Reporting a Change in Provider Status
Providers are responsible for notifying Medicaid when information related to their business or practice changes. How a change is reported to Medicaid depends on the type of change that is being reported.
- All forms must be signed by the individual provider or, for a group, the authorized agent.
- Changes submitted using the Medicaid Provider Change Form (62 KB PDF) may be submitted by mail or fax.
- Changes that require the submittal of a new Provider Enrollment Packet, Enrollment Addendum, or new Provider Participation Agreement must be submitted by mail because an original signature is required.
Additional Documentation Required for a Site Address Change
Documentation Required for Individuals Reporting a Name Change
| Type of Change | Submit the following | |
|---|---|---|
| 1 | For changes to your Carolina ACCESS practice (change in contact person's name, after-hours telephone number, restriction information, enrollment limits, counties served) | Medicaid Provider Change Form(62 KB PDF) |
| 2 | For changes to your National Provider Number | Medicaid Provider Change Form (62 KB PDF) with a copy the NPPES Letter attached to the form |
| 3 | For CLIA recertification | Medicaid Provider Change Form (62 KB PDF) with a copy of your new certificate attached to the form |
| 4 | For voluntary participation termination | Medicaid Provider Change Form (62 KB PDF) with a notification letter on your letterhead attached to the form |
| 5 | For bed capacity changes | Medicaid Provider Change Form (62 KB PDF) with a copy your new license attached to the form |
| 6 | For changes to your billing contact information or site (physical location) contact information (telephone number, fax number, e-mail) | Medicaid Provider Change Form (62 KB PDF) |
| 7 | For changes to your billing address | Medicaid Provider Change Form (62 KB PDF) |
| 8 | For changes to your site (physical location) address |
|
| 9 | To add a site | A new Provider Enrollment Packet |
| 10 | To add or delete an individual to your group |
|
| 11 | For group name/tax name changes | A new Provider Enrollment Packet |
| 12 | For individual name/tax name/tax number changes |
|
| 13 | For group tax number changes | A new Provider Enrollment Packet |
| 14 | For a change in ownership | A new Provider Enrollment Packet |
| 15 | For Residential Child Care Treatment Facility treatment level changes | Medicaid Provider Change Form (62 KB PDF) with a copy your new license and Letter of Endorsement attached to the form |
| 16 | Federally Qualified Health Center Providers Rural Health Clinic Providers - To add a new service to the services you are currently enrolled to provide |
A new Provider Enrollment Packet |
| 17 | Community Alternatives Program Providers - To add a new service to the services you are currently enrolled to provide | Complete an Add a CAP Service application. |
| 18 | Community Intervention Service Providers - To add a new service to the services you are currently enrolled to provide | Complete an Add a CIS Service application. |
Additional Documentation Required for a Site Address Change
| Provider Type | Required Documentation |
|---|---|
| Adult Care Homes | New License |
| Ambulance Services | New License |
| Ambulatory Surgery Centers | New CMS Approval Letter |
| At Risk Case Management | New Certification |
| Birthing Centers | New Certification |
| Certified Registered Nurse Anesthetists, Individuals | New License and New CMS Approval Letter |
| Community Alternatives Programs (CAP/C, CAP/DA, CAP/Choice) | Applicable Accreditation/Licensure |
| Community Alternatives Programs (CAP/MR-DD) | Applicable Accreditation/Licensure/Endorsement |
| Community Intervention Services | Applicable Accreditation/Licensure/Endorsement |
| Dental Providers, Individuals | New License |
| Dialysis Centers | New CMS Approval Letter |
| Durable Medical Equipment | New Permit New CMS Approval Letter |
| Federally Qualified Health Centers | New CMS Approval Letter |
| Free-standing Independent Laboratories | New Certification |
| Hearing Aid Providers | New License |
| HIV Case Management | New Certification |
| Home Infusion Therapy Providers | New License |
| Home Health Services | New License and New CMS Approval Letter |
| Hospice Services | New License and New CMS Approval Letter |
| Hospitals | New CMS Approval Letter |
| Hospitals, Critical Access | New CMS Approval Letter |
| ICF/MR Providers | New License |
| Independent Diagnostic Testing Facility | New CMS Approval Letter |
| Independent Practitioners, Individuals | New Certification |
| Maternity Care Coordination Services | New Certification |
| Nurse Midwives, Individual | New License |
| Nurse Practitioner (non-mental health), Individuals | New License |
| Nursing Facility Services | New CMS Approval Letter |
| Orthotics and Prosthetics Providers | New Certification |
| Outpatient Mental Health Providers, Individuals | Applicable Accreditation/Licensure/Endorsement |
| Personal Care Services | New License |
| Pharmacies | New Permit |
| Physicians, Individuals | New License |
| Portable X-ray Services | New License |
| Private Duty Nursing | New License |
| Psychiatric Hospitals | New License and New CMS Approval Letter |
| Psychiatric Residential Treatment Facilities | New License |
| Residential Child Care Facilities | New License |
| Rural Health Clinics | New CMS Approval Letter |
Documentation Required for Individuals Reporting a Name Change
| Provider Type | Required Documentation |
|---|---|
| Certified Registered Nurse Anesthetists | New License, New Certification, and New CMS Approval Letter |
| Dentists | New License |
| Independent Practitioners | New Certification |
| Nurse Midwives | New License and New Certification |
| Nurse Practitioners | New License and New Certification |
| Orthotics and Prosthetics Providers | New Certification |
| Outpatient Mental Health Providers | Applicable Accreditation/Licensure |
| Physicians | New License |