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Roster billing for Part B providers

First Coast has created standard roster forms for COVID-19, monoclonal antibodies (mAb), flu, pneumococcal, and hepatitis B services. These forms are available to providers through the First Coast website along with an example of the modified CMS-1500 (02/12) claim form, which serves as the cover document for the roster claim. Use of these forms should simplify roster billing for the providers and, since most paper claims received are scanned using Optical Character Recognition (OCR) technology, use of the standard roster form should expedite claims processing. The roster form allows up to five patients per page. It is acceptable to submit up to 20 single-sided roster form pages, up to a total of 100 beneficiaries. Up to 20 roster form pages per modified CMS-1500 (02/12) claim form will be accepted. 
If more than 20 roster form pages per CMS-1500 claim form are received, they will be returned. These returned roster form pages should be resubmitted with a new CMS-1500 claim form, up to 20 pages.

Claims will be rejected as unprocessable when the updated standard roster forms (linked below) are not submitted with the modified CMS-1500 (02/12) claim form or if the roster form or CMS-1500 claim form is incomplete.

Roster billing

Roster bills can be submitted on paper or electronically. If billing for both influenza and pneumococcal vaccines, these need to be submitted on separate claims. If billing for both COVID-19 vaccines and mAb infusions, these need to be submitted on separate claims as well. Do not bill for the other service(s) on the same claim. Do not use roster billing for a single beneficiary. 

Modified CMS-1500 (02/12) claim form instructions

Complete a modified CMS-1500 (02/12) claim form containing the information in the table below to serve as a cover document to the roster bill.

Item Number Information to Enter
1 -- Type of insurance "X" in Medicare block
2 -- Patient's Name Enter "SEE ATTACHED ROSTER"
11 -- Insured's Policy Group or Federal Employees' Compensation Act (FECA) Number Enter "NONE"
20 -- Outside Lab "X" in the NO block
21 -- Diagnosis or Nature of Illness or Injury

Line A: Enter "Z23"

Enter "0" for ICD Indicator between dotted lines
24B -- Place of Service (POS)

Enter "60" on lines 1 and 2

Note: POS code "60" must be used for roster billing
24D -- Procedure, Services, or Supplies

Line 1: Appropriate pneumococcal vaccine, influenza virus, or hepatitis B vaccination code

Line 2: Appropriate COVID-19 vaccine, influenza, mAb infusion, or hepatitis B administration code

  • Note: Medicare will not provide payment for the COVID-19 vaccine or mAb products that healthcare professionals receive for free, as will be the case upon the product’s initial availability in response to the COVID-19 PHE. Providers should not bill for product if it is received for free.

 
24E -- Diagnosis Pointer (Code)

Line 1: A

Line 2: A
24F -- Charges

List charge for each service *Not total for all patients

If no charge, enter "$0.00"
27 -- Accept Assignment? Enter "X" in YES block
29 -- Amount Paid Enter "$0.00"
31 -- Signature of Physician or Supplier Entity's representative must sign
32 -- Service Facility Location Information Name, address and ZIP of location where services were rendered
32a -- Service Facility Location number National Provider Identifier (NPI) of service facility
33 -- Billing Provider Information & Phone Number Enter billing provider information and phone number
33a -- Billing Provider NPI Enter the NPI of the billing provider or group

Attach the standard COVID-19, mAb, flu or pneumococcal roster form with the following information completed:

  • Provider's name and NPI
  • Date of service
  • Beneficiary
    • Medicare number
    • Date of birth
    • Signature or stamped "signature on file"
    • Name (last, first, middle initial)
    • Sex
    • Address 

Note: If the beneficiary's actual signature cannot be obtained, the phrase "signature on file” can be used if the provider has a signed authorization on file from the beneficiary to bill Medicare for services.

Roster forms

First Coast houses the roster forms on the Forms page of our website, under the “Immunization roster billing” section. CMS indicates the pneumococcal roster needs to include the following language:

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

Rely on patient's memory to determine prior vaccination status.

References

Returned claims

If a claim returns for OCR references, you will receive notification through your normal provider voucher or reconciliation file with the appropriate returned information. It is your responsibility to verify that all information is complete before resubmitting the claim.

References