Centralized Billing for Influenza Virus and Pneumococcal Vaccines

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 centralized billing must contact the Centers for Medicare & Medicaid Services (CMS) Central Office (CO), in writing, at the following address by June 1 of the year they wish to begin centrally billing.

Center for Medicare & Medicaid Services
Division of Practitioner Claims Processing
Provider Billing and Education Group
7500 Security Boulevard
Mail Stop C4-10-07
Baltimore, Maryland 21244

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. The approximate dates for when the vaccinations will be given;

4. A list of the States in which influenza virus and pneumococcal clinics will be held;

5. The type of services generally provided by the corporation (e.g., ambulance, home health, or visiting nurse);

6. Whether the nurses who will administer the influenza virus and pneumococcal vaccinations are employees of the corporation or will be hired by the corporation specifically for the purpose of administering influenza virus and pneumococcal vaccinations;

7. Names and addresses of all entities operating under the corporation’s application;

8. Contact information for designated contact person for centralized billing program.
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 immunization services for influenza virus and pneumococcal 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).

• Since there is no coinsurance or deductible for the influenza virus and pneumococcal benefit, 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.

o 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 Novitas Solutions, Inc.

• 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 Media Claims standard format. Paper claims will not be accepted.

• Centralized billers must obtain certain information for each beneficiary including name, health insurance number, date of birth, sex, and signature. Novitas Solutions, Inc. 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 beneficiary’s Medicare Health Insurance Claim Number) as the contractor will not be able to process incomplete or incorrect claims. For questions regarding these requirements, please contact the Customer Service Center.

• Centralized billers must obtain an address for each beneficiary so that a Medicare Summary Notice (MSN) can be sent to the beneficiary by the contractor. Beneficiaries are sometimes confused when they receive an MSN from a contractor other than the contractor that normally processes their claims which results in unnecessary beneficiary inquiries to the Medicare contractor. Therefore, centralized billers must provide every beneficiary receiving an influenza virus or pneumococcal vaccination with the name of the processing contractor. 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. Novitas Solutions, Inc. can provide this information. For questions regarding these regulations, please contact the Customer Service Center.

• Though centralized billers may already have a Medicare provider number, for purposes of centralized billing, they must also obtain a provider number from Novitas Solutions, Inc. This can be done by completing the Form CMS-855 (Provider Enrollment Application) from Novitas Solutions, Inc. Please visit the Enrollment Center on our website to obtain the CMS-855 form and instructions for completion of the form.

• If an individual or entity’s request for centralized billing is approved, the approval is limited to the 12 month period from September 1 through August 31 of the following year. It is the responsibility of the centralized biller to reapply to CMS CO for approval each year by June 1. Claims will not be processed for any centralized biller without permission from CMS.

• Each year, the centralized biller must contact Novitas Solutions, Inc. 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.

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