Providers may expand their operations by adding an additional location to their parent provider.
Type of Change
Adding/Deleting Branch Office (Services will be billed under the parent provider's Medicare number)
When adding a branch office, the state agency will make the final determination if the branch office meets the qualifications of a branch office. Prior to submitting the CMS 855A, contact the state agency to inform them of the provider's plans to expand operations.
CMS 855A Sections Required
Section 1 (A.1, A.2.,A.3)
Section 4.A. Check Add/Delete Box and provide the effective date. Complete Section
Section 6 (for authorized representative, if no application is on file)
Section 15
Type of Change
Adding a Provider-Based Clinic (Hospitals only)
CMS 855A Sections Required
Section 1 (A.1, A.2.,A.3)
Section 2 (A.1, A.2, A.3)
Section 4.A.
Section 6 (for authorized representative, if no application is on file.)
Section 15
Provider also needs to submit a CMS 855B to the appropriate the Carrier to obtain a Part B billing number. If clinic is provider-based, please refer to the provider-based instructions provided in the provider enrollment section of the Palmetto GBA web site.
Type of Change
Hospice Satellite Office
CMS 855A Sections Required
No CMS 855A is required. Contact state agency to determine state notification requirements.
Actions Taken by Intermediary
Providers will receive a confirmation letter notifying them of the new location. State agencies will be notified by copy of this letter and a copy of the enrollment application.