Reporting Address Changes and Other Changes of Information
Medicare Part B providers and suppliers are required to report all changes in enrollment information, including address changes, to the Medicare carrier within 90 days of the effective date of the change.
Note: IDTF changes in ownership, changes of location, changes in general supervision, and adverse legal actions must be reported to the contractor via the CMS-855B within 30 calendar days of the change. All other changes to the IDTF's enrollment information must be reported within 90 calendar days.
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-855R: Reassignment of Medicare Benefits
You may print the electronic versions of these forms from the Centers for Medicare & Medicaid (CMS) Website:
http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp#TopOfPage 
The form(s) 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 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 or supplier reports the correct address information on the appropriate CMS 855 form.
CMS 855 enrollment forms should be mailed or delivered to the following addresses:
WPS Medicare Part B
Provider Enrollment Department
P.O. Box 8248
Madison, WI 53708-8248
Priority Delivery Address
WPS Medicare Part B
Provider Enrollment Department
1707 West Broadway
Madison, WI 53713-1834
Page Last Updated: Wednesday, 31-Dec-2008 10:48:52 CST
