Change of Information Guide

Supplier Standard 2 requires suppliers to notify the NPE West of any change to the information provided on the CMS 855S or as reported in Internet-based PECOS within 30 days of the change. Therefore, if you have added or stopped providing a specialty, product or service; moved to a new location; or made changes to your ownership, you must notify the NPE West. Failure to do so may result in the revocation of your billing privileges and/or overpayments.

Change in Products or Services
If a supplier is adding products or services to be provided to a Medicare beneficiary state required licenses should be submitted along with the CMS 855S. This indicates compliance with state and federal regulations with regard to the new specialty, product or service (Supplier Standard 1).

Information as to what licenses are required is available under Licensure Information. The licensure information should only be used as a guide. Federal and state agencies have the final authority to determine what licenses are required. Suppliers are responsible for ensuring they have all the licenses required to operate their business.

Listed below are the common sections for making changes to a supplier enrollment.

Common Sections for all Changes of Information (CMS 855S)

Section 1A (Reason for Submitting This Application)

Section 1B (What Information Is Changing?)

  • As instructed, check all that apply  

Section 2B (Business Identification)

  • List the supplier’s legal business name (LBN) 
  • List the NPI   
  • List the Tax Identification Number (TIN) 
  • List the Supplier Billing Number (PTAN)

Section 3 (Adverse Legal Actions/Convictions)
Review the information in this section and check the appropriate box. Do not leave this section blank. If the section does not apply, check 'No'. If you need to report any actions, check 'Yes' and provide the required information.

Section 13 (Contact Person)
List the name and contact information of an individual the NPE West analyst may contact to obtain additional information or to obtain clarification.

Section 15B - (Authorized Official Certification Statement) or 15D - (Delegated Official)
Include signatures and dates. Signatures cannot be stamped for paper applications.

Required Sections
See below the change of information guidelines for common changes to be made on the CMS 855S enrollment application. These sections should be completed in addition to the sections completed for all changes of information as listed above.

  • Changes of Address
    • 2A1 to update supplier’s business location information to phone number, fax number, email address, and hours of operation 
    • 4A 1099 Mailing Address 
    • 4B Correspondence Mailing Address 
    • 4C Revalidation Package Mailing Address
    • 4D Remittance Notices/Special Payments Mailing Address 
    • 4E Records Storage Address 
  • Changes In Ownership 
    • 3 Adverse Legal Actions 
    • 5 Organizational Ownership changes (complete section in its entirety)  
    • 6 Individual Ownership changes (complete section in its entirety)
  • Changes in Specialty/Products and Services 
    • 2E Products And Accreditation Information 
  • Voluntary Termination 
    • 1A (indicate effective date of termination) 
    • 4 (If the business location is closing, you may also need to submit this section to update appropriate mailing address or addresses.)  
  • Change of Legal Business Name
    • 2B and 4A

Please note in order to update the legal business name a copy of an official document from the IRS must be submitted verifying the name in Section 4A.

Reasons for Delays in Processing
Listed below are some reasons for delays in processing the change of information or that may prevent your supplier enrollment from being updated.

A.    Failure to respond to a development request within the 30-day time frame. You have a 30-day timeframe, or the request will be closed resulting in deactivation of Medicare billing privileges or rejection.

B.    Failure to provide current licenses.

C.    Omitting the signature and date from your change of information.

Last Updated: 05/23/2022