Reporting Changes of Information

Physicians; physician assistants; nurse practitioners; clinical nurse specialists; certified registered nurse anesthetists; certified nurse-midwives; clinical social workers; clinical psychologists; registered dietitians or nutrition professionals; and organizations (e.g., group practices) consisting of any of the categories of individuals identified in this paragraph:

  • Changes of ownership (all individuals and organizations reported in Sections 5 and 6 of the CMS-855B, including authorized and delegated officials); final adverse legal actions; and changes in practice location must be reported within 30 days of the effective date of the change. Note: Failure to report final adverse legal actions or changes in practice location within 30 days of their effective date may result in revocation of the provider's Medicare billing privileges.
  • All other changes must be reported within 90 days of the effective date of the change.

All providers other than those listed above and other than independent diagnostic testing facilities:

  • Changes of ownership (all individuals and organizations reported in Sections 5 and 6 of the CMS-855B, including authorized and delegated officials) must be reported within 30 days.
  • All other changes must be reported within 90 days of the effective date of the change.

Independent diagnostic testing facilities (IDTFs):

  • Changes in ownership (all individuals and organizations reported in Sections 5 and 6 of the CMS-855B, including authorized and delegated officials); changes of location; changes in general supervision; and adverse legal actions must be reported within 30 days of the effective date of the change.
  • All other changes must be reported with 90 days of the effective date of the change.

Changes must be reported by submitting the appropriate CMS-855 application form, completing those sections of the form designated as required in Section 1 for the type of change being reported. Note: If an enrolled entity obtains a new employer identification number (EIN), it is not considered a "change of information" for Medicare enrollment purposes. Rather, it is considered to be a new entity, and a new enrollment form must be completed in its entirety.

An individual or entity reporting a change of information may be required to submit a complete CMS-855I or CMS-855B to update their Medicare enrollment information. If the required CMS-855I or CMS-855B is not submitted within 60 days of the request, the change of information will not be processed, and the provider's Medicare enrollment will be subject to revalidation requirements per 42 CFR § 424.515.

The following CMS-855 enrollment forms are used in Part B of the Medicare program to report changes of information, including voluntary terminations, as well as to apply for initial enrollment:

  • CMS-855B: Clinics, Group Practices, and Other Organizations.
  • CMS-855I: Individual Physicians and Nonphysician Practitioners, including those who are the sole owner of a professional corporation, a professional association, or a limited liability company.
  • CMS-855O: Eligible Ordering and Referring Physicians and Non-Physician Practitioners
  • CMS-855R: Reassignment of Medicare Benefits

Most types of changes can be reported via the Internet-based Provider Enrollment Chain and Ownership System (PECOS) To report changes, or to apply for enrollment, via Internet-based PECOS, go to http://www.cms.gov/MedicareProviderSupEnroll/04_InternetbasedPECOS.asp(external link)

You may also print the electronic versions of these forms from the Centers for Medicare & Medicaid (CMS) website: http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-List.html(external link). These forms cannot be submitted electronically. They must be printed, signed, and mailed to us

Note: The U.S. Postal Service returns checks and remittance notices to WPS Medicare when the address is incorrect. They cannot be forwarded to another address. The Provider Enrollment Department is notified when checks and remittance notices are returned, and all payments, including electronic funds transfers, are stopped until the provider reports the correct address information on the appropriate CMS-855 form.

Certification statements and required documents for Internet-based PECOS applications, and CMS-855 paper enrollment forms, should be mailed or delivered to the following addresses:

Priority Mailing Address
Wisconsin Physicians Service
Medicare Provider Enrollment
1707 W. Broadway
Madison, WI 53713-1834
 
Wisconsin Physicians Service
Medicare Provider Enrollment
P.O. Box 8248
Madison, WI 53708-8248

Page Last Updated: Thursday, 05-Apr-2012 12:11:53 CDT