Provider Address Job Aid

Published 12/31/2020

This Provider Address job aid was created to assist Part A and home health and hospice providers in completing and understanding the address sections of the CMS-855A enrollment application. In the charts below you will find the CMS-855A address with each Palmetto GBA department.

 CMS-855A Address

(Corresponding Fiscal Intermediary Shared system [FISS] Address Field Title) 

  Palmetto GBA Department Mailings
CMS-855A: Section 2 C, Correspondence Address

(FISS: Other Address) 
  • Audit and Reimbursement: Rate Reviews / Payment Notification for Part A Providers, Periodic Interim Payment (PIP) Reviews for PIP Elected Hospitals and Hospices, hospice CAP Reviews, Cost Report Reminder Letters and Notifications for Late Cost Reports/First Demand Letters
  • Finance: Credit Balance Demand Letters, Credit Balance Late Notification Letters and Rejected Credit Balance Letters
  • Medical Affairs: LCD reconsideration request letters, coverage request letters, responses to Notice of Hearing (NOH) letters, non-cancer length of stay letters (NCLOS), Administrative Law Judge (ALJ) withdrawals, and ALJ position papers
  • Medical Review: Additional Documentation Requests (ADRs), CERT TIP Letters
  • Provider Contact Center: Inquiry Response Letters
  • Provider Enrollment: Revalidation Letters, Approval Letters, Electronic Funds Transfer (EFT) Letters
CMS-855A: Section 4 A, Practice Location Address

(FISS: Master Address)
  • Finance: Overpayment Demand Letters (All Contractors), Appeal Balance Due Letters, 935-Special Interest Letters, Appeal Acknowledgement Letters and Extended Repayment Schedule (ERS) Communication Letters
  • Provider Enrollment: Revocation Letters, Denial Letters
  • Benefit Integrity Unit: All Mailings

CMS-855A: Section 4 B, Remittance Notices or Special Payments Mailing Address

(FISS: Remit Address, Check Address)
  • Paper Remittance Notices or Special Payments
  • Appeals: Redetermination Notices, Dismissal Letters 
  • Finance: Refund Letters

 

Other Mailing Addresses 

  Palmetto GBA Department Mailings
Electronic Data Interchange (EDI) Department  Correspondence will be sent to the addresses listed on the EDI applications/agreements or currently on file with EDI Operations
Provider Enrollment: Application Processing Questions If questions arise during the processing of this application, the fee-for-service contractor will contact the individual shown in this section (if listed, email would be the primary method of contact) 

On the CMS-855A 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. It cannot be the address of a billing agency, management services organization, chain home office or the provider’s representative (e.g., attorney, financial advisor). It can, however, be a P.O. Box or, in the case of an individual practitioner, the person’s home address.
  • 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 4D, complete this section with the address of the storage location.
  • Section 4 D, Base of Operations Address for Mobile or Portable Providers: 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 C, Chain Home Office Information
  • Section 8, Billing Agency Address
  • Section 12 B, Contracted Nursing Registry for HHAs 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, Section 1 A: Organization with Ownership or Investment Interest in a Physician-Owned Hospital Address.

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