Change of Information Guide

Supplier Standard 2 requires suppliers to notify the NSC 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 NSC. 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 that will 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 file.

Common Sections for all Changes of Information (CMS-855S Version 05/16)

Section 1B  (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 1C (Reason for Submitting This Application)

Section 1D (What Information Is Changing?)

  • As instructed, check all that apply  

Section 7 (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 11 (Contact Person)
List the name and contact information of an individual the NSC analyst may contact to obtain additional information or to obtain clarification.

Section 15 - (Authorized Official Certification Statement) or 14 - (Delegated Official)
Signatures and dates must be original. If not original the CMS 855S will be returned.

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 
    • 7 Adverse Legal Actions 
    • 8 Organizational Ownership changes (complete section in its entirety)  
    • 9 Individual Ownership changes (complete section in its entirety)
  • Changes in Specialty/Products and Services 
    • 3A, 3C and 3D 
  • Voluntary Termination 
    • 1C (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
    • 1B and 4A

Please note that 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 file from being updated.

A.    Failure to respond to a development request within the 30-day time frame. If you do not respond timely, the updates will not be made and the supplier will be required to resubmit the request.

B.    Failure to list your NPI and provide a copy of the notification from the NPI enumerator. Per CMS, no enrollment documentation will be processed without the NPI information.

C.    Failure to provide current licenses.

D.    Omitting the original signature and date from your change of information.

Last Updated: 12/12/2016

File Attachment Icon
Sections Required to Change Billing Agency.pdf
File Attachment Icon
Sections Required to Change Payment Address.pdf
File Attachment Icon
Sections Required to Change the Current Business Location.pdf
File Attachment Icon
Sections Required to Change Specialties, Products or Services.pdf
File Attachment Icon
File Attachment Icon
Sections Required to Change Where Correspondence are Sent.pdf
File Attachment Icon
File Attachment Icon
File Attachment Icon
File Attachment Icon
File Attachment Icon
File Attachment Icon
File Attachment Icon
File Attachment Icon
Sections Required for All Changes of Information.pdf
File Attachment Icon
Sections Required to Change the Legal Business Name.pdf
File Attachment Icon
Sections Required to Voluntarily Terminate Billing Privileges.pdf