We have created standard roster billing forms for the COVID-19, monoclonal antibody, influenza, and pneumococcal services, along with examples of the modified CMS-1500. The CMS-1500 claim form serves as the cover document for the roster bill. Use of these forms should simplify roster billing, 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 billing form allows you to report five patients per page. It is acceptable to submit up to 20 single-sided pages per CMS-1500 claim form for a total of 100 beneficiaries.
Effective with claims received on and after May 13, if more than 20 single-sided pages are submitted, they will be returned as unprocessable. Resubmit a 1500 claim form with no more than 20 single-sided pages.
Claims will be returned as unprocessable when the standard influenza or pneumonia roster billing forms are not submitted with the modified CMS-1500 (02/12) claim form or if the roster billing form/CMS-1500 claim forms are incomplete.
Roster bills can be submitted on paper or electronically. If billing for COVID-19, monoclonal antibody, influenza, and pneumococcal vaccines, these must be submitted on separate claims. Do not bill for other services on the same claim. Do not use the roster bill for a single beneficiary.
Complete a modified CMS-1500 claim form with information contained in the table below to serve as a cover document to the roster bill.
Box number |
Information to enter |
1 – Type of health insurance |
Enter “X” in Medicare block |
2 – Patient’s name |
Enter “See attached roster” |
11 – Insured’s policy group or Federal Employee’s Compensation Act number |
Enter “None” |
20 – Outside lab |
Enter “X” in no block |
21 – Diagnosis or nature of illness or injury |
For vaccine billing: Enter “Z23” on line A Enter “0” for ICD indicator between vertical dotted lines For mAb billing: Enter appropriate diagnosis coded to highest level of specificity (U071 – use as appropriate) Enter "0" for ICD Indicator between dotted lines |
24B – Place of service |
Enter “60” on lines 1 and 2 |
24D – Procedure, services, or supplies |
Line 1: Appropriate COVID-19 vaccination, monoclonal antibody infusion or the influenza, or pneumococcal vaccination code. Line 2: Appropriate COVID-19, monoclonal antibody infusion, influenza, or pneumococcal administration code. Note: If the healthcare professional receives the product free of charge, do not include on the roster bill. |
24E – Diagnosis pointer (code) |
Line 1: A Line 2: A |
24F – Charges |
Enter charge for each service *not total for all patients If no charge, enter “$0.00” |
24J – Rendering provider |
If the billing provider is a group, enter the rendering physician's NPI in the lower unshaded portion. If the billing provider is an individual, this information is not required. |
27 – Accept assignment? |
Enter “X” in yes block |
29 – Amount paid |
Enter “$0.00” |
31 – Signature of physician or supplier |
Enter entity’s representative must sign |
32 – Service facility location information |
Enter name, address, and zip code |
32A – Facility NPI |
Enter NPI of service facility |
33 – Billing provider information & telephone number |
Enter name, complete address, and telephone number |
33A - Billing NPI |
Enter the NPI of the billing provider |
Attach the standard COVID-19, monoclonal antibody, influenza, or pneumococcal roster billing form with the following information:
Provider’s name and NPI
Date of service
Beneficiary name
Medicare number
Date of birth
Signature or stamped “signature on file”
Name (last, first, middle initial)
Address
Note: If the beneficiary’s signature cannot be obtained, the phrase “signature on file" can be used if you have a signed authorization on file from the beneficiary to bill Medicare for services.
When completing the roster form, use the roster form from the Forms Catalog (JH)(JL) of our website. Fill in the information accordingly. Do not change the font type or size.
Complete fields on the roster form using all caps.
Use the center alignment when inputting information into fields.
Complete all the data fields in the proper MM/DD/YYYY format.
Only fill in the fields for the number of beneficiary's who have received services. If the entire roster is not needed, leave additional fields blank.
Additional documentation and attachments are not required when submitting a roster bill.
Roster billing forms are available on the Forms Catalog (JH)(JL) of our website.
The pneumococcal roster must include the following:
Warning: Beneficiaries must be asked if they have received a pneumococcal vaccination.
Rely on patient’s memory to determine prior vaccination status.
If a claim is returned for incomplete or invalid information, you will receive notification on your normal voucher or reconciliation file with the appropriate returned information. It is your responsibility to verify that all information is complete before resubmitting the claim.
Note: For electronic Medicare claim billers, all existing batch and claim level returns for OCR references will be retained. Use the PCLR 5001-5004 reports for these returns.
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