Change of Information Requirements

Anytime a provider is adding, deleting, or changing information under the same tax identification number for an existing provider number, the change must be reported via a submission of a CMS-855A application within 90 calendar days. Changes of information cannot be accepted by telephone call, on letterhead, or on a postal change of address form.

The provider should complete Section 1A to identify itself and indicate within Section 1B exactly what is changing. Report the changes within the appropriate sections(s) – these sections can be found referenced within the third column of Section 1B. Section 15 must be completed and signed by the appropriate Authorized Official. A current date is also required with each submission. The entire CMS 855A application does not need to be completed for changes of information being reported (the only exception to this rule would be if the change is pertaining to the Tax ID, indicating a change of ownership). In situations of changes of ownership, an entire application must be completed for the new entity.

Please note: the contractor may request additional information after receipt of your application.

The contractor is required to withhold all payments to an entity if the postal service returns mail as undeliverable. To avoid this situation, it is imperative that you report all address changes as soon as possible, preferably, prior to the move.

Changes of Ownership

If you have sold your facility, changed ownership, or transferred stock, you must submit a CMS 855A application within 30 calendar days. For a CHOW in accordance with 42 CFR 489.18, the current/selling owner should check the “Change of Ownership” box in Section 1A and complete the following sections:

Seller/Former Owner - must submit 1A, 2F, 13, and either 15, or 16. Please note: A section 6 will be required of the person signing the application if we do not currently have one on file for this individual.

Buyer/New Owner - must submit an ENTIRE application except for sections 2G and 2H.

All Acquisitions, Mergers, and Consolidations are also reported in the same manner. Note: The acquiring provider is always required to submit an application for enrollment.

If the acquiring entity accepts the assignment of the Provider Agreement, there is no lapse in Medicare certification/billing. However, the acquiring entity would be accepting all assets and liabilities regardless of the terms of agreement. All payments, collections, and/or suspensions pertaining to the Medicare program become the inherited issues of the new owners. There is no distinction between which entity actually owned the provider number during the period of the debt becoming due. The debt will still be owed.

Terminations

In order to process a termination of a Medicare number, there are several steps that must be taken:

• You must first get in contact with your state representative in order to determine what their requirements are prior to contacting Medicare when terminating a number (i.e., notice of the termination in the local newspaper for 3 days prior to termination). Please note: this requirement does not apply to Federally Qualified Health Centers.
• You must submit a CMS-855A application indicating the date of requested termination.