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Reporting Changes of Information
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An 855A change of information should be submitted if you are changing, adding, or deleting information under your current tax identification number. In accordance with 42 C.F.R. 424.516(e), unless otherwise noted below, changes in your existing enrollment data must be reported to WPS GHA within 90 days of the effective date of the change.
Information changes to be reported include:
- Legal Business or Doing Business as Name - Section 2
- Change of Ownership - all sections must be submitted and must be reported within 30 days of the effective date of the change
- Adverse History - Section 3 must be reported within 30 days of the effective date
- Main Practice Location Change, to add an Additional Location or to Delete a Location - Section 4 - must be reported within 30 days of the effective date
- Ownership Interest or Managing Control Information - Section 5 for Entities, Section 6 for Individuals and Section 7 for Chain Home Office changes
- Billing Agency Information - Section 8
- Authorized or Delegated Officials - complete both a Section 6 and either a Section 15 or 16
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.
If you are already enrolled in Medicare and are not receiving Medicare payments via Electronic Funds Transfer (EFT), any change to your enrollment information will require you to submit a CMS-588 application. All future payments will then be made via EFT.
Changes must be reported by submitting the CMS-855A application form; completing the sections 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.
Most types of changes can be reported via the Internet-based Provider Enrollment Chain and Ownership System (PECOS). To learn more about Internet-based PECOS, visit the CMS website.
You may also print the electronic versions of these forms from the CMS website. These forms cannot be submitted electronically. They must be printed, signed, and mailed to WPS GHA.
Note: The U.S. Postal Service returns checks and remittance notices to WPS GHA 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:
Regular Mail | Overnight Delivery Mailing Address |
---|---|
WPS GHA Medicare Provider Enrollment P.O. Box 8248 Madison, WI 53708-8248 |
WPS GHA Medicare Provider Enrollment 1717 W. Broadway Madison, WI 53713-1834 |
An 855A change of information should be submitted if you are changing, adding, or deleting information under your current tax identification number. In accordance with 42 C.F.R. 424.516(e), unless otherwise noted below, changes in your existing enrollment data must be reported to WPS GHA within 90 days of the effective date of the change.
Information changes to be reported include:
- Legal Business or Doing Business as Name - Section 2
- Change of Ownership - all sections must be submitted and must be reported within 30 days of the effective date of the change
- Adverse History - Section 3 must be reported within 30 days of the effective date
- Main Practice Location Change, to add an Additional Location or to Delete a Location - Section 4 - must be reported within 30 days of the effective date
- Ownership Interest or Managing Control Information - Section 5 for Entities, Section 6 for Individuals and Section 7 for Chain Home Office changes
- Billing Agency Information - Section 8
- Authorized or Delegated Officials - complete both a Section 6 and either a Section 15 or 16
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.
If you are already enrolled in Medicare and are not receiving Medicare payments via Electronic Funds Transfer (EFT), any change to your enrollment information will require you to submit a CMS-588 application. All future payments will then be made via EFT.
Changes must be reported by submitting the CMS-855A application form; completing the sections 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.
Most types of changes can be reported via the Internet-based Provider Enrollment Chain and Ownership System (PECOS). To learn more about Internet-based PECOS, visit the CMS website.
You may also print the electronic versions of these forms from the CMS website. These forms cannot be submitted electronically. They must be printed, signed, and mailed to WPS GHA.
Note: The U.S. Postal Service returns checks and remittance notices to WPS GHA 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:
Regular Mail | Overnight Delivery Mailing Address |
---|---|
WPS GHA Medicare Provider Enrollment P.O. Box 8248 Madison, WI 53708-8248 |
WPS GHA Medicare Provider Enrollment 1717 W. Broadway Madison, WI 53713-1834 |
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, visit the CMS website.
You may also print the electronic versions of these forms from the CMS website. 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 GHA 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:
Regular Mail | Priority Mailing Address |
---|---|
WPS GHA Medicare Provider Enrollment P.O. Box 8248 Madison, WI 53708-8248 |
WPS GHA Medicare Provider Enrollment 1717 W. Broadway Madison, WI 53713-1834 |
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, visit the CMS website.
You may also print the electronic versions of these forms from the CMS website. 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 GHA 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:
Regular Mail | Priority Mailing Address |
---|---|
WPS GHA Medicare Provider Enrollment P.O. Box 8248 Madison, WI 53708-8248 |
WPS GHA Medicare Provider Enrollment 1717 W. Broadway Madison, WI 53713-1834 |
global-tags: J8A,J5A,Provider Enrollment,J8B,J5B,Change of Information
Need help?
Contact Us About Provider Enrollment
(866) 518-3285
7:00 AM - 5:00 PM CT, Monday - Friday
USPS Mailing Address
WPS GHA
Medicare Provider Enrollment
P.O. Box 8248
Madison, WI 53708-8248
Overnight Delivery
WPS GHA
Medicare Provider Enrollment
1717 W. Broadway
Madison, WI 53713-1834
(866) 234-7331
8:00 AM - 5:00 PM ET, Monday - Friday
USPS Mailing Address
WPS GHA
Medicare Provider Enrollment
P.O. Box 8248
Madison, WI 53708-8248
Overnight Delivery
WPS GHA
Medicare Provider Enrollment
1717 W. Broadway
Madison, WI 53713-1834
(866) 518-3285
7:00 AM - 5:00 PM CT, Monday - Friday
USPS Mailing Address
WPS GHA
Medicare Provider Enrollment
P.O. Box 8248
Madison, WI 53708-8248
Overnight Delivery
WPS GHA
Medicare Provider Enrollment
1717 W. Broadway
Madison, WI 53713-1834
(866) 234-7331
8:00 AM - 5:00 PM ET, Monday - Friday
USPS Mailing Address
WPS GHA
Medicare Provider Enrollment
P.O. Box 8248
Madison, WI 53708-8248
Overnight Delivery
WPS GHA
Medicare Provider Enrollment
1717 W. Broadway
Madison, WI 53713-1834
.
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- CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. IN NO EVENT SHALL CMS BE LIABLE FOR DIRECT, INDIRECT, SPECIAL, INCIDENTAL, OR CONSEQUENTIAL DAMAGES ARISING OUT OF THE USE OF SUCH INFORMATION OR MATERIAL.