Palmetto GBA
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Jurisdiction 11 Part B
Address Changes: Important Reminder

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
  • Name
  • 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 MAC
    Part B Provider Enrollment
    Mail Code AG-310
    P.O. Box 100190
    Columbia, SC  29202-3190


last updated on 05/01/2014
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