Influenza and Pneumococcal Roster Billing Packet and Forms


Roster billing is a simplified process used by mass immunizers. Palmetto GBA has prepared a packet for health care providers who mass immunize their patients against influenza and pneumonia. The packet contains instructions on how to submit claims using the roster billing method. Access a copy of this packet, as well as the forms, by selecting the link at the end of this article. Please share this information with appropriate members of your staff.

A PC-ACE Pro32 Software User's Manual has been created to provide you with information on Medicare’s courtesy software, PC-ACE Pro32, which allows for electronic roster billing. Medicare provides the software and technical support free of charge. A copy of this packet is located under EDI under Topics, then select "Software & Manuals."


Influenza_and_Pneumococcal_Roster_Billing_Packet.pdf (PDF - 149 KB)
Influenza-Pneumococcal_Roster_Forms-Part_B_with_ICD-10.pdf (PDF - 297 KB)
Influenza_Claim_Form_with_ICD-10.pdf (PDF - 2 MB)
Pneumococcal_Claim_Form_with_ICD-10.pdf (PDF - 2 MB)


Last Updated: 06/17/2020