Medicare Enrollment Application for Eligible Ordering and Referring Physicians and Non-physician Practitioners- CMS 855O

Forms and Documents

Document Name	Status
Form CMS-855(O) Change of Information Application Form and Instruction	New
Form CMS-855(O) Initial Application Form and Instruction	New
CMS-855O - Responses to Public Comments - 06282011.doc Supplementary Document	2011-06-30
CMS-855(O).SupportingStatementPart-A(05162011).doc Supporting Statement A	2011-05-25

IC Document Collections

IC ID	Document Title	Status
197862	Change of Information Application Form and Instruction	New
197861	Initial Application Form and Instruction	New

ICR Details

OMB Control No: 0938-1135	ICR Reference No: 201105-0938-013
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Enrollment Application for Eligible Ordering and Referring Physicians and Non-physician Practitioners- CMS 855O
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/01/2011
	Date Received in OIRA: 05/26/2011
Terms of Clearance: Approved for one year since CMS has advised that further revisions to this form will be made in January. The approval currently extends only to the mode of collection (paper based form) contained in this request.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2012	36 Months From Approved
Responses	48,000	0	0
Time Burden (Hours)	46,000	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The publication of the Patient Protection and Affordable Care Act (PPACA), section 6405 - "Physicians Who Order Items or Services Required to be Medicare Enrolled Physicians or Eligible Professionals" (regulation CMS 6010-F), contains a requirement for certain physicians and non-physician practitioners to enroll in the Medicare program for the sole purpose of ordering or referring items or services for Medicare beneficiaries. The PPACA has an effective date applicable to written orders and certifications made on or after July 1, 2010. The CMS 855O allows a physician to receive a Medicare identification number (without being approved for billing privileges) for the sole purpose of ordering and referring Medicare beneficiaries to Medicare approved providers and suppliers. This new Medicare application form allows physicians who do not provide services to Medicare beneficiaries to be given a Medicare identification number without having to supply all the data required for the submission of Medicare claims. It also allows the Medicare program to identify ordering and referring physicians without having to validate the amount of data necessary to determine claims payment eligibility (such as banking information), while continuing to identify the physician's credentials as valid for ordering and referring purposes.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 6405 Name of Law: Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 6405 Name of Law: Affordable Care Act

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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: 2

IC Title	Form No.	Form Name
Change of Information Application	CMS-855(O)	Medicare Enrollment Application - fOr EligiblE OrdEring and rEfErringPhySiCianS and nOn-PhySiCian PraCtitiOnErS
Initial Application	CMS-855(O)	Medicare Enrollment Application - fOr EligiblE OrdEring and rEfErringPhySiCianS and nOn-PhySiCian PraCtitiOnErS

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ICR Summary 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	48,000	0	48,000	0	0	0
Annual Time Burden (Hours)	46,000	0	46,000	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement: This is a new information collection request.

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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: 05/26/2011

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