Type of Change
Adding a Billing Agent
CMS 855A Sections Required
Section 1 (A.1,A.2,A.3)
Section 6 (for authorized representative, if no application is on file.)
Section 8 Select "Add" and provide the effective date. Complete this section in its entirety.
Section 15
Type of Change
Changing a Billing Agent
CMS 855A Sections Required
Section 1 (A.1,A.2,A.3)
Section 6 (for authorized representative, if no application is on file.)
Section 8 Select "Change" and provide the effective date. Complete only the fields that are changing.
Section 15
Type of Change
Deleting a Billing Agent
CMS 855A Sections Required
Section 1 (A.1,A.2,A.3)
Section 6 (for authorized representative, if no application is on file.)
Section 8 Select "Delete" and provide the effective date. Complete 8.B.1.
Section 15
Supporting Documentation
The intermediary may request a copy of the billing agreement. You do not have to submit the agreement in with the application.
Actions Taken By Intermediary
Providers will receive a confirmation letter notifying them that the billing agent information has been changed.
Please note you will need to contact the EDI/EMC Helpline at 866.749.4301 to change/add/delete a submitter ID's for claims submission.