If you are credentialed with Palmetto GBA as a Medicare provider, you must notify Palmetto GBA within 30 days of any changes that occur within your practice location(s). These changes include but are not limited to:
- Any address change
- 'Pay to' address
- Email address
- Practice location
- Billing agency address
- Mailing address ('correspondence address')
- Medical specialty
- Telephone number
- Potential change/termination of current ownership
- Authorized/delegated officials
- Fax number
- Deactivation of Medicare billing numbers (such as a provider that has retired or left a group)
- Contact person
- Billing agency
All changes must be submitted on the CMS-855B or CMS 855-I application.
Please Note: Failure to notify our office of these important changes may delay the reimbursement and issuance of checks and Remittance Advice statements (both electronic and paper).
Options for submitting changes:
- Complete an online application
- Update or enroll using Internet-based PECOS as an alternative to submitting paper applications. Refer to the CMS website for more details and to access the online system. The two-page Certification Statement must be mailed to Palmetto GBA within seven days of your electronic submission.
- Download and submit on paper
- CMS 855B (PDF, 641 KB): Application for Health Care Suppliers that will Bill Medicare Carriers (including group practices)
- CMS 855I (PDF, 496 KB): Application for Individual Health Care Practitioners.
- Mail completed applications to:
Palmetto GBA-J11 MAC
Part B Provider Enrollment
Mail Code AG-310
P.O. Box 100190
Columbia, SC 29202-3190