RHCs have always had certain preventive vaccines paid outside their All-Inclusive Rate (AIR) for their traditional Medicare patients. Beginning July 1, 2025, Rural Health Clinics are required to bill these preventive vaccines and their administration at the time of service:
- Influenza (regular and high dose)
- Pneumococcal (all types)
- Hepatitis B
- COVID-19
This wasn’t simply a billing update—it changed the operational workflow for Rural Health Clinics.
Under current CMS policy, RHCs bill these vaccines at the time of service and later reconcile the actual vaccine and administration costs through the Medicare cost report. If these vaccines are not billed correctly, your clinic will not receive the full Medicare reimbursement it has earned. While the vaccine claims may be paid, improper billing can prevent the vaccine and administration costs from being included in the Medicare cost report reconciliation.
An Important Operational Reminder
For Medicare RHC billing, these preventive vaccines should generally be billed on the UB-40. If the patient has an RHC visit, the vaccine should be billed on the same UB-04 claim as the visit. If there is no qualifying RHC visit, the vaccine may still be billed separately on a UB-04 claim.
In either situation, Condition Code A6 is required. In addition, vaccine charges should not be bundled with the RHC encounter charges, as doing so could incorrectly create patient coinsurance for services that are intended to be covered without cost-sharing.
Why This Matters
We recently worked with a clinic that had been billing these preventive vaccines on a CMS-1500 claim directly to Medicare Part B. While the claims were paid, those services did not appear on the clinic’s Medicare Provider Statistical & Reimbursement (PS&R) report—the report used during the Medicare cost report process.
Situations like this illustrate why it’s important to periodically review Medicare vaccine billing workflows. Even when claims are being paid, the downstream reimbursement and cost reporting implications may not be immediately apparent.
A Good Time for an Operational Check
If your clinic hasn’t reviewed its Medicare vaccine billing process since this change took effect, now is an excellent time.
Ask yourself:
- Is your team consistently billing eligible Medicare vaccines at the time of service?
- Are preventive vaccine claims being submitted on the appropriate claim form?
- Are billing and clinical workflows aligned?
- Is everyone following the same process?
- Are you positioned to capture the reimbursement your clinic has earned?
Sometimes small operational gaps can have a larger financial impact than expected. Taking time now to review your process can help avoid surprises later.
HSA Can Help
At HSA, we know successful Rural Health Clinic operations depend on more than compliance—they depend on reliable systems and consistent processes.
If you have questions about Medicare vaccine billing, reimbursement, cost reporting, or operational workflows, our team is here to help. We can review your current processes, identify potential gaps, and help ensure your clinic is positioned for accurate reimbursement and cost reporting.
For complete CMS guidance regarding Medicare vaccine billing for Rural Health Clinics, go HERE.