Institutional & Professional Claims

Roster billing is a quick and easy way for you to submit multiple claims for COVID-19, flu, and pneumococcal shots. Bill each type of shot on a separate roster bill. Don’t combine shots on the same roster bill.

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 the flu shot and administration on your claim 
• Medicare pays for the flu shot and administration through the cost report

 Federal Qualified Health Center (FQHC):

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

How to Submit Professional Claims

You may use roster billing format, or submit individual claims using the Health Insurance Claim Form (CMS-1500) (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

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).

Roster Billing for Mass Immunizers

Providers who give the COVID-19, flu, and pneumococcal shot to groups of individuals (like people who live in a retirement community) are considered mass immunizers.  Mass immunizers may use a roster bill or submit a traditional claim form, such as a Health Insurance Claim Form (CMS-1500) (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 shots are exempt from the HIPAA electronic billing requirement. This exemption applies to providers submitting mass immunization claims on paper.

Mass Immunizer 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 COVID-19, flu, and pneumococcal shots.
• Bill a MAC.
• Bill only COVID-19, flu, and pneumococcal shots and administration using this process. We pay all administration fees if you give multiple shots on the same visit.

*  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)

 

Centralized Billing for Roster Bills

Centralized billing is 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. 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.

How to Submit a Centralized Bill

If you’re enrolled as a centralized biller you can submit a professional claim to Novitas Solutions, regardless of where you administered the shots.

You must operate in at least 3 MAC jurisdictions.

How to Enroll as a Centralized Biller

To enroll as a centralized biller, you must complete and submit the following to Novitas Solutions:

• Centralized Billing: Request for Approval Form
• Medicare Enrollment Form

Note: Your approval is ongoing after your initial approval for centralized billing. Approved providers are no longer required to reapply on an annual basis.

Send your applications for centralized billing to:

Novitas Solutions, Inc.

Provider Enrollment Services

Attn: Centralized Billing Program

P.O. Box 3095

Mechanicsburg, PA 17055-1813