics, and other suppliers apply via a CMS-855B.

4. Follow the flu season parameters. If you plan on submitting flu shot claims, the annual Medicare flu vaccine season runs from Aug. 1 to July 31 each year — so you’ll need to get your enrollment application ahead of time. Influenza vaccinations are given per flu season and not by year, so Medicare beneficiaries can reasonably receive more than one booster a year as long as the shot is medically necessary and documentation backs up the necessity.

5. Know the basics on centralized billing. Providers administering mass vaccinations in three or more states can utilize centralized billing, “a way for mass immunizers to send all COVID-19, flu, and pneumococcal shot roster bill claims to a single Medicare Administrative Contractor (MAC), Novitas Solutions,” CMS explains in online guidance. “Medicare pays based on where you administer the shot. You can enroll in and use centralized billing, regardless of where you administer the shot. You must submit all centralized biller claims in electronic format as professional claims on a roster bill,” the agency notes.

6. Recognize the differences between institutional and professional claims. Here are the two claims types you should know for roster billing options:

• Institutional claims: “Institutional providers can use roster billing when administering the influenza, pneumococcal, or COVID-19 vaccines, or monoclonal antibody infusions to at least 5 patients on the same date, unless the institution is an inpatient hospital,” says Part A MAC Novitas Solutions. There are two required forms that these mass immunizers must use to submit claims, the CMS-1450 form and a MAC-specific roster form.
• Professional claims: Providers should submit professional claims via a modified CMS-1500 or 837P electronic format as well as a roster billing form from the MAC in their jurisdiction.