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Flu Shot Requirements and Roster Claims Submissions

Provider Administrative Policy

General Billing
Policy Date
April 2007
Revised/February 2015
Provider Type(s)
All Providers  


Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts


Flu Shot Requirements and Roster Claims Submissions

Blue Cross of Idaho accepts claims for flu shots through different methods. In addition to the traditional individual CMS 1500 claim forms, providers also have the option to submit a single roster when numerous shots are administered on the same day in a setting other than the office.

CMS 1500 and UB04 Forms

  • If you are a contracting provider with Blue Cross of Idaho, please submit your claim forms to us electronically. We will accept paper claims if absolutely necessary. Your allowances for flu shots are reflected in your provider contract fee schedule and, in most cases, also through the on-line provider allowance to by CPT/HCPCS code. When submitting a CMS 1500 or UB04 claim form, you can only submit the services for one member per form.
  • The roster billing form must be completed in its entirety to meet BlueCard regulations for billing.
    • If roster billings include BlueCard members, we will forward the roster billings submitted by providers who typically bill on a UB04 claim form to the BlueCard member's home plan for processing. To expedite the process, you may consider providing the patient with a receipt to submit to his home plan on his own rather than including BlueCard members on your roster billing form.
  • Mail roster billing form to:
    BlueCross of Idaho
    Attention: Provider Relations
    PO BOX 7408
    Boise, ID 83707
  • An electronic copy of the roster billing form is available in the secure provider portal of the Blue Cross of Idaho website at

*Note - Flu Mist may be included on the roster billing form.

Please refer to PAP505 for additional information regarding immunization billing.

Roster Billing Form

Policy History

Date Action Reason
November 2013 Revised Added additional clarification
March 2009 Revised Minor word changes and Flu Mist added
May 2008 Revised NPI added to form

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