Provider Address Job Aid

This job was created to assist Part B providers in completing and understanding the address sections of the CMS-855B enrollment application. In the charts below, you will find the CMS-855B address with each Palmetto GBA department.

On the CMS-855B Enrollment Application, the address sections are:

• Section 2 C, Correspondence Address: The correspondence address must be one where the Medicare Administrative Contractor (MAC) can directly contact the applicant to resolve any issues once the provider or supplier is enrolled in the Medicare program. The address can be a P.O. Box or, in the case of an individual practitioner, the person’s home address may be used. The address cannot belong to a billing agency, management services organization, chain home office, or the provider’s representative (i.e attorney, financial advisor, and etc.)
• Section 4 A, Practice Location Address: Report all practice locations where services will be furnished. If there is more than one location, copy and complete this section for each. Please list your primary practice location first.
• Section 4 B, Remittance Notices or Special Payments Mailing Address: Since payment will be made by EFT, the 'Special Payments' address will indicate where all other payment information (e.g., remittance notices, special payments) are sent
• Section 4 C, Patients’ Medical Records Address: If you store patients’ medical records (current and/or former patients) at a location other than the location in Section 4A or 4E, complete this section with the address of the storage location
• Section 4 D, Rendering Services in Patients’ Homes:  If you are changing, adding, or deleting information, check the applicable box, furnish the effective date and complete the appropriate fields in this section
• Section 4 E, Base of Operations Address for Mobile or Portable Suppliers (Location of Business Office or Dispatcher/Scheduler):  The base of operations is the location from where personnel are dispatched, where mobile/portable equipment is stored, and when applicable, where vehicles are parked when not in use
• Section 5 A , Ownership/Managing Control Organization Address
• Section 7, For Future Use (This section not applicable)
• Section 8, Billing Agency Address
• Section 13, Application Contact Person Address: If questions arise during the processing of this application, the fee-for-service contractor will contact the individual shown in this section
• Attachment 1, Geographic Area:  Complete this section with information about the geographic areas in which the company provides ambulance services
• Attachment 2, Independent Diagnostic Testing Facilities (IDTF):  If a practice performs diagnostic tests, other than clinical laboratory or pathology tests, and are required to enroll as an IDRF, the practice must complete Attachment 2