Mass Immunization Roster Billers
An entity or individual who wishes to furnish mass immunization services, but may not otherwise qualify as a Medicare provider, may be eligible to enroll as a mass immunizer.
Qualification Requirements
Mass immunization roster billers must meet the following requirements:
- The supplier, as well as all personnel who administer the shots must meet all applicable state and local licensure or certification requirements
- Submit claims through the roster billing process to bill the Part A/B Medicare administrative contractor
- Use this process to bill for seasonal influenza virus, pneumococcal, hepatitis B, COVID-19 vaccinations, and administration only
- Accept assignment on both the vaccinations and their administration
- Provide the beneficiary with a record of the seasonal influenza virus vaccination
You can find more information on the requirements for mass immunization roster billers on the CMS webpage Roster Billing for Mass Immunizers.
Documentation Requirements and Recommendations
Complete one of the following forms to enroll as a mass immunizer:
- CMS-855I form (for individuals) or the equivalent application in PECOS:
- Indicate Mass Immunization Roster Biller as the Non-physician Specialty in Section 2D
- CMS-855B form (for groups) or the equivalent application in PECOS:
- Indicate Mass Immunization (Roster Biller Only) in the Type of Supplier in Section 2A
- In section 4 of the Form CMS-855, the supplier need not list each off-site location (e.g., county fair, shopping mall) at which it furnishes services. It need only list its base of operations (e.g., county health department headquarters, drug store location)
- To expedite the processing of your provider enrollment application, use internet-based PECOS, which allows you to complete the application process online
- Include signed and dated certification statement (stamped or faxed signatures will not be accepted):
- If you submitted your application through internet-based PECOS, you may either sign the application electronically or submit your paper certification statement within 15 days of your electronic submission
- Also submit a completed Electronic Funds Transfer (EFT) Authorization Agreement (CMS-588) and associated documentation (e.g., copy of a voided check or a deposit slip). Please click here for more information on the CMS-588 Electronic funds transfer (EFT):
- If a provider or supplier already receives payments electronically and is not making a change to his or her banking information, the CMS-588 is not required
Additional Documentation Requirements (When Applicable)
Medicare may require additional documentation, when applicable, to validate key information contained within the enrollment application (e.g., name change, tax identification number, proof of citizenship) or to address specific issues that could adversely affect a practitioner’s potential eligibility for enrollment (e.g., adverse legal actions, financial relationships):
- Written confirmation from the IRS verifying provider’s TIN is associated with the provider’s legal business name (e.g., IRS CP 575)
- Final adverse action documentation: Include copies of legal documents associated with any final adverse action(s) taken against the provider as well as copies of any the legal documents showing its resolution (e.g., notifications, reinstatement letters):
- Documents containing a summary of the adverse actions taken or their resolution will not be accepted
References