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Last Modified: 2/8/2018 Location: FL, PR, USVI Business: Part A, Part B

Mass immunization roster billers

Qualification requirements

Mass immunization roster billers must:
Bill a carrier or Part A/B Medicare administrative contractor
Be properly licensed in the states in which they operate
Use roster bills
Use this process to bill for seasonal influenza virus and/or pneumococcal 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 in the MLNŽ Booklet Mass Immunizers and Roster Billing: Simplified Billing for Influenza Virus ad Pneumococcal Vaccinations external pdf file.

Documentation requirements and recommendations

Complete one of the following forms to enroll as a mass immunizer:
CMS-855I form (for individuals)
Indicate Mass Immunization Roster Biller as the Non-physician Specialty in Section 2D
CMS-855B form (for groups)
Indicate Mass Immunization (Roster Biller Only) in the Type of Supplier in Section 2A
Note: To expedite the processing of your provider enrollment application, you may use the internet-based Provider Enrollment Chain and Ownership System (PECOS) external link, which will automatically select the appropriate form and allow you to complete the application process online.
Signed and dated certification statement -- all signatures must be original and signed in ink (blue ink preferred). Stamped, faxed, or copied signatures will not be accepted.
Note: 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.
Completed Electronic Funds Transfer (EFT) Authorization Agreement (CMS-588) external pdf file and associated documentation (e.g., copy of a voided check and/or a deposit slip). Please click here for more information.
Note: If a provider/supplier already receives payments electronically and is not making a change to his/her banking information, the CMS-588 is not required. In addition, physicians and non-physician practitioners who are reassigning their benefits to another entity are not required to submit the CMS-588.

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).
Driver’s license
Social Security card
Marriage license
U.S. passport
Written confirmation from the Internal Revenue Service (IRS) verifying provider’s tax identification number (TIN) is associated with the provider’s legal business name (e.g., IRS CP 575)
Final adverse action documentation: Please 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).
Note: Documents containing a summary of the adverse actions taken or their resolution will not be accepted.
Statement in writing from the applicant’s bank (or other financial institution) -- if Medicare payments will be sent to an applicant’s bank with which the applicant has a lending relationship (i.e., any type of loan), then the applicant must provide a statement in writing from the bank -- which must be specified in the loan agreement -- that the lender has agreed to waive its right of offset for Medicare receivables.
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First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.