What Providers Should Know About the Submission and Reimbursement of Medicare Influenza Claims Bridgitté M. Davis Health Insurance Specialist Centers for Medicare & Medicaid Services

Introduction Medicare pays 100 percent for the influenza vaccine and its administration. There are no applicable co-payments and/or deductibles. Medicare generally allows one flu shot per year.

Who Can Participate as a Medicare Influenza Immunizer? Providers and suppliers already enrolled in the Medicare program may use their provider identification number to provide influenza vaccinations and bill for reimbursement. Mass Immunizer Providers/suppliers who enroll in the Medicare program to offer the influenza vaccinations to a large number of individuals. Must meet the licensure requirements in States in which they plan to operate flu clinics. Enrollment is ongoing. Please contact your local carrier to apply.

Who Can Participate as a Medicare Influenza Immunizer? Mass Immunizer Centralized Biller Mass immunizers can apply to become a centralized biller when they operate in at least three different payment localities for which there are three different carriers processing claims. Claims are processed by one carrier regardless of the locality of where the service was rendered. Must meet licensure requirements in the States where they plan to operate flu clinics Participation is limited to one year and must be renewed annually.

Enrollment Requirements Providers/suppliers must enroll in the Medicare program even if mass immunizations are the only service to be provided. Providers/suppliers applying to the Medicare program for the sole purpose of mass immunization will apply as specialty type 73 (Mass Immunization Roster Biller).

Enrollment Requirements Mass Immunization Centralized Biller: Accept assignment on both the vaccine and its administration; Bill only for influenza and/or PPV vaccinations; Submit claims electronically using software provided by the designated carrier; and Submit claims to the designated carrier only. Mass Immunization Roster Biller: Accept assignment on both the vaccine and its administration; Bill only for influenza and/or PPV vaccinations; Submit claims using roster bills; and Submit your claims to your local carrier.

Enrollment Requirements Providers/suppliers must enroll by completing the Form CMS-855 application. Individuals complete the Form CMS-855I Groups complete the Form CSM-855B Applications are available from your local carrier or from the CMS website at http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp#TopOfPage Applicants are encouraged to begin the application process as early as possible to allow sufficient time for processing. The enrollment process may take 8-12 weeks.

Enrollment Requirements Providers/suppliers interested in more information on enrolling as a Medicare Mass Immunizer should contact their local carrier. Carrier and fiscal intermediary information can be found at www.cms.hhs.gov/MLNProducts/Downloads/CallCenterTollNumDirectory.zip .

Submitting Claims for Reimbursement Important information to remember when submitting claims for reimbursement: Utilize the August 2005 version of the modified preprinted Form CMS-1500 that captures information on the provider/supplier and the patient roster form.

Submitting Claims for Reimbursement The patient roster form must capture the following information on each patient: Beneficiary Name and Address; Beneficiary Health Insurance Claim Number; Date of Birth: Sex; Date of Service; Beneficiary Signature or stamped “Signature on File”; Provider’s Name and Identification Number; and Control Number for the Contractor

Submitting Claims for Reimbursement Roster claim form may not have other services listed on it. Rosters can not contain claims for both flu and PPV vaccinations. A separate roster must be completed for each vaccine type.

Submitting Claims for Reimbursement Completing the modified CMS-1500 Cover Sheet: A separate Form CMS-1500 (08-05) must be completed for each facility where flu shots are given in order for carriers to reimburse by correct payment locality. Instructions on completing the modified Form CMS-1500 can be found in Publication 100-04, Chapter 18, Section 10.3.1 , Subsection A (Modified Form CMS-1500 (08-05) for Cover Document ).

News You Can Use!!! The Rhode Island Flu Pilot Project Beginning with the 2007-2008 flu season, the Rhode Island Department of Health will purchase and distribute influenza vaccine for Rhode Island residents. Healthcare providers must order their adult flu vaccine through the Health Department. Providers will only be reimbursed for the administration of vaccine. To learn more about the program, visit www.health.ri.gov .