Medicare Enrollment Application (Form 855S)

ICR 201210-0938-010

OMB: 0938-1056

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Removed
Form and Instruction
Modified
Form and Instruction
Modified
Form and Instruction
Modified
Supporting Statement A
2012-12-20
ICR Details
0938-1056 201210-0938-010
Historical Active 201105-0938-016
HHS/CMS
Medicare Enrollment Application (Form 855S)
Revision of a currently approved collection   No
Regular
Approved with change 12/20/2012
Retrieve Notice of Action (NOA) 10/31/2012
  Inventory as of this Action Requested Previously Approved
12/31/2015 36 Months From Approved 07/31/2014
43,350 0 140,290
113,550 0 331,620
0 0 0

The primary function of the CMS 855S DMEPOS supplier enrollment application is to gather information from a supplier that tells us who it is, whether it meets certain qualifications to be a health care supplier, where it renders its services or supplies, the identity of the owners of the enrolling entity, and information necessary to establish the correct claims payment. The goal of evaluating and revising the CMS 855S DMEPOS supplier enrollment application is to simplify and clarify the information collection without jeopardizing our need to collect specific information. Additionally, periodically new congressional legislation requires CMS to update the Medicare Provider Enrollment Applications (CMS 855s). Recently approved/passed legislation requires CMS to make slight revisions to the CMS 855S application. The majority of these changes are very minor in nature such as a question with a "Yes/No" check box, spelling and formatting corrections, removal of duplicate fields, instruction clarification for the DMEPOS supplier and indicating services rendered from check lists.

PL: Pub.L. 105 - 33 4313 Name of Law: Balanced Budget Act of 1997
   PL: Pub.L. 104 - 134 31001(I) Name of Law: Debt Collection Improvement Act of 1996
   US Code: 42 USC 1395l Name of Law: Payment of Benefits
   US Code: 42 USC 1395f Name of Law: Requirements of Requests and Certifications
   US Code: 42 USC 1395g Name of Law: Requirements of Requests and Certifications
   US Code: 42 USC 1395cc Name of Law: AGREEMENTS WITH PROVIDERS OF SERVICES; ENROLLMENT PROCESSES
   US Code: 42 USC 1395m Name of Law: SPECIAL PAYMENT RULES FOR PARTICULAR ITEMS AND SERVICES
  
None

Not associated with rulemaking

  77 FR 20403 04/04/2012
77 FR 43288 07/24/2012
No

  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 43,350 140,290 0 -96,940 0 0
Annual Time Burden (Hours) 113,550 331,620 0 -218,070 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
Yes
Miscellaneous Actions
The burden decreased based on the proposed revisions to the CMS 855S. The new total annual burden associated with this information collection is approximately 113,550 hours. The total individual burden associated with this information collection is approximately 4 hours per application.

$0
No
No
No
No
No
Uncollected
William Parham 4107864669

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
10/31/2012


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