Medicare Enrollment Application

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-855A Medicare Enrollment Application - Institutional Providers	Form and Instruction	Modified	Available
Form CMS-855(R) Medicare Enrollment Application -REASSIGNMENT OF MEDICARE BENEFITS	Form and Instruction	Modified	Available
Form CMS-855(I) Medicare Enrollment Application -Physicians and Non-Physician Practitioners	Form and Instruction	Modified	Available
Form CMS-855B Medicare Enrollment Application - Clinics/group Practices and Certain Other Suppliers	Form and Instruction	Modified	Available
CMS-855(A,B,I,R). Response to Public Comments (06282011).doc	Supplementary Document	Uploaded 2011-06-30	Available
CMS-855(A,B,I,R).Revised Supporting Statement Part A (06282011).doc	Supporting Statement A	Uploaded 2011-06-30	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8284	Medicare Enrollment Application	Form and Instruction	Modified	Medicare Enrollment Application - Institutional Providers
8284	Medicare Enrollment Application	Form and Instruction	Modified	Medicare Enrollment Application -REASSIGNMENT OF MEDICARE BENEFITS
8284	Medicare Enrollment Application	Form and Instruction	Modified	Medicare Enrollment Application -Physicians and Non-Physician Practitioners
8284	Medicare Enrollment Application	Form and Instruction	Modified	Medicare Enrollment Application - Clinics/group Practices and Certain Other Suppliers

ICR Details

OMB Control No: 0938-0685	ICR Reference No: 201105-0938-012
Status: Historical Active	Previous ICR Reference No: 200809-0938-014
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Enrollment Application
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/01/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/25/2011
Terms of Clearance: Approved for one year since CMS has advised that this collection will be revised in January. The approval currently extends only to the mode of collection (paper based form) contained in this request.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2012	36 Months From Approved	01/31/2012
Responses	429,450	0	400,000
Time Burden (Hours)	856,395	0	785,702
Cost Burden (Dollars)	0	0	0

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Abstract: CMS is revising the CMS-855 Medicare Enrollment Applications Package (OMB No. 0938-0685) to remove the CMS-855S application from its collection. CMS has found that the regulations governing the standards required of suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) are revised and increased more frequently than the other provider types reimbursed by Medicare. The ability to revise the CMS 855S separately from the other CMS 855 enrollment applications will lessen the burden on both CMS and OMB as well as the public during the Federal Register notice period, as only one subset of suppliers will be effected by CMS 855S revisions.

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Authorizing Statute(s): PL: Pub.L. 104 - 134 31001(I) Name of Law: Debt Collection Improvement Act of 1996
   US Code: 42 USC 1395f Name of Law: Conditions of and Limitations on Payment for Services
   PL: Pub.L. 105 - 33 4313 Name of Law: Provision of certain identification numbers
   US Code: 42 USC 1395g Name of Law: Payment to Providers of Services
   US Code: 42 USC 1395l Name of Law: Payment of Benefits
   US Code: 42 USC 1395u Name of Law: Provisions related to the Administration of Part B
   US Code: 42 USC 1395m Name of Law: SPECIAL PAYMENT RULES FOR PARTICULAR ITEMS AND SERVICES
   US Code: 42 USC 1395cc Name of Law: AGREEMENTS WITH PROVIDERS OF SERVICES; ENROLLMENT PROCESSES
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 13415	03/11/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 29247	05/20/2011
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Medicare Enrollment Application	CMS-855B, CMS-855(I), CMS-855(R), CMS-855A	Medicare Enrollment Application - Clinics/group Practices and Certain Other Suppliers ,   Medicare Enrollment Application -Physicians and Non-Physician Practitioners ,   Medicare Enrollment Application -REASSIGNMENT OF MEDICARE BENEFITS ,   Medicare Enrollment Application - Institutional Providers

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	429,450	400,000	0	29,450	0	0
Annual Time Burden (Hours)	856,395	785,702	0	70,693	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The currently approved total annual hour burden for respondents to the CMS-855A, CMS-855B, CMS-855I and CMS-855R is 785,702.3 hours. As outlined above, we estimate that the changes described in section 12 of this document will add 70,693 hours to this burden at a cost of $7,744,860. Therefore, the total hour burden for the respondents to the CMS-855A, CMS-855B, CMS-855I and CMS-855R is 856,395.3 hours. The group/clinic and individual burden has decreased due to the removal of a previously proposed supplier attachment. However, the overall burden hour estimate has increased slightly due to additional role-specific ownership and managerial control data collection for institutional providers.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 05/25/2011

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