The primary function of the CMS 855B enrollment application for Clinics, Group Practices and Certain Other Suppliers is to gather information from the organization that tells us what it is, whether it meets certain qualifications to be a health care supplier, where it renders services and information necessary to establish the correct claims payment. The goal of evaluating and revising the CMS 855B enrollment application is to simplify and clarify the information collection without jeopardizing our need to collect specific information. The majority of the revisions are very minor in nature such as spelling and formatting corrections, removal of duplicate fields and instruction clarification for the organization/group. The Sections and Sub-Sections within the form are also being re-numbered and re-sequenced to create a more logical flow of the data collection. In addition, CMS is adding a data collection for an address to mail the periodic request for the revalidation of enrollment information (only if it differs from other addresses currently collected). Other than the revalidation mailing address described above, new data being collected in this revision package is a checkbox indicating whether or not an organization is wholly owned or operated by a hospital, the inclusion of a new supplier type (Centralized Flu Biller) and information on, if applicable, where the supplier stores its patient records electronically.
US Code:
31 USC 7701(c)
Name of Law: Tax Payer Identification Number
US Code:
26 USC 501
Name of Law: Exemption from tax on corporations, certain trusts, etc.
US Code:
26 USC 3402(t)
Name of Law: Income tax collected at source
US Code:
42 USC 1395g
Name of Law: PAYMENT TO PROVIDERS OF SERVICES
US Code:
42 USC 1320a-3
Name of Law: DISCLOSURE OF OWNERSHIP AND RELATED INFORMATION
US Code:
42 USC 1320a-3a
Name of Law: DISCLOSURE REQUIREMENTS FOR OTHER PROVIDERS UNDER PART B OF MEDICARE
US Code:
42 USC 1395f
Name of Law: CONDITIONS OF AND LIMITATIONS ON PAYMENT FOR SERVICES
US Code:
42 USC 1395l
Name of Law: PAYMENT OF BENEFITS
US Code:
42 USC 1395cc
Name of Law: AGREEMENTS WITH PROVIDERS OF SERVICES; ENROLLMENT PROCESSES
US Code:
42 USC 1395u
Name of Law: PROVISIONS RELATING TO THE ADMINISTRATION OF PART B
This is a request for a new control number. However, the CMS-855B is also approved under 0938-0685. Once the new contorl number is issued, the burden assigned under 0938-0685 will be removed.
$0
No
No
Yes
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.
Form CMS-855B Change of Information
855B PECOS Screen Shots for PRA Package - 04192012.DOCX
CMS 855B - Revisons Spreadsheet - 04182012.xlsx
Change of Information