Reporting Address Changes and Other 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); 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 within 30 days of their effective date may result in revocation of 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) 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); 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-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 
.
The form(s) cannot be submitted electronically. They must be printed, signed, and mailed to us.
You may also report most types of changes or enroll via the Internet-based Provider Enrollment Chain and Ownership System (PECOS). To report changes or apply for enrollment via the Internet-based PECOS, go to: http://www.cms.hhs.gov/MedicareProviderSupEnroll/ .
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, based on the state in which services are provided.
| State | Mailing/Delivery Address | Telephone Number |
|
Wisconsin Illinois Michigan |
Mailing Address: Wisconsin Physicians Service Medicare Part B Provider Enrollment Department P.O. Box 8248 Madison, WI 53708-8248 Courier Delivery Address: Wisconsin Physicians Service Medicare Part B Provider Enrollment Department 1707 West Broadway Madison WI 53713 |
(877) 908-8476 |
| Minnesota |
Mailing and Delivery Address: Wisconsin Physicians Service Medicare Part B Provider Enrollment Department 8120 Penn Avenue South Suite 200 Bloomington, MN 55431-1394 |
(866) 564-0315 |
Page Last Updated: Wednesday, 17-Feb-2010 14:29:11 CST
