Claims Submitted to MACs (Part A) for Mass Immunizations of

10.3.2 - Claims Submitted to MACs (Part A) for Mass Immunizations of Influenza, Pneumococcal, and/or COVID-19 Virus Vaccinations (Rev. 11355; Issued:04-14-22; Effective:05-16-22; Implementation:05-16-22) To increase the number of beneficiaries who obtain needed preventive vaccinations, simplified roster billing procedures are also available to mass immunizers that bill MACs (Part A). The simplified roster claims filing procedure has been expanded from availability for influenza and pneumococcal virus vaccinations to also include COVID-19 virus vaccinations. A mass immunizer is defined as any entity that gives the influenza, pneumococcal, or COVID-19 virus vaccinations to a group of beneficiaries, e.g., at public health clinics, shopping malls, grocery stores, senior citizen homes, and health fairs. To qualify for roster billing, immunizations of at least five beneficiaries on the same date are required. (See §10.3.2.2 for an exception to this requirement for inpatient hospitals.) The simplified roster billing claims filing procedure applies to providers other than RHCs and FQHCs that conduct mass immunizations. Since independent and provider based RHCs and FQHCs do not submit individual Form CMS-1450s for the influenza virus vaccine, they do not utilize the simplified billing process. Instead, payment is made for the vaccine at the time of cost settlement. The simplified roster billing process involves use of the provider billing form (Form CMS-1450) with preprinted standardized information relative to the provider and the benefit. Mass immunizers attach a standard roster to a single pre-printed Form CMS-1450 that contains the variable claims information regarding the service provider and individual beneficiaries. Qualifying individuals and entities must attach a roster, which contains the variable claims information regarding the supplier of the service and individual beneficiaries. The roster must contain at a minimum the following information: • Provider name and NPI; • Date of service; • Patient name and address; • Patient date of birth; • Patient sex; • Patient Medicare Beneficiary Identifier (MBI) number; and • Beneficiary signature or stamped "signature on file." In addition, for inpatient Part B services (12x and 22X) the following data elements are also needed: • Admission date; • Admission type; • Admission diagnosis; • Admission source code; and • Patient status code. NOTE: A stamped "signature on file" can be used in place of the beneficiary's actual signature for all institutional providers that roster bill from an inpatient or outpatient department provided the provider has a signed authorization on file to bill Medicare for services rendered. In this situation, they are not required to obtain the patient signature on the roster. However, the provider has the option of reporting "signature on file" in lieu of obtaining the patient's actual signature on the roster. The pneumococcal vaccination roster must contain the following language to be used by providers as a precaution to alert beneficiaries prior to administering the pneumococcal vaccine. Warning: Beneficiaries must be asked if they have been vaccinated with the pneumococcal vaccine. • Rely on the patients' memory to determine prior vaccination status. • If patients are uncertain whether they have been vaccinated within the past 5 years, administer the vaccine, • If patients are certain that they have been vaccinated within the past 5 years, do not revaccinate. For providers using the simplified billing procedure, the modified Form CMS-1450 shows the following preprinted information in the specific form locators (FLs). Information regarding the form locator numbers that correspond to the data element names below is found in Chapter 25: • The words "See Attached Roster" (Patient Name); • Patient Status code 01 (Patient Status); • Condition code M1 (Condition Code) (See NOTE below); • Condition code A6 (Condition Code); • Revenue code 636 (Revenue Code), along with the appropriate HCPCS code in FL 44 (HCPCS Code); • Revenue code 771 (Revenue Code), along with the appropriate "G" HCPCS code (HCPCS Code); • "Medicare" (Payer, line A); • The words "See Attached Roster" (Provider Number, line A); and • Diagnosis code • ICD-10-CM - Use Z23 for an encounter for immunization effective with the implementation of ICD-10. • Influenza virus and COVID-19 vaccines require: • the provider’s own NPI to be reported in the NPI field for the attending physician on claims submitted on or after May 23, 2007. Providers conducting mass immunizations are required to complete the following fields on the preprinted Form CMS-1450: • Type of Bill; • Total Charges; • Provider Representative; and • Date. NOTE: Medicare Secondary Payer (MSP) utilization editing is bypassed in CWF for all mass immunization roster bills. However, if the provider knows that a particular group health plan covers the pneumococcal vaccine and all other MSP requirements for the Medicare beneficiary are met, the primary payer must be billed. First claim development alerts from CWF are not generated for influenza, pneumococcal or COVID-19 vaccination claims. Contractors use the beneficiary roster list to generate claim records to process the pneumococcal virus vaccination claims by mass immunizers indicating condition code M1 to avoid MSP editing. Standard System Maintainers must develop the necessary software to generate records that will process through their system. Providers that do not mass immunize must continue to bill for the influenza, pneumococcal and COVID-19 virus vaccinations using the normal billing method, (e.g., submission of a Form CMS- 1450 or electronic billing for each beneficiary).