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Wisconsin Immunization Program

Billing Manual for Local Health Departments

This manual has been designed to assist Wisconsin’s local public health departments in obtaining insurance reimbursement for their clients whose health plans cover immunizations. Insurance reimbursement would help accomplish the following:

  • Maintain a more stable vaccine supply for uninsured  and underinsured children by increasing the public funds available, through a cost recovery reimbursement mechanism, to purchase pediatric vaccines.
  • Provide additional funding to support and improve adult and adolescent immunization programs or programs targeting other vulnerable populations.
  • Strengthen immunization infrastructure.
  • Replenish vaccine inventory.

Immunization Billing Manual (PDF files)
Entire Immunization Billing Manual P-00536 Note: This is a very large file and may take several minutes to download.


Appendices: 1-24 

  1. NPI (National Provider Identifier) Record – sample [page 1]
  2. Letter of intent – sample [page 2]
  3. CAQH (Council for Affordable Quality Healthcare)
    UPD (Universal Provider DataSource) – application process [page 3]
  4. NCQA (National Committee for Quality Assurance) – credentialing standards  [page 9]
  5. Wisconsin HEDIS (Healthcare Effectiveness Data and Information Set) – provider scores 2013  [page 10]
  6. URAC (Utilization Review Accreditation Commission) – credentialing standards [page 12]
  7. Revalidation letter for Medicare – sample [page 15]
  8. Medical curriculum vitae – content information [page 21]
  9. MOU (Memorandum of Understanding) – sample template [page 23]
  10. Agreement format – typical payer standard contract [page 24]
  11. Certificate of coverage – sample [page 26]
  12. Commercial timely filing limits [page 27]
  13. COB (Coordination of Benefits) – determination rules example [page 28]
  14. Procedure codes for immunizations [page 34]
  15. CPTฎ (Current Procedural Terminology) – corrections errata sample [page 41]
  16. CPTฎ – modifiers  [page 42]
  17. Place of Service – codes 2013 [page 47]
  18. Immunization coding 2013 [page 48]
  19. Superbill – sample [page 52]
  20. CMS (Centers for Medicare & Medicaid Services) 1500 Claim form [page 54]
  21. CMS 1500 to 837P format crosswalk [page 55]
  22. Gateway EDI (Electronic Data Interchange) Clearinghouse – payer list [page 60]
  23. WPS (Wisconsin Physicians Service) Insurance – commercial claims enrollment form 837 and 835 [page 64]
  24. EOB (Explanation of Benefits) – sample [page 70]

Appendices:  25-48

  1. Medicare summary notice – reading guide [page 1]
  2. Julian calendar converter – day-of-year tables [page 5]
  3. Patient registration form – sample [page 7]
  4. Eligibility decision tree [page 9]
  5. Grandfathered plans [page 10]
  6. Immunizations and Medicare [page 12]
  7. MMCAP (Minnesota Multistate Contracting Alliance for Pharmacy) – membership application and agreement [page 17]
  8. MMCAP – application user guide [page 23]
  9. Grant proposal – template [page 27]
  10. Grant glossary [page 28]
  11. Grant proposal – cover sheet sample [page 31]
  12. Grant budget – sample [page 32]
  13. National Physicians Fee Schedule – Relative value 2013 April release [page 34]
  14. CDC (Centers for Disease Control and Prevention) – price list example [page 49]
  15. VFC (Vaccines for Children) Maximum Regional Vaccine Administration Charges 2013 [page 52]
  16. Sliding Fee Schedule – application sample [page 54]
  17. Payer reimbursement comparison table [page 58]
  18. EHR/EMR (Electronic Health Record/Electronic Medical Record) – vendor pricing template [page 64]
  19. EHR/EMR – vendor reference checking form [page 66]
  20. EHR/EMR – service level agreement items [page 68]
  21. ClaimRemedi Clearinghouse – payer lists [page 70]
  22. EHR/EMR – features [page 75]
  23. EHR/EMR – contract elements [page 78]
  24. Major Wisconsin Payers [page 81]

Contact

Anna Kocharian 
Wisconsin Division of Public Health 
Bureau of Communicable Diseases and Emergency Response
(Phone 608-266-8621)  (Fax 608-267-9493)

Last Revised: April 17, 2014