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Get Roster Billing
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How to fill out the Roster Billing online
Filling out the Roster Billing form is an essential step for mass immunizers who provide vaccinations for influenza, influenza A (H1N1), and pneumococcal diseases. This guide will walk you through each component of the form to ensure accurate completion and efficient submission.
Follow the steps to successfully complete the Roster Billing form
- Press the ‘Get Form’ button to obtain the form and open it in your preferred editor.
- Begin by entering your provider information. Make sure to type the required details clearly, or use black or blue ink if writing.
- In Item 1, enter 'X' in the 'Other' box to indicate the type of billing. This is crucial for classification.
- For the patient's name, indicate 'See attached roster' in the specified field.
- Indicate the diagnosis codes in Item 21 based on the type of vaccination provided. Use the codes V04.81, V06.6, or V03.82 for the respective vaccines.
- Complete Items 24D and 24E with the appropriate CPT or HCPCS codes for the vaccines and their administration.
- Enter your charges in Item 24F, noting that if no charge is applicable, you should denote this as '0.00' or 'NC' (no charge).
- Ensure that you accept assignment by marking 'X' in the 'Yes' block in Item 27.
- In Item 31, provide the signature of the healthcare provider or supplier, including credentials, and the date on which the form was signed.
- Fill out the address and NPI of the location where vaccinations were administered in Item 32 and 32a.
- Finally, enter the billing provider's name, address, and NPI number in Item 33 and 33a before reviewing the entire form for accuracy.
- After completing the form, save your changes, and prepare to print or share your submission as necessary.
Complete your Roster Billing form online today for smooth processing of your immunization claims.
An itemized bill must include detailed information about each service provided, including descriptions, dates of service, and associated charges. Additionally, it should reflect any adjustments or payments made by insurance or the patient. Using roster billing can simplify this process, by allowing you to compile and submit patient data in an organized manner.
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