Final

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: September 14, 2020

Information & Requirements

• *NEW* Effective September 20, 2021, Flu & Pneumococcal Vaccines: Expanded SNF Enforcement Discretion for Certain Pharmacy Billing
• Get payment allowances & effective dates for the 2021-2022 season 
• Find the right HCPCS, CPT, & ICD-10 codes
• You may use roster billing or submit individual claims
• All providers who administer the flu shot must accept assignment
• Entities, like local health facilities, must get a national provider identifier (PDF) if they’ve never submitted Medicare claims
• Learn about roster billing, mass immunizers, & centralized billing

How to Submit Institutional Claims

You may use roster billing format, or submit individual claims. CMS systems will accept roster bills for 1 or more patients who get the same type of shot on the same date of service.

What Are Valid Types of Bills for Roster Billing?

• 12X, Hospital Inpatient**
• 13X, Hospital Outpatient**
• 22X, Skilled Nursing Facility (SNF) covered Part A stay (paid under Part B) & Inpatient Part B
• 23X, SNF Outpatient
• 34X, Home Health (Part B Only)
• 72X, Independent and Hospital-based Renal Dialysis Facility
• 75X, Comprehensive Outpatient Rehabilitation Facility
• 81X, Hospice (Nonhospital-based)
• 82X, Hospice (Hospital-based)
• 85X, Critical Access Hospital

** For hospitalized patients, we pay for the flu and pneumococcal shots separately from the diagnosis-related group rate. In addition, hospitals don’t bill vaccines on an 11X type of bill. Hospitals bill on a 12X type of bill.

How Do I Submit an Institutional Claim?

Electronic Claims — Use Direct Data Entry:

1. Option 02, Claims Attachment
2. Option 87, Roster Bill Entry

Paper Claims:

1. CMS-1450 (UB-04)
2. Roster bill for patients (find your Medicare Administrative Contractor's (MAC's) website to learn more about or set up roster billing)

Exceptions for RHCs & FQHCs

Rural Health Clinic (RHC):

• Don’t include influenza vaccine and administration on your claim
• Medicare pays for influenza vaccine and administration through the cost report

 
Federal Qualified Health Center (FQHC):

• List charges for the vaccine and administration on a separate claim line from the billable visit
• Don’t bill if you only provided vaccine administration
• We pay for influenza vaccine and administration through the cost report
   

How to Submit Professional Claims

You may use roster billing format, or submit individual claims using the CMS-1500 form (PDF) or the 837P electronic format. CMS systems will accept roster bills for 1 or more patients that get the same type of shot on the same date of service.

How Do I Submit a Professional Claim?

Electronic Claims:
Download and use free PC-ACE billing software (PDF) to electronically submit professional claim roster billing directly to your MAC.

Paper Claims:

1. Health Insurance Claim Form (CMS-1500) (PDF)
2. Roster bill for patients (find your MAC's website to learn more about or set up roster billing).

What if I'm a Mass Immunizer?

Mass immunizers may use a roster bill or submit a traditional claim form, such as a CMS-1500 form (PDF) or the 837P electronic format. CMS systems will accept roster bills for 1 or more patients that get the same type of shot on the same date of service. 

Medicare-covered vaccines are exempt from the HIPAA electronic billing requirement. This exemption applies to providers submitting mass immunization claims on paper. When you submit roster bills, don’t list other covered services with the flu or pneumococcal shot and administration. If you have other services to bill, use normal claims filing procedures and forms.

Roster Billing Requirements

• Licensed in states where you operate.
• Enrolled in the Medicare Program*.
• Accept assignment on shots and their administration. This means that you accept Medicare payment as payment in full. You can’t collect a deductible, copayment, or coinsurance on these services.
• Submit separate roster bill claims for flu and for pneumococcal shots.
• Bill a MAC.
• Bill only flu and pneumococcal shots and administration using this process. We pay both administration fees if you give both shots on the same visit. Use separate administration codes for the seasonal flu shot (G0008) and pneumococcal shot (G0009).

*  To enroll in the Medicare Program solely as a Mass Immunization Roster Biller (provider specialty type 73), complete a Medicare Enrollment Application:

• Individuals - Physicians and Non-Physician Practitioners (CMS-855I) (PDF)
• Groups - Clinics/Group Practices and Other Suppliers (CMS-855B) (PDF)

How to Submit a Centralized Bill

Providers enrolled as centralized billers can submit a professional claim to Novitas, regardless of where you administered the vaccines.

You must operate in at least 3 MAC jurisdictions.

Find out how to become a centralized biller. 

 

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DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.