The application collects 3 addresses. 1) Correspondence Address (Section 2.C)All the correspondence sent from Palmetto GBA will be sent to this address.
2) Practice Location (Physical Location) (Section 4.A)Physical location of the provider should be listed in this section.
3) Pay To Address (Section 4.F)Hard copy checks and remittance advices will be sent to this address.
If all three addresses are impacted by the change and the address is the same for all three addresses, you must still complete each section. Special Note ' Pay to Address - If the pay to address is changing and the provider does not have an entire CMS 855A on file, then CMS requires that the entire CMS 855A application be completed. Medicare began using this form (or its predecessor the HCFA 855) to enroll providers in October 1997. Providers certified prior to October 1997 would not have an application on file, unless the provider has gone through a change of ownership since October 1997.
Special Note EFT Change ' A change in the Electronic Funds Transfer (EFT) is considered a change in the pay to address. To process an EFT change, a complete CMS 855A must be on file. The authorizing signature on the EFT form must agree to the signature on the CMS 855A. CMS 855A Instructions (CMS 855A is ON FILE.)Type of Change Correspondence Address CMS 855A Sections RequiredSection 1.A.1, (Mark Change of Information and the section being changed) 1.A.2, 1.A.3
Section 2.C (Mark the Change Box and list the effective date of the change.)
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Physical LocationCMS 855A Sections RequiredSection 1 (A.1, A.2, A.3)
Section 4.A (Mark the Change Box and list the effective date of the change
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Pay To AddressCMS 855A Sections RequiredSection 1 (A.1, A.2, A.3)
Section 4.F (Mark the Change Box and list the effective date of the change
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Actions Taken By IntermediaryIntermediary will update claims system. Providers will receive a confirmation letter notifying them that the address has been changed. State agencies will be notified by copy of this letter of physical location address changes. All other address changes are not communicated to the state agency.
CMS 855A Instructions (CMS 855A NOT on file.)Correspondence AddressCMS 855A Sections RequiredSection 1.A.1, (Mark Change of Information and the section being changed) 1.A.2, 1.A.3
Section 2.C (Mark the Change Box and list the effective date of the change.)
Section 6
(Because no application is on file, section 6 must be submitted for the authorized representative.)
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Physical LocationCMS 855A Sections RequiredSection 1 (A.1, A.2, A.3)
Section 4.A (Mark the Change Box and list the effective date of the change
Section 6
(Because no application is on file, section 6 must be submitted for the authorized representative.)
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Pay To Address ' including EFT changesCMS 855A Sections RequiredAll Sections must be addressed except ' Section 9,11&12
In Section 1.A.1 ' Please select Initial Enrollment to identify application as first submission and put in parenthesis pay to address change.
Supporting DocumentationAlso refer to Section 17 (Attachments) ' The supporting documentation needed for processing is:
Copy of License to render services if required.
IRS Document confirming tax ID.
Adverse Legal Action Documentation (if applicable)
Partnership agreement (If applicable)
Articles of Incorporation (If applicable)
Actions Taken By IntermediaryIntermediary will update the systems. Providers will receive a confirmation letter notifying them that the address has been changed. State agencies will be notified by copy of this letter of physical location address changes. All other address changes are not communicated to the state agency.
Electronic Funds TransfersOnce the provider enrollment area has verified the information provided on the CMS 855, the EFT forms are forwarded to the Finance and Accounting Department. The Finance and Accounting Department performs a pre-notification test to ensure that the bank information is accurate. This process takes approximately two weeks. During this two-week period, the provider will receive hard copy checks at the address listed on the pay to address. Finance and Accounting will send a letter to the provider to notify them of the effective date of the EFT. Please obtain the EFT forms, please refer to the provider enrollment section of the Palmetto GBA web site and access,
'Part A & RHHI Electronic Funds Transfer (EFT) Enrollment Packet'.