Step 1: Make sure you are enrolled in the Medicare program and have a provider number.
You can’t bill Medicare for covered services unless you are enrolled in the Medicare program and have a provider number. If you are physician practicing in an office, a health department, a self-employed nurse or a non-traditional provider, like a drug store, and are not currently enrolled in the Medicare program, call your local carrier and ask for the CMS-855 Provider/Supplier Application Form. If you are a durable medical equipment (DME) supplier, like some pharmacists, and currently bill the DME regional carrier, you will still need to call your local carrier and complete a CMS-855 Provider/Supplier Application Form to get a provider number for billing the local carrier for immunizations. If you only plan to provider immunizations and other covered Medicare services, like mammography, then you only need to complete certain sections of the CMS-855.
If you are an institutional provider, like a hospital, skilled nursing facility, home health agency, etc., and bill the intermediary, you must complete the CMS-855 Provider/Supplier Application Form. If you only plan to provide immunizations and no other covered Medicare services, then you only need to complete certain sections of the CMS-855.
Step 2: Select the billing method that works best in your setting.
Manual and electronic billing are available through your local contractor. Decide which method works best for you. Roster Billing is a simplified billing process which allows mass immunizers to submit one claim form with a list of immunized beneficiaries.
A mass immunizer is a provider who:
a) agrees to accept assignment for the influenza and pneumococcal vaccines (what Medicare will pay), and,
b) bills Medicare for the influenza and pneumococcal vaccines for multiple beneficiaries.
The roster must include certain information, like the beneficiary’s name, address, health insurance claim (HIC) number, date of birth, sex, date of service, and signature. If the beneficiary is incompetent and cannot sign his or her name, a stamped “signature on file” is allowed, as long as the provider has access to a beneficiary’s signature (e.g., in the beneficiary’s medical records).
A physician standing order is not required for Medicare coverage of influenza immunizations; however, individual State law may require a physician order or other physician involvement. Effective for date of service on or after August 15, 2000, Medicare no longer requires a standing order for the pneumococcal vaccination.
Step 3: Bill Medicare!
If you are a nonparticipating physician, provider, or supplier that does not accept assignment you may collect payment from the beneficiary, but you must submit an unassigned claim on the beneficiary’s behalf. Participating physicians, providers, and suppliers must bill Medicare for payment.
If you are billing the carrier, use a CMS-1500 claim form. If you are billing the intermediary, use a HCFA-1450 claim form, also known as the UB-92. Make sure the appropriate code appears on the claim. The following are the influenza and pneumococcal codes you will need to include on both the HCFA-1500 and HCFA-1450 claim forms:
Vaccine Code & Description Administration Code Diagnosis Code
Influenza 90657 – Split virus, 6-35 months dosage, for intramuscular or jet injection use G0008 V04.81
90658 – Split virus, 3 years and above dosage, for intramuscular or jet injection use
Pneumococcal 90732 – Pneumococcal polysaccharide vaccine, 23-valent, adult dosage, for subcutaneous or intramuscular use G0009 V03.82
Check with your local carrier or fiscal intermediary in September for any current allowables.
Include your provider number and place of service codes on the claim form you submit to carriers to collect reimbursement. A separate claim must be submitted for each Medicare beneficiary. Influenza and pneumococcal roster billing cannot be combined on the same claim form. Separate 1500 claim forms must be used for each vaccine.
Medicare reimburses for both the cost of the vaccine and its administration.reimbursement to providers billing the carrier is on a reasonable charge basis. Reimbursement to providers billing the intermediary is in accordance with the Outpatient Prospective Payment System.