CMS Pub. 100-04, ch. 18, § 10.3.1

Submitted to AB MACs (B) for Mass Immunization

(Rev. 11355; Issued:04-14-22; Effective:05-16-22; Implementation:05-16-22)

If the PHC or other individual or entity qualifies to submit roster claims, it may use a preprinted

Form CMS-1500 that contains standardized information about the entity and the benefit. See Pub.

100-04, Chapter 26, §10 for more information about the CMS-1500 claim form. Key information

from the beneficiary roster list and the abbreviated claim form is used to process pneumococcal,

influenza, and COVID-19 vaccination claims.

Separate CMS-1500 claim forms, along with separate roster bills, must be submitted for influenza

virus, pneumococcal, and COVID-19 roster billing.

If other services are furnished to a beneficiary along with pneumococcal, influenza, or COVID-19

vaccines, individuals and entities must submit claims using normal billing procedures, e.g.,

submission of a separate claim for each beneficiary.

MACs (Part B) must create and count one claim per beneficiary from roster bills. They must split

claims for each beneficiary if there are multiple beneficiaries included in a roster bill. Providers

must show the unit cost for one service on the claim. The MACs (Part B) must replicate the claim

for each beneficiary listed on the roster.

MACs (Part B) must provide Palmetto-Railroad Retirement Board (RRB) with local pricing files

for pneumococcal, influenza, and COVID-19 vaccines and their administration. If PHCs or other

individuals or entities inappropriately bill pneumococcal, influenza, or COVID-19 vaccinations

using the roster billing method, MACs (Part B) shall return the claim as unprocessable with the

appropriate rejection message. MACs (Part B) may not deny these claims.

Providers must retain roster bills with beneficiaries' signatures at their permanent location for a

time period consistent with Medicare regulations.

A. Modified Form CMS-1500 for Cover Document

Entities submitting roster bills to MACs (Part B) must complete the following blocks on a single

modified Form CMS-1500 claim form, which serves as the cover document for the roster for each

facility where services are furnished. In order for MACs (Part B) to reimburse by correct payment

locality, a separate Form CMS-1500 must be used for each different facility or physical location

where services are furnished.

Item # Instruction

Item 1: An X in the Medicare block

Item 2: (Patient's Name): "SEE ATTACHED ROSTER"

Item 11: (Insured's Policy Group or FECA Number): "NONE"

Item 20: (Outside Lab?): An "X" in the NO block

Item 21: (Diagnosis or Nature of Illness):

Line A: Choose appropriate diagnosis code from §10.2.1

ICD Ind. Block: Enter ICD-10-CM code.

Enter the indicator as a single digit between the vertical dotted lines.

Item 24B: (Place of Service (POS)):

Line 1: "60"

Line 2: "60"

NOTE: POS Code “60" must be used for roster billing.

Item 24D: (Procedures, Services or Supplies):

Line 1:

Vaccine code

Line 2:

Vaccine Administration code

Item 24E: (Diagnosis Pointer): Lines 1 and 2: "A"

Item 24F: ($ Charges): The entity must enter the charge for each listed service. If

the entity is not charging for the vaccine or its administration, it should

enter 0.00 or "NC" (no charge) on the appropriate line for that item. If

your system is unable to accept a line item charge of 0.00 for an

immunization service, do not key the line item. Likewise, electronic

media claim (EMC) billers should submit line items for free immunization

services on EMC pneumococcal or influenza virus vaccine claims only if

your system is able to accept them.

Item 27: (Accept Assignment): An "X" in the YES block.

Item 29: (Amount Paid): "$0.00"

Item 31: (Signature of Physician or Supplier): The entity's representative must sign

the modified Form CMS-1500.

Item 32: Enter the name, address, and ZIP code of the location where the service

was provided (including centralized billers).

Item32a: Enter the NPI of the service facility.

Item 33: (Physician's, Supplier's Billing Name): The entity must complete this

item.

Item 33a: Effective May 23, 2007, and later, enter the NPI of the billing provider or

group.

B. Format of Roster Claims

Qualifying individuals and entities must attach to the CMS-1500 claim form, a roster bill which

contains the claims information regarding the supplier of the service and individual beneficiaries.

While qualifying entities must use the modified Form CMS-1500 claim form without deviation,

MACs (Part B) must work with these entities to develop a mutually suitable roster bill that contains

the minimum data necessary to satisfy claims processing requirements for these claims. MACs

(Part B) must key information from the beneficiary roster bill and abbreviated Form CMS-1500

claim form to process pneumococcal, influenza virus, and COVID-19 vaccination claims.

The roster must contain at a minimum the following information:

• Provider name and number;

• Date of service;

NOTE: Providers must include the individual date of service for each beneficiary's

vaccination on the roster bill.

• Control number for MAC (Part B);

• Patient's Medicare beneficiary identifier number;

• Patient's name;

• Patient's address;

• Date of birth;

• Patient's sex; and

• Beneficiary's signature or stamped "signature on file”.

NOTE: A stamped "signature on file" qualifies as an actual signature on a roster bill if the

provider has a signed authorization on file to bill Medicare for services rendered. In this situation,

the provider is not required to obtain the patient signature on the roster, but instead has the option

of reporting signature on file in lieu of obtaining the patient's actual signature.

The pneumococcal roster must contain the following language to be used by providers as a

precaution to alert beneficiaries prior to administering the pneumococcal vaccination.

WARNING: Beneficiaries must be asked if they have received a pneumococcal vaccination.

• Rely on patients' memory to determine prior vaccination status.

MACs (Part B) shall use the data on the CMS-1500 claim form cover sheet and the roster bill

to correct or add missing claims data and continue to process the claims for payment.

Contractors shall not return a claim as unprocessable if the following data fields on the CMS-

1500 are not completed:

Item 1,

Item 2, or

Item 20.

The MAC (Part B) shall allow the roster claims to continue to process for payment. The

MAC (Part B) shall complete the incomplete fields if the data is available on the attached

roster bill.

The MAC (Part B) may fill in missing or incomplete information on the attached roster bill

when the required data such as provider’s name and NPI is missing but is included on the

abbreviated CMS-1500 claim form. The MAC shall fill in the missing information and

continue to process the claim for payment.