Centralized Billing for Influenza Virus and Pneumococcal Vaccines to

10.3.1.1 - Centralized Billing for Influenza Virus and Pneumococcal Vaccines to A/B MACs (B) (Rev. 11355; Issued:04-14-22; Effective:05-16-22; Implementation:05-16-22) The CMS currently authorizes providers to centrally bill for influenza, pneumococcal, and COVID- 19 vaccination claims. That is to say, they bill all of the claims for those vaccinations to one MAC, rather than to each of the MACs that service the location where the services are rendered. Centralized billing is an optional program available to providers who qualify to enroll with Medicare as the provider type “Mass Immunization Roster Biller,” as well as to other individuals and entities that qualify to enroll as regular Medicare providers. Centralized billers must roster bill, must accept assignment, and must bill electronically. The contractor assigned to process the claims for centralized billing will be chosen at the discretion of The Centers for Medicare & Medicaid Services (CMS) based on such considerations as workload, user-friendly software developed by the contractor for billing claims, and overall performance. Currently the specialty contractor for centralized billing is Novitas (JH). To qualify for centralized billing, a mass immunizer must be operating in at least three payment localities for which there are three different MACs processing claims. Individuals and entities providing the vaccine and administration must be properly licensed in the State in which the vaccinations are given and the MAC will verify this through the enrollment process. As previously stated, centralized billers must send all claims for influenza, pneumococcal, and COVID-19 vaccinations to a single MAC for payment, regardless of the jurisdiction in which the vaccination was administered. (This does not include claims for the Railroad Retirement Board, United Mine Workers or Indian Health Services. These claims must continue to go to the appropriate processing entity.) Payment is made based on the payment locality where the service was provided. Centralized billing is only available for claims for the influenza, pneumococcal, and COVID-19 vaccines and their administration. The general coverage and coding rules still apply to these claims. This section applies only to those individuals and entities that provide mass immunization services for influenza, pneumococcal, and COVID-19 virus vaccinations that have been authorized by CMS to centrally bill. All other providers, including those individuals and entities that provide mass immunization services that are not authorized to centrally bill, must continue to submit claims to their regular MAC (Part B) per the instructions in §10.3.1 of this chapter. The claims processing instructions in this section apply only to claims submitted to the designated processing MAC. However, all MACs (Part B) must follow the instructions in §10.3.1.1.J, below, “Provider Education Instructions for All MACs (Part B).” A. Request for Approval Centralized Billing for Influenza, Pneumococcal and COVID-19 Virus Vaccinations A. Information for Providers Interested in Applying for Centralized Billing In order to qualify as a centralized biller, a provider must be operating in at least three payment localities for which there are three different MACs processing claims. Individuals and corporations who wish to enroll as a CMS centralized biller must send their request in writing to Novitas, (the current specialty contractor) at the address at the end of this section. Providers must include the following information in their application to become a centralized biller. 1. Providers must indicate that they agree to the following: a) Centralized billers providing the vaccine and administration must be properly licensed in the States in which the vaccinations are given. b) Centralized biller must agree to accept assignment (i.e., they must agree to accept the amount that Medicare pays for the vaccine and the administration). Since there is no coinsurance or deductible for the influenza, pneumococcal and COVID-19 vaccinations, accepting assignment means that Medicare beneficiaries cannot be charged for the vaccination, i.e., beneficiaries may not incur any out-of-pocket expense. For example, a drugstore may not charge a Medicare beneficiary $10 for an influenza virus vaccination and give the beneficiary a coupon for $10 to be used in the drugstore. This practice is unacceptable. c) Centralized billers must understand that beginning December 11, 2021 the payment rate for the administration of the COVID-19 vaccine is $40 and $30 for the other preventive vaccinations. These payment amounts are geographically adjusted by locality. Therefore, the centralized biller must be willing to accept that payments received may vary based on the geographic locality where the service was performed. d) Centralized billers must understand that the payment rates for the vaccines will be determined by the standard method used by Medicare for reimbursement of drugs and biologicals. e) Centralized billers must agree to submit their claims in a CMS approved electronic media claims standard format. Paper claims will not be accepted. f) In addition to the elements required by regular roster billing, centralized billers must complete the service facility location in order for the MAC to be able to pay correctly by geographic locality. Centralized billers should contact the processing contractor for specific information. g) Centralized billers must obtain certain information for each beneficiary including name, Medicare Beneficiary Identifier, date of birth, sex, and signature. Novitas must be contacted prior to the season for exact requirements. The responsibility lies with the centralized biller to submit correct beneficiary Medicare information (including the correct MBI as Novitas will not be able to process incomplete or incorrect claims. h) Centralized billers must obtain an address for each beneficiary so that a Medicare Summary Notice (MSN) can be sent to the beneficiary. Beneficiaries are sometimes confused when they receive an MSN from a MAC other than the MAC that normally processes their claims, which results in unnecessary beneficiary inquiries to the MAC. Therefore, centralized billers must notify every beneficiary receiving an influenza, pneumococcal or COVID-19 virus vaccination that the claim will be processed by Novitas. This notification must be in writing, in the form of a brochure or handout, and must be provided to each beneficiary at the time he or she receives the vaccination. i) Centralized billers must retain roster bills with beneficiary signatures at their permanent location for a time period consistent with Medicare regulations. Novitas can provide this information. j) Though centralized billers may already have a National Provider Identifier (NPI) number, for purposes of centralized billing, they must also enroll with Novitas. This can be done by completing the Form CMS-855 (Provider Enrollment Application) that can be obtained from Novitas. k) If the request for centralized billing is approved, for influenza and pneumococcal, and COVID-19 vaccinations, that approval is ongoing. It is the responsibility of the approved centralized billers to contact Novitas to make updates to their provider enrollment data on file (i.e. clinic locations, name change, and change to ownership are a few examples) . Claims submitted without approval will be denied. l) If a centralized biller is applying to provide COVID-19 vaccinations only, that approval will be ongoing. It is the responsibility of the approved centralized billers to contact Novitas to make updates to their provider enrollment data on file (i.e. clinic locations, name change, and change to ownership are a few examples). Claims submitted without approval will be denied. 2. Applicants for centralized billing should also include responses to the following: a. A list of the States in which vaccination clinics will be held; b. Contact information for a designated contact for the centralized billing program. Applications for centralized billing must be sent to the specialty MAC for centralized billing at: Novitas Solutions, Inc. Provider Enrollment Services Attention: Centralized Billing Program P.O. Box 3095 Mechanicsburg, PA 17055-1813 All applicants must meet the criteria for centralized billing at the time they apply for approval. Failure to provide a response to each statement will result in the request not being processed. Novitas will reach out to the applicant to attempt to complete any missing data. Should they be unable to resolve the matter via outreach efforts, Novitas shall return the application with details explaining why the submission could not be processed. B. Review of Applications Novitas will review the information provided by applicants for completeness. Novitas will approve or deny the applicant’s request for participation based on the information provided. Applicants who are approved shall continue to the next steps of enrollment through Novitas’ provider enrollment department. Novitas will send a letter of disapproval to applicants who are determined ineligible to participate in the Medicare centralized billing program. The letter will clearly explain why the request was denied. Submitting a request for participation does not automatically provide approval to set up vaccination clinics, vaccinate beneficiaries, and bill Medicare for reimbursement. All new participants must complete the approval process, including submission of a CMS-855 Application for enrollment with Novitas and receive a final approval before they vaccinate Medicare beneficiaries and bill Medicare for reimbursement. If a provider’s request is approved for centralized billing for influenza, pneumococcal and COVID-19 vaccinations, the approval shall be ongoing. Approved providers will no longer be required to reapply on an annual basis. Centralized billers shall contact Novitas with any changes to their enrollment and/or that states in which they operate. C. Enrollment COVID-19 Mass Immunizer Centralized Biller Enrollment For more information on enrolling as a COVID-19 mass immunizer centralized biller go to: https://www.cms.gov/medicare/covid-19/enrollment-administering-covid-19-vaccine-shots D. Electronic Submission of Claims on Roster Bills All centralized billers must agree to submit their claims on roster bills in an electronic media claims format. The processing contractor must provide instructions on acceptable roster billing formats to the approved centralized billers. Paper claims will not be accepted. E. Required Information on Roster Bills for Centralized Billing In addition to the roster billing instructions found in §10.3.1 of this chapter, centralized billers must provide on the claim the ZIP code of where the service was rendered (to determine the payment locality for the claim), and the provider of service/supplier’s billing name, address, ZIP code, and telephone number. In addition, the NPI of the billing provider or group must be appropriately reported. F. Payment Rates and Mandatory Assignment The payment rates for the administration of the vaccinations are based on the Medicare Physician Fee Schedule (MPFS) for the appropriate year. Payment made through the MPFS is based on geographic locality. Therefore, payments vary based on the geographic locality where the service was performed. The HCPCS codes G0008 and G0009 for the administration of the vaccines are not paid on the MPFS. However, prior to March 1, 2003, they must be paid at the same rate as HCPCS code 90782, which is on the MPFS. The designated contractor must pay per the correct MPFS file for each calendar year based on the date of service of the claim. Beginning March 1, 2003, HCPCS codes G0008, G0009, and G0010 are to be reimbursed at the same rate as HCPCS code 90471. Effective for claims with dates of service January 1, 2020 through December 31, 2021, the payment rates for G0008, G0009, and G0010, rather than being linked to the MPFS payment rate for 90471, they were to be paid at the same rate as they had been in 2019. Beginning January 1, 2022, the national payment rate for HCPCS G0008, G0009, and G0010 is $30. This payment amount is adjusted based on the Geographic Practice Cost Indices used in the MPFS. Locality-adjusted payment rates for HCPCS G0008, G0009, and G0010 are available of the CMS website: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B- Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing Beginning January 1, 2022 and through the end of the calendar year in which the PHE for COVID- 19 ends, the national payment rate for the administration of COVID-19 vaccines is $40. This payment amount is adjusted based on the Geographic Practice Cost Indices used in the MPFS. Locality-adjusted payment rates for the administration of COVID-19 vaccines are available of the CMS website: https://www.cms.gov/medicare/medicare-part-b-drug-average-sales-price/covid-19- vaccines-and-monoclonal-antibodies Effective January 1 of the year following the year in which the PHE for COVID-19 ends, the payment rate for COVID-19 vaccine administration will be set at a rate to align with the payment rate for the administration of other Part B preventive vaccines. In order to pay claims correctly for centralized billers, the designated contractor must have the correct name and address, including ZIP code, of where the service was provided. The following remittance advice and Medicare Summary Notice (MSN) messages apply: Claim adjustment reason code 16, “Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code, Remittance advice remark code MA114, “Missing/incomplete/invalid information on where the services were furnished.” MSN 9.4 - “This item or service was denied because information required to make payment was incorrect.” The payment rates for the vaccines must be determined by the standard method used by Medicare for reimbursement of drugs and biologicals. (See chapter 17 for procedures for determining the payment rates for vaccines.) Effective for claims with dates of service on or after February 1, 2001, §114, of the Benefits Improvement and Protection Act of 2000 mandated that all drugs and biologicals be paid based on mandatory assignment. Therefore, all providers Medicare covered preventive must accept assignment for the vaccine. In addition, as a requirement for both centralized billing and roster billing, providers must agree to accept assignment for the administration of the vaccines as well. This means that they must agree to accept the amount that Medicare pays for the vaccine and the administration. Also, since there is no coinsurance or deductible for the influenza, pneumococcal, and COVID-19 vaccine benefits, accepting assignment means that Medicare beneficiaries cannot be charged for the vaccination. G. Common Working File Information To identify these claims and to enable central office data collection on the project, special processing number 39 has been assigned. The number should be entered on the HUBC claim record to CWF in the field titled Demonstration Number. H. Provider Education Instructions for the Designated Processing Part B MAC The designated Part B MAC must fully educate the centralized billers on the processes for centralized billing as well as for roster billing. General information on influenza, pneumococcal, and COVID-19 vaccine coverage and billing instructions is available on the CMS Web site for providers. I. Provider Education Instructions for All MACs (Part B) By XXXX of every year, all MACs (Part B) must publish in their bulletins and put on their Web sites the following notification to providers. Questions from interested providers should be forwarded to Novitas, the designated processing Part B MAC for the centralized billing workload at the address below. MACs (Part B) must enter the name of the assigned processing contractor where noted before sending. NOTIFICATION TO PROVIDERS Centralized billing is a process in which a provider, who provides mass immunization services for influenza virus and pneumococcal pneumonia virus (PPV) immunizations, can send all claims to a single contractor for payment regardless of the geographic locality in which the vaccination was administered. (This does not include claims for the Railroad Retirement Board, United Mine Workers or Indian Health Services. These claims must continue to go to the appropriate processing entity.) This process is only available for claims for the influenza virus and pneumococcal vaccines and their administration. The administration of the vaccinations is reimbursed at the assigned rate based on the Medicare physician fee schedule for the appropriate locality. The vaccines are reimbursed at the assigned rate using the Medicare standard method for reimbursement of drugs and biologicals. Individuals and entities interested in influenza and pneumococcal centralized billing must contact Novitas, to begin centrally billing for influenza and pneumococcal vaccines. Applications to become a mass immunizer centralized biller for the COVID-19 vaccine is an ongoing enrollment. Individuals and entities can submit a request to become a centralized mass immunizer at any time. For more information on enrolling as a COVID-19 mass immunizer centralized biller go to: https://www.cms.gov/medicare/covid- 19/enrollment-administering-covid-19-vaccine-shots . By agreeing to participate in the centralized billing program, providers agree to abide by the following criteria. CRITERIA FOR CENTRALIZED BILLING • To qualify for centralized billing, an individual or entity providing mass vaccination services for influenza virus, pneumococcal, and COVID-19 vaccinations must provide these services in at least three payment localities for which there are at least three different contractors processing claims. • Individuals and entities providing the vaccine and administration must be properly licensed in the state in which the immunizations are given. • Centralized billers must agree to accept assignment (i.e., they must agree to accept the amount that Medicare pays for the vaccine and the administration). Accepting assignment means that Medicare beneficiaries cannot be charged for the vaccination, i.e., beneficiaries may not incur any out-of-pocket expense. For example, a drugstore may not charge a Medicare beneficiary $10 for an influenza virus vaccination and give the beneficiary a coupon for $10 to be used in the drugstore. NOTE: The practice of requiring a beneficiary to pay for the vaccination upfront and to file their own claim for reimbursement is inappropriate. All Medicare providers are required to file claims on behalf of the beneficiary per §1848(g)(4)(A) of the Social Security Act and centralized billers may not collect any payment. • The contractor assigned to process the claims for centralized billing is chosen at the discretion of CMS based on such considerations as workload, user-friendly software developed by the contractor for billing claims, and overall performance. The assigned contractor for this year is [Fill in name of contractor.] • The payment rates for the administration of the vaccinations are based on the Medicare physician fee schedule (MPFS) for the appropriate year. Payment made through the MPFS is based on geographic locality. Therefore, payments received may vary based on the geographic locality where the service was performed. Payment is made at the assigned rate. • The payment rates for the vaccines are determined by the standard method used by Medicare for reimbursement of drugs and biologicals. Payment is made at the assigned rate. • Centralized billers must submit their claims on roster bills in an approved electronic format. Paper claims will not be accepted. • Centralized billers must obtain certain information for each beneficiary including name, MBI number, date of birth, sex, and signature. [The designated Part B MAC] must be contacted prior to submitting claims for verification of billing requirements. The responsibility lies with the centralized biller to submit correct beneficiary Medicare information (including the beneficiary’s Medicare Health Insurance Claim Number) as the contractor will not be able to process incomplete or incorrect claims. • Centralized billers must obtain an address for each beneficiary so that a Medicare Summary Notice (MSN) can be sent to the beneficiary by the Part B MAC. Beneficiaries are sometimes confused when they receive an MSN from a Part B MAC other than the MAC that normally processes their claims which results in unnecessary beneficiary inquiries. Therefore, centralized billers must provide every beneficiary receiving an influenza virus or pneumococcal vaccination with the name of the processing Part B MAC. This notification must be in writing, in the form of a brochure or handout, and must be provided to each beneficiary at the time he or she receives the vaccination. • Centralized billers must retain roster bills with beneficiary signatures at their permanent location for a time period consistent with Medicare regulations. [The designated Part B MAC] can provide this information. • Though centralized billers may already have a Medicare provider number, for purposes of centralized billing, they must also obtain a provider number from [The designated Part B MAC]. This can be done by completing the Form CMS-855 (Provider Enrollment Application), which can be obtained from [The designated Part B MAC]. NOTE: Influenza/Pneumococcal Mass Immunizer Centralized Billers DO NOT need to enroll separately as a COVID-19 Mass Immunizer Centralized Biller to administer COVID-19 vaccine shots. • If an individual or entity’s request for centralized billing of influenza, pneumococcal, and/or COVID-19 vaccines is approved, the approval is ongoing. Claims will not be processed for any influenza, pneumococcal, or COVID-19 centralized biller without approval from the designated Part B MAC. • Each year the centralized biller must contact the designated Part B MAC to verify understanding of the coverage policy for the administration of the pneumococcal vaccine, and for a copy of the warning language that is required on the roster bill. • The centralized biller is responsible for providing the beneficiary with a record of the pneumococcal vaccination. • The information in items 1 through 8 below must be included with the individual or entity’s annual request to participate in centralized billing: 1. Estimates for the number of beneficiaries who will receive influenza virus vaccinations; 2. Estimates for the number of beneficiaries who will receive pneumococcal vaccinations; 3. Estimates for the number of beneficiaries who will receive COVID-19 vaccinations (if applicable); 4. The approximate dates for when the vaccinations will be given; 5. A list of the states in which influenza, pneumococcal, and COVID-19 vaccination clinics will be held; 6. The type of services generally provided by the corporation (e.g., ambulance, home health, or visiting nurse); 7. Whether the nurses who will administer the influenza, and pneumococcal, and COVID-19 vaccinations are employees of the corporation or will be hired by the corporation specifically for the purpose of administering influenza, pneumococcal, and COVID-19 vaccinations; 8. Names and addresses of all entities operating under the corporation’s application (not clinic locations); 9. Contact information for designated contact person for centralized billing program.