CMS Pub. 100-08, ch. 10, § 10.4.4

A. General Information

Unless as stated otherwise in this chapter, the following apply:

(i) The instructions in this section 10.4.4 apply to Part A and Part B enrollments.

(ii) In the event an instruction in sections 10.6.1 et seq. or 10.6.22 et seq. of this chapter

contradicts that in this section 10.4.4, the section 10.6.1 et seq. or 10.6.22 et seq. guidance takes

precedence (e.g., transitioned certified provider/supplier change of information instructions in

section 10.6.1.2 of this chapter).

(iii) Except as otherwise specified in this chapter or another CMS directive, if an enrolled

provider/supplier is adding, deleting, or changing information under its existing tax identification

number, it must report the change using the applicable Form CMS-855 or CMS-20134.

(Letterhead is impermissible.) The provider/supplier shall: (a) furnish the changed data in the

applicable section(s) of the form; and (b) sign and date the certification statement.

(iv) The timeframes for reporting changes are generally addressed in § 424.516.

B. Time Requirements to Report Changes of Information via a Form CMS-855/20134

Application

(For purposes of the regulatory provisions referenced in this section 10.4.4(B) (e.g., §

424.57(c)(2)):

• A practice location “change” includes location additions, deletions, and relocations.

• All practice location changes – regardless of the provider or supplier type involved –

must be reported within 30 days of the change.)

• All adverse legal action additions/changes – regardless of the provider or supplier type

involved -- must be reported within 30 days of the change.

1. Physicians/Non-Physicians/Groups

Pursuant to § 424.516(d), change of information requirements apply to physicians, non-physician

practitioners, and physician and non-physician practitioner organizations (i.e., clinic/group

practices). These supplier types must report the following changes within 30 days: (1) a change

of ownership; (2) adverse legal action; and (3) a change in practice location. All other changes

must be reported within 90 days.

2. DMEPOS Suppliers

Per 42 CFR §§ 424.57(c)(2) and 424.516(c), DMEPOS suppliers must report any change to their

enrollment information within 30 days.

3. IDTFs

Per 42 CFR §§ 410.33(g)(2) and 424.516(b), IDTFs must report any change in adverse legal

actions, ownership, location, and general supervision within 30 days. All other changes must be

reported within 90 days.

4. MDPP Suppliers

Per 42 CFR §§ 424.205(d)(5) and 424.516(e), an MDPP supplier must update its enrollment

application within 30 days of any change of ownership, practice location, change to its coach

roster (including due to coach ineligibility or because the coach is no longer an employee,

contractor, or volunteer of the MDPP supplier), or change in final adverse action history. All

other changes must be reported within 90 days.

5. All Other Provider/Supplier Types

Consistent with 42 CFR § 424.516(e), all other provider/supplier types not specifically

referenced in § 424.516(b) through (e) are subject to the following reporting timeframes:

(i) Changes of ownership or control (including changes in authorized official(s) or delegated

official(s)); change of practice location; and adverse legal action additions/changes – 30 days

(ii) All other changes – 90 days

(In addition, and per § 424.516(e)(3), an air ambulance supplier must report a revocation or

suspension of its license or certification to the contractor within 30 days of the

revocation/suspension. The following FAA certifications must be reported: (a) specific pilot

certifications including, but not limited to, instrument and medical certifications; and (b)

airworthiness certification.)

C. Signatories and Notifications

1. Signer Not on Record - If the signer has never been reported in Section 6 of the Form

CMS-855 or CMS-20134, Section 6 must be completed in full with information about the

individual. (This policy applies regardless of whether the provider/supplier already has a Form

CMS-855/20134 on file.) The contractor shall conduct all required validations concerning the

individual.

2. Notifications – For changes of information that do not require state agency or SOG

Location approval (e.g., Form CMS-855I changes, Form CMS-855B changes not involving

ambulatory surgical centers or portable x-ray suppliers, minor Form CMS-855A/B certified

provider/supplier changes), the contractor shall:

(i) Furnish written, e-mail, PCV, or fax confirmation to the provider that the change has

been made; and

(ii) Document PECOS (per sections 10.3 and 10.6.19 of this chapter) with the date and time

the confirmation was made. If, however, the transaction only involves an area code/ZIP code

change, the contractor need not send confirmation to the provider that it has processed the

change.

3. Confirmation of Change in Practice Location Address

In cases where a provider submits a Form CMS-855 or Form CMS-20134 request to change its

practice location address, the contractor shall contact the location currently associated with the

provider in PECOS or MCS to verify that the provider/supplier is no longer there and did in fact

move.

D. Change in Special Payments Address

Note that the instructions in this subsection (D) are in addition to, and not in lieu of, those in

section 10.6.23 and vice versa.

1. Submitted Change - If the provider/supplier submits a change to its special payments address,

the contractor shall verify the change by contacting the individual physician/practitioner (Form

CMS-855I changes), an authorized or delegated official (Form CMS-855A, Form CMS-855B,

and Form CMS-20134 changes), or the contact person listed in Section 13 (for Form CMS-855A,

Form CMS-855B, Form CMS-20134, and Form CMS-855I changes). If the contractor cannot

reach, as applicable, the individual physician/practitioner or an authorized or delegated official, it

shall confirm the change with the contact person.

2. Revalidation - When processing a revalidation application, the contractor shall (unless

another CMS directive instructs otherwise) follow the instructions in sections 10.4.4(D) and

10.4.4(C)(3) above, respectively, if the practice location address or special payment address on

the application is different from that currently associated with the provider in PECOS or MCS.

E. Provider or Supplier Changing Specialty Type

With the exception of individual physicians and certain situations described in section 10.3 of

this chapter, providers and suppliers who wish to change their enrolled provider/supplier type

must terminate their current enrollment and submit an initial enrollment application (Screening

and an application fee (if applicable) applies for the new enrollment.)

F. Changes Involving Complete Form CMS-855 or CMS-20134 Applications

A provider must submit a complete Form CMS-855 or CMS-20134 application if it (1) submits

any change request and (2) does not have an established enrollment record in PECOS. (For

purposes of this requirement, the term “change request” includes EFT changes.) It is immaterial

whether: (1) the provider or another party (e.g., local government changes street name) was

responsible for triggering the changed data; or (2) the signer of the change request or EFT form

already has a signature on file with the contractor.

If the contractor receives a change request from a provider that is not in PECOS, the contractor

shall develop for the entire application consistent with the procedures described in this chapter

(i.e., the contractor shall treat the transaction as a request for additional information). Consistent

with existing policies for requesting additional data, the provider has 30 calendar days from the

date of the contractor’s request to furnish a complete Form CMS-855 or CMS-20134. During

this period, the contractor should “hold” (i.e., not process) the change request until the entire

application arrives; no L & T record shall be created in PECOS at this point.

If the provider fails to submit a complete application within the aforementioned 30-day period,

the contractor shall follow the instructions in section 10.4.1.4.3 of this chapter.

If the provider submits the application, the contractor shall process it in accordance with the

instructions in this chapter and all other applicable CMS directives. This includes:

(i) Processing the complete application consistent with the timeframes for initial applications

outlined in this chapter.

(ii) Validate all data elements on the Form CMS-855 or CMS-20134 consistent with the

instructions in this chapter pertaining to initial applications. The contractor shall not approve the

change request until it has verified all data on the complete Form CMS-855 or CMS-20134

consistent with the instructions in this chapter.

(iii) Creating a record in PECOS prior to approving the change request. (The receipt date

should be the date on which the complete application was received, not the date on which the

initial change request was received.) The transaction should be treated as an initial enrollment in

PECOS; internally, the contractor shall treat it as a change of information. As the complete

application will presumably incorporate the changed data reported on the original Form CMS-

855 or CMS-20134 change request, the contractor shall not take two separate counts (one initial

and one change request) for the transaction. (NOTE: Any PECOS 2.0 policies or procedures that

are contrary to those in this subparagraph (iii) take precedence over the latter.)

G. Incomplete or Unverifiable Changes of Information

(The contractor shall follow the instructions in this section 10.4.4(G) if it cannot process the

submitted change request to completion.)

There can be instances where a provider has an enrollment record in PECOS and submits a

change request but: (1) fails to timely respond to the contractor’s request for additional or

clarifying information; or (2) the changed information cannot be validated. The contractor in

these situations shall reject the change request in accordance with section 10.4.1.4.3 of this

chapter. Moreover, if the changed information is of such materiality that the contractor cannot

determine whether the provider still meets all enrollment requirements, the contractor shall refer

the matter to its PEOG BFL for guidance. Examples include but are not limited to: (i) change in

the provider’s lone practice location; (ii) change in ownership; or (iii) change in EFT

information.

H. Change of EFT Information

(Note that the instructions in this subsection (H) are in addition to, and not in lieu, those in

section 10.6.23 and vice versa.)

If the provider submits a Form CMS-588 request to change the bank name, depository routing

transit number, or depository account number, the contractor shall contact the individual

physician/practitioner (for Form CMS-855I enrollees), an authorized or delegated official on

record (for Form CMS-855A, CMS-855B, and Form CMS-20134 enrollees), or the Section 13

contact person on record (for Form CMS-855A, Form CMS-855B, Form CMS-20134 and Form

CMS-855I enrollees) to verify the change. If the contractor cannot reach, as applicable, the

individual physician/practitioner or an authorized or delegated official, it shall confirm the

change with the contact person.

I. Special Instructions for Certified Providers, ASCs, and Portable X-ray Suppliers

1. Timeframe for State Review

In situations where state and/or SOG Location review of the change of information is required

(see sections 10.6.1.2 and 10.6.22.1), the contractor may (via any means) advise the provider that

it may take several months for the request to be approved.

2. Post-Recommendation Changes

If an applicant submits a change request after the contractor recommends approval of the

provider’s initial Form CMS-855 application but before the state or SOG Location (as

applicable) notifies the contractor that, respectively, it recommends approval of or approves the

initial application, the contractor shall process the newly submitted data as a separate change of

information. The contractor shall not take the changed information/corrected pages and,

immediately upon receipt, send them directly to the state/SOG Location for incorporation into

the existing application.

In entering the change request into PECOS, the contractor shall use the date on which it received

the change request in its mailroom as the actual receipt date in PECOS; the contractor shall not

use the date on which the contractor received the aforementioned state/SOG Location

approval/recommendation. The contractor shall explain the situation in PECOS.

J. Critical Access Hospital (CAH) Addition of New Provider-Based Locations

Regulations found at 42 CFR § 485.610(e)(2) and in the State Operations Manual state that the

CAH’s provider-based location must meet certain distance requirements from the main campus

of another hospital or CAH.

The contractor shall contact the appropriate SOG Location while processing the Form CMS-

855A to verify that the CAH’s new provider-based location is more than 35 miles (15 miles in

the case of mountainous terrain or an area with only secondary roads) from the main campus of

another hospital or CAH. The contractor may not make a recommendation for approval without

receiving a response from the SOG Location.

If the SOG Location finds that CAH’s new provider-based location meets the distance

requirements, the contractor shall continue processing the application normally. If the SOG

Location determines that the location does not meet the distance requirements, the contractor

shall reject the application and issue to the CAH the applicable rejection letter outlined in section

10.7 et seq.

The SOG Location will provide the CAH with three options if the location does not meet the

distance requirements:

1. The CAH keeps the new provider-based location, which will cause an involuntary termination

in 90 days (as outlined in the Pub. 100-07, chapter 3, section 3012).

2. The CAH terminates the new provider-based location and continue its enrollment as a CAH.

3. The CAH keeps the new provider-based location but converts to a hospital (as outlined in Pub.

100-07, chapter 2, sections 2256G and 2256H).

For each option, the contractor shall keep the CAH’s enrollment in an approved status in

PECOS. For Option #1 above, the contractor will receive notice from the SOG Location of the

termination, which will lead to revocation of the CAH’s enrollment. For Option #2, the CAH’s

enrollment remains approved and the contractor shall expect no further communication from the

SOG Location. If the CAH chooses Option #3 to convert to a hospital, the contractor will receive

a Form CMS-855A to terminate the CAH’s enrollment and a new Form CMS-855A to enroll as a

hospital.