Medicare Enrollment Application- Reassignment of Medicare Benefits

Forms and Documents

Document Name	Status
Form CMS-855R Terminating a Reassignment Form and Instruction	New
Form CMS-855R Establishing a reassignment of benefits enrollment application Form and Instruction	New
CMS 855R - Revisons Spreadsheet - 01052012.xlsx Supplementary Document	2012-06-22
CMS 855R - section mapping - 01112012.xlsx Supplementary Document	2012-06-22
CMS-855R Supporting Statement Part A.docx Supporting Statement A	2012-06-22

IC Document Collections

IC ID	Document Title	Status
202867	Terminating a Reassignment Form and Instruction	New
202866	Establishing a reassignment of benefits enrollment application Form and Instruction	New

ICR Details

OMB Control No: 0938-1179	ICR Reference No: 201206-0938-007
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Enrollment Application- Reassignment of Medicare Benefits
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: 11/01/2012
	Date Received in OIRA: 06/25/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2015	36 Months From Approved
Responses	200,000	0	0
Time Burden (Hours)	50,000	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The primary function of the CMS 855R enrollment application is to allow physicians and non-physician practitioners to reassign their Medicare benefits to a group practice and to gather information from the individual that tells us who he/she is, where he or she renders services, and information necessary to establish correct claims payment. The goal of evaluating and revising the CMS 855R enrollment application is to require the physician or non-physician practitioner to identify a primary group location where the physician or non-physician practitioner will render most of his or her services. This identification does not add any additional burden to the physicians or non-physician practitioners.

---

Authorizing Statute(s): None

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 4564	01/30/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 35982	06/15/2012
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Establishing a reassignment of benefits enrollment application	CMS-855R	Reassignment of Medicare Benefits
Terminating a Reassignment	CMS-855R	Reassignment of Medicare Benefits

---

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	200,000	0	0	200,000	0	0
Annual Time Burden (Hours)	50,000	0	0	50,000	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: This is a new information collection request.

---

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]? No

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

---

Common Form ICR:  No

---

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: 06/25/2012

---