CMS-855 - Supporting_Statement_Part_A

Supporting Statement for Paperwork Reduction Act Submissions

CMS-855 Medicare Enrollment Applications Package Revision

1. BACKGROUND

The primary function of the CMS-855 Medicare enrollment application is to gather information from a provider or supplier that tells us who it is, whether it meets certain qualifications to be a health care provider or supplier, where it practices or renders services, the identity of the owners of the enrolling entity, and other information necessary to establish correct claims payments. For reasons discussed below, CMS is revising the CMS-855 Medicare Enrollment Applications Package (OMB No. 0938-0685).

1. Affordable Care Act Disclosure Provisions

On March 23, 2010, the President signed into law H.R. 3590, the Patient Protection and Affordable Care Act (ACA), Public Law 111-148. The law established a number of important payment safeguard provisions involving the reporting of certain information by Medicare providers and suppliers. These provisions included section 6001, which requires Medicare hospitals to report whether they have any physician owners.

2. Additional CMS-855 Application Revisions

Besides the above-referenced CMS-855 application changes, CMS needs to make further revisions to the forms. Those that will require the provider/supplier to submit new or additional information will be discussed in section 12 below.

2. JUSTIFICATION

1. Need and Legal Basis

Various sections of the Act and the Code of Federal Regulations require providers and suppliers to furnish information concerning the amounts due and the identification of individuals or entities that furnish medical services to beneficiaries before payment can be made.

• Sections 1814(a), 1815(a), and 1833(e) of the Act require the submission of information necessary to determine the amounts due to a provider or other person.

• Section 1842(r) of the Act requires us to establish a system for furnishing a unique identifier for each physician who furnishes services for which payment may be made. In order to do so, we need to collect information unique to that provider or supplier.

• Section 1842(u) of the Act requires us to deny billing privileges under Medicare to physicians and certain other health care professionals certified by a State Child Support Enforcement Agency as owing past-due child support.

• Section 1866(j)(1)(C) of the Act requires us to consult with providers and suppliers of services before making changes in provider enrollment forms.

• The Balanced Budget Act of 1997 (BBA) (Public Law 105-33) section 4313, amended sections 1124(a)(1) and 1124A of the Act to require disclosure of both the Employer Identification Number (EIN) and Social Security Number (SSN) of each provider or supplier, each person with ownership or control interest in the provider or supplier, as well as any managing employees. The Secretary of Health and Human Services (the Secretary) signed and sent to the Congress a “Report to Congress on Steps Taken to Assure Confidentiality of Social Security Account Numbers as Required by the Balanced Budget Act” on January 26, 1999, with mandatory collection of SSNs and EINs effective on or about April 26, 1999.

• Section 31001(I) of the Debt Collection Improvement Act of 1996 (DCIA) (Public Law 104-134) amended 31 U.S.C. 7701 by adding paragraph (c) to require that any person or entity doing business with the Federal Government provide their Tax Identification Number (TIN).

• Section 1866(b)(2)(D) and 1842(h)(8) of the Act require denial of enrollment (directly or indirectly) of persons convicted of a felony for a period not less than 10 years from the date of conviction.

• The Social Security Act, section 302 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, paragraph 1834(a)(20) requires us to collect additional information about accreditation of Advanced Diagnostic Imaging Suppliers.

• The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), section 135(a) amended section 1834(e) of the Social Security Act and required the Secretary to designate organizations to accredit suppliers, including but not limited to physicians, non-physician practitioners and Independent Diagnostic Testing Facilities, that furnish the technical component of advanced diagnostic imaging services.

• The Tax Increase Prevention and Reconciliation Act of 2005 (TIPRA), section 511 requires us to collect information necessary to withhold 3% withholding tax from Medicare providers/suppliers.

• The Internal Revenue (IRS) Code, section 3402(t) requires us to collect additional information about the proprietary/non-profit structure of a Medicare provider/supplier to allow exclusion of non-profit organization from the mandatory 3% tax withholding.

• The IRS section 501(c) requires each Medicare provider/supplier to report information about its proprietary/non-profit structure to the IRS for tax withholding determination.

• The Patient Protection and Affordable Care Act, section 3109(a) allows certain Medicare supplier types to be exempt from the accreditation requirement.

• Social Security Act, section 6401 - Provider Screening and Other Enrollment Requirements under Medicare, Medicaid, and CHIP.

• Section 508 of the Rehabilitation Act of 1973, as incorporated with the Americans with Disabilities Act of 2005 requires all Federal electronic and information technology to be accessible to people with disabilities, including employees and members of the public.

• We are authorized to collect information on the CMS-855 (Office of Management and Budget (OMB) approval number 0938-0685) to ensure that correct payments are made to providers and suppliers under the Medicare program as established by Title XVIII of the Act.

The CMS-855 applications collect this information, including the information necessary to uniquely identify and enumerate the provider/supplier. Additional information necessary to process claims accurately and timely is also collected on the CMS-855 application.

2. Purpose and users of the information

The CMS-855 is submitted at the time the applicant first requests a Medicare billing number. The application is used by Medicare contractors to collect data to ensure that the applicant has the necessary credentials to provide the health care services for which they intend to bill Medicare, including information that allows the Medicare contractor to correctly price, process and pay the applicant’s claims. It also gathers information that allows Medicare contractors to ensure that the provider/supplier is not sanctioned from the Medicare program, or debarred, suspended or excluded from any other Federal agency or program.

3. Improved Information Techniques

This collection lends itself to electronic collection methods. The Provider Enrollment, Chain and Ownership System (PECOS) is a secure, intelligent and interactive national data storage system maintained and housed within the CMS Data Center with limited user access through strict CMS systems access protocols.  Access to the data maintained in PECOS is limited to CMS and Medicare contractor employees responsible for provider/supplier enrollment activities.  The data stored in PECOS mirrors the data collected on the CMS 855s (Medicare Enrollment Applications) and is maintained indefinitely as both historical and current information.  CMS also supports an internet based provider/supplier CMS 855 enrollment platform which allows the provider/supplier to complete an online CMS 855 enrollment application, transmit it to the Medicare contractor database for processing and then the data is transferred from the Medicare contractor processing database into PECOS by the Medicare contractor. Periodically CMS will require adjustment to the format of the CMS 855 form (either paper, electronic or both) for clarity or to improve form design.  These adjustments do not alter the current OMB data collection approval.

PECOS began housing provider/supplier information in 2003 in compliance with the Government Paperwork Elimination Act. However, until CMS adopts an electronic signature standard, providers/suppliers will be required to submit a hard copy signature page of the applicable CMS-855 with an original signature.

4. Duplication and Similar Information

There is no duplicative information collection instrument or process.

5. Small Business

Each of the data collections described above will impact small businesses. However, because of the relative infrequency with which the information will need to be submitted and the minimal time involved in each data collection, we believe that the overall impact on small businesses will be extremely negligible. In addition, these businesses have been required to provide CMS with substantially the same information in order to enroll in the Medicare Program and for CMS to successfully process their claims.

6. Less Frequent Collections

This information is collected on an as needed basis. The information provided on the CMS-855 is necessary for enrollment in the Medicare program. It is essential to collect this information the first time a provider/supplier enrolls with a Medicare contractor so that CMS’ contractors can ensure that the provider/supplier meets all statutory and regulatory requirements necessary for enrollment and that claims are paid correctly.

In addition, to ensure uniform data submissions, CMS requires that all changes to previously submitted enrollment data be reported via the appropriate provider enrollment application.

7. Special Circumstances

There are no special circumstances associated with this collection.

8. Federal Register Notice/Outside Consultation

The 60-day Federal Register notice published on April 4, 2012.

9. Payment/Gift to Respondents

N/A.

10. Confidentiality

CMS will comply with all Privacy Act, Freedom of Information laws and regulations that apply to this collection. Privileged or confidential commercial or financial information is protected from public disclosure by Federal law 5 U.S.C. 522(b)(4) and Executive Order 12600.

11. Sensitive Questions

There are no sensitive questions associated with this collection.

12. Burden Estimate (hours)

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 below, we estimate that the changes described in this section 12 will add 70,693 hours to this burden at a cost of $7,744,860.

In calculating the cost, we used the following assumptions:

• The CMS 855I and CMS 855R will likely be completed by administrative staff.

• The CMS 855A and CMS 855B will likely be completed by professional staff (attorney or accountant).

• The cost per respondent per form has been determined using the follow wages:

• $20.00 per hour (administrative wage)

• $150.00 per hour (professional wage)

• Our estimates below as to the number of providers and suppliers that will complete each form include initially enrolling and revalidating providers and suppliers, as well as those submitting a change of information involving the data element in question. We note, though, that these numbers are merely averages; the actual numbers will vary each year.

A. CMS-855A

1. Physician-Owned Hospital Checkbox

We have added a checkbox to section 2A of the CMS-855A that will identify whether the hospital is a physician-owned hospital. We estimate that an average of 40,000 providers will complete this CMS-855A each year. Out of this total, we project that 2,000 providers will complete this checkbox. We believe it will take the provider 5 minutes to complete the checkbox, at a per hour labor cost of $150. This results in a 167-hour burden (2,000 X .0833 hours) and a total annual cost of $25,050 (167 X $150).

2. Registration of Business

To ensure compliance with § 511 of the Tax Increase Prevention and Reconciliation Act of 2005 (TIPRA), we will require the provider in section 2B1 of the application to identify how its business is registered with the Internal Revenue Service (IRS).

Using our earlier estimate of 40,000 providers that will complete this CMS-855A each year, we believe it will take each provider 5 minutes to furnish this information, at a per hour labor cost of $150. This results in a 3,332-hour burden (40,000 X .0833 hours) and a total annual cost of $499,800 (3,332 X $150).

3. Indian Health Facilities

To ensure that CMS-855A enrollment applications are routed to the correct Medicare contractor, we will require the provider in section 2B1 of the application to answer the following question: “Is this provider an Indian Health Facility enrolling with Trailblazer Health Enterprises?”

We project that it will take the provider 5 minutes to furnish this information. Using our previous estimate of 40,000 providers, this results in a 3,332-hour burden (40,000 X .0833 hours), at a total annual cost of $499,800 (3,332 X $150 per hour).

4. Cost Report Date

We are reinserting into section 2B of the CMS-855A a data element that asks for the provider’s year-end cost report date.

We estimate that it will take the provider 5 minutes to provide this information. Using our previous figure of 40,000 providers, results in a 3,332-hour burden (40,000 X .0833 hours) and a total annual cost of $499,800 (3,332 X $150 per hour).

5. Effective Dates of Ownership or Managerial Control

We are reinserting into sections 5 and 6 of the CMS-855A a data element that requests the effective date of an entity/individual’s ownership/managerial interest in the provider. This is to help verify the entity/individual’s relationship with the provider.

We believe that it will take the provider 1 hour to disclose this information for all of its owners and managing employees. Using our earlier estimate of 40,000 providers, results in a 40,000-hour burden (40,000 X 1 hour) and a total annual cost of $6,000,000 (40,000 X $150 per hour).

6. Percentage of Direct and Indirect Ownership

In sections 5 and 6 of the CMS-855A, we request information on the percentage of direct or indirect ownership a particular entity or individual has in the provider. This is to help verify the extent of the entity/individual’s ownership interest.

We estimate that it will take the provider 30 minutes to provide this information for all of its owners. Using our earlier estimate of 40,000 providers, results in a 20,000-hour burden (40,000 X .5 hours) and a total annual cost of $3,000,000 (20,000 X $150 per hour).

7. Purchase of Provider

In Section 5 of the CMS-855A, we have inserted a checkbox for the provider to indicate whether the owning entity was created for the purpose of acquiring the provider. This is to help us determine whether the owner is a holding company.

We estimate that it will take the provider 15 minutes to provide this information for all of its organizational owners. Using our earlier estimate of 40,000 providers, this results in a 10,000-hour burden (10,000 X .25 hours), with a total annual cost of $1,500,000 (10,000 X $150 per hour).

8. Contractual Services

In sections 5 and 6 of the CMS-855A, we request that the provider identify the type of contractual services (if any) that its managing organizations/employees furnish. This is to help verify the specific relationship the provider has with the managing entity/individual.

We estimate that it will take the provider 20 minutes to provide this information for all of its managing organizations/individuals that provide contractual services. Using our earlier estimate of 40,000 providers, results in a 13,333-hour burden (40,000 X .333 hours). The total annual cost would be $1,999,950 (13,333 X $150 per hour).

9. Billing Agent Date of Birth

We are requesting the billing agent’s date of birth in section 8 of the CMS-855A if the provider has a billing agent who is an individual. This is necessary for the verification of the agent’s tax identification number (TIN) in the Provider Enrollment, Chain and Ownership System (PECOS) and to ensure consistency between the CMS-855A paper and electronic forms.

We project that of the aforementioned 40,000 providers, 4,000 will have an individual billing agent. We estimate that it will take the provider 10 minutes to furnish this information, resulting in a 667-hour burden (4,000 X .1666 hours) at a total annual cost of $100,050 (667 X $150 per hour).

10. IRS Determination Letter

To ensure compliance with § 511 of TIRPA, we will require the provider to submit a copy of its “IRS Determination Letter” if it is registered with the IRS as a non-profit entity.

Of the aforementioned 40,000 providers, we estimate that 6,000 will provide this letter. We project that this requirement will take the provider 10 minutes to fulfill, resulting in a 1,000-hour burden (6,000 X .1666 hours) at a total annual cost of $150,000 (1,000 X $150 per hour).

11. Submission of Additional Documents

We have added a statement to section 17 of the CMS-855A to the effect that the Medicare contractor may request from the provider additional documents not listed in section 17. This is to ensure that the provider is in compliance with all enrollment requirements.

Of the aforementioned 40,000 providers, we project that 8,000 will be requested to submit additional verifying documentation. We estimate that it will take the provider 10 minutes to produce this information. This results in a 1,333-hour burden (8,000 X .1666 hours) at a total annual cost of $199,950 (1,333 X $150 per hour).

12. Confirmation of LLC/Disregarded Entity Status

In section 17 under the title "Mandatory, if Applicable," we have added a checkbox stating that "Written confirmation from the IRS confirming your Limited Liability Company (LLC) is automatically classified as a Disregarded Entity” may be required. This is to verify the provider’s “disregarded entity” status.

Of the 40,000 aforementioned providers, we estimate that 2,000 will be requested to submit IRS documentation verifying the provider’s “disregarded entity” status. We estimate that it will take the provider 10 minutes to produce this information. This results in a 333-hour burden (2,000 X .1666 hours) at a total annual cost of $49,950 (333 X $150).

Table 1 below outlines the burden costs associated with furnishing the CMS-855A information outlined above:

Table 1 – Burden of Producing Information for CMS-855A Changes

Provision	OMB Control No.	Respondents	Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($)	Total Cost ($)
Physician-Owned Hospital Checkbox	0938-0685	2,000	2,000	.0833	167	150	25,050
Registration of Business	0938-0685	40,000	40,000	.0833	3,332	150	499,800
Indian Health Facilities	0938-0685	40,000	40,000	.0833	3,332	150	499,800
Cost Report Dates	0938-0685	40,000	40,000	.0833	3,332	150	499,800
Effective Dates of Ownership	0938-0685	40,000	40,000	1	40,000	150	6,000,000
Percentage of Direct and Indirect Ownership	0938-0685	40,000	40,000	.5	20,000	150	3,000,000
Purchase of Provider	0938-0685	40,000	40,000	.25	10,000	150	1,500,000
Contractual Services	0938-0685	40,000	40,000	.3333	13,333	150	1,999,950
Billing Agent DOB	0938-0685	4,000	4,000	.1666	667	150	100,050
IRS Determination Letter	0938-0685	6,000	6,000	.1666	1,000	150	150,000
Submission of Additional Documents	0938-0685	8,000	8,000	.1666	1,333	150	199,950
Confirmation of LLC Status	0938-0685	2,000	2,000	.1666	333	150	49,950
TOTAL		302,000	302,000		96,829		14,524,350

B. CMS-855B

1. Registration of Business

To ensure compliance with § 511 of TIPRA, we will require the supplier to identify how its business is registered with the IRS.

We project that 120,000 suppliers will complete the CMS-855B annually and, in the process, disclose their business registration. We estimate that it will take the provider 5 minutes to furnish this information at a per hour labor cost of $150. This results in a 10,000-hour burden (120,000 X .0833 hours) at a total annual cost of $1,500,000 (10,000 X $150).

2. Indian Health Facilities

To ensure that CMS-855B enrollment applications are routed to the correct Medicare contractor, we will require the supplier in section 2 to respond to this question: “Is this provider an Indian Health Facility enrolling with Trailblazer Health Enterprises?”

We estimate that it will take the supplier 5 minutes to furnish this information. Using our estimate of 120,000 suppliers, we project a 10,000-hour burden (120,000 X .0833 hours) and a total annual cost of $1,500,000 (10,000 X $150 per hour).

3. Ambulatory Surgical Center Accreditation

In Section 2 of the CMS-855B, we will require accredited ambulatory surgical centers (ASCs) to report the expiration date of their accreditation. This will help enable CMS to monitor the supplier’s accreditation status.

Of the 120,000 aforementioned suppliers, we project that 1,400 ASCs will furnish this data. The estimated time involved will be 10 minutes. We therefore project a 233-hour burden (1,400 X .1666 hours) at a total annual cost of $34,950 (233 X $150 per hour).

4. Advanced Diagnostic Imaging Information

In Section 2 of the form, we will request information from advanced diagnostic imaging services (ADIs) suppliers regarding: (1) the services the supplier provides, and (2) whether the supplier is accredited.

Of the 120,000 aforementioned suppliers, we project that 20,000 ADI suppliers will furnish this data. The estimated time involved will be 15 minutes. We therefore project a 5,000-hour burden (20,000 X .25 hours) at a total annual cost of $750,000 (5,000 X $150 per hour).

5. Effective Dates of Ownership

We are reinserting into sections 5 and 6 a data element that requests the effective date of an entity’s or individual’s ownership/managerial interest in the supplier. This is to help verify the organization’s/person’s relationship with the supplier.

We believe that it will take the provider 20 minutes to disclose this information for all of its owners and managing employees. Using our earlier estimate of 120,000 providers, results in a 40,000-hour burden (120,000 X .3333 hours) and a total annual cost of $6,000,000 (40,000 X $150 per hour).

6. Title of Section 6 Official

We are reinserting into section 6 a data element that asks for the titles of the individuals listed in that section. This is to help verify the person’s status within the organization.

We project that it will take the provider 5 minutes to furnish this information for all of its officials. Using our estimate of 120,000 suppliers, this results in a 10,000-hour burden (120,000 X .0833 hours) at a total annual cost of $1,500,000 (10,000 X $150).

7. Place of Birth of Section 6 Official

We are inserting into section 6 a data element that asks for the birthplaces of the individuals listed in that section. This is to help verify the person’s identity.

We project that it will take the provider 5 minutes to furnish this information. Using our estimate of 120,000 suppliers, this results in a 10,000-hour burden (120,000 X .0833 hours) at a total annual cost of $1,500,000 (10,000 X $150).

8. Billing Agent Date of Birth

We are requesting the billing agent’s date of birth if the supplier has a billing agent who is an individual. This is necessary for the verification of the agent’s TIN in PECOS and to ensure consistency between the CMS-855B paper and electronic forms.

Of the 120,000 suppliers that will complete the CMS-855B each year, we project that 24,000 of them will have an individual billing agent. We estimate that it will take the supplier 5 minutes to furnish this information. This results in a 2,000-hour burden (24,000 X .0833 hours) at a total annual cost of $300,000 (2,000 X $150).

9. IRS Determination Letter

To ensure compliance with § 511 of TIRPA, we will require the supplier to submit a copy of its “IRS Determination Letter” if it is registered with the IRS as a non-profit entity.

We estimate that 20,000 of the 120,000 aforementioned suppliers will provide this letter. We estimate that this requirement will take the provider 10 minutes to fulfill, resulting in a 3,333- hour burden (20,000 X .1666 hours) at a total annual cost of $499,950 (3,333 X $150 per hour).

10. Submission of Additional Documents

We added a statement to section 17 to the effect that the Medicare contractor may request additional documents not listed in section 17 from the supplier. This is to ensure that the supplier is in compliance with all enrollment requirements.

Of the aforementioned 120,000 suppliers, we estimate that 20,000 will be requested to submit additional verifying documentation. We project that it will take the supplier 10 minutes to produce this information. This results in a 3,333-hour burden (20,000 X .1666 hours) at a total annual cost of $499,950 (3,333 X $150).

11. Confirmation of LLC/Disregarded Entity Status

In section 17 under the title "Mandatory, if Applicable," we added a checkbox stating that "Written confirmation from the IRS confirming your Limited Liability Company (LLC) is automatically classified as a Disregarded Entity” may be required. This is to verify the supplier’s “disregarded entity” status.

Of the estimated 120,000 suppliers that will annually complete the CMS-855B, we believe that 6,000 will be requested to submit IRS documentation verifying its LLC status. We project that it will take the supplier 10 minutes to produce this information. This results in a 1,000-hour burden (6,000 X .1666 hours) at a total annual cost of $150,000 (1,000 X $150).

12. Submission of TIN Documentation

In section 17, we require the supplier to submit written confirmation from the IRS of the supplier TIN (e.g., CP-575) if the supplier is a professional corporation, professional association, or limited liability corporation, or is a sole proprietor using an EIN.

We believe that 20,000 suppliers will be required to submit this information. We project that it will take the supplier 10 minutes to do so. This results in a 3,333-hour burden (20,000 X .1666 hours) at a total annual cost of $499,950 (3,333 X $150).

Table 2 below outlines the burden costs associated with furnishing the CMS-855B information outlined above:

Table 2 – Burden of Producing Information for CMS-855B Changes

Provision	OMB Control No.	Respondents	Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($)	Total Cost ($)
Registration of Business	0938-0685	120,000	120,000	.0833	10,000	150	1,500,000
Indian Health Facilities	0938-0685	120,000	120,000	.0833	10,000	150	1,500,000
ASC Accreditation	0938-0685	1,400	1,400	.1666	233	150	34,950
ADIs Information	0938-0685	20,000	20,000	.25	5,000	150	750,000
Effective Dates of Ownership	0938-0685	120,000	120,000	.3333	40,000	150	6,000,000
Title of Section 6 Official	0938-0685	120,000	120,000	.0833	10,000	150	1,500,000
Birthplace of Section 6 Official	0938-0685	120,000	120,000	.0833	10,000	150	1,500,000
Billing Agent DOB	0938-0685	24,000	24,000	.0833	2000	150	300,000
IRS Determination Letter	0938-0685	20,000	20,000	.1666	3,333	150	499,950
Submission of Additional Documents	0938-0685	20,000	20,000	.1666	3,333	150	499,950
Confirmation of LLC Status	0938-0685	6,000	6,000	.1666	1,000	150	150,000
TIN Documentation	0938-0685	20,000	20,000	.1666	3,333	150	499,950
TOTAL		711,400	711,400		98,232		14,734,800

3. CMS-855I

1. Acceptance of New Patients

In section 2A, we have added the following question: “Do you accept new patients?” Medicare beneficiaries have requested that the “Medicare Physician and Healthcare Provider Directory” indicate whether physicians are accepting new patients.

We estimate that 220,000 physicians/practitioners will complete the CMS-855I each year and identify whether he/she accepts new patients. We estimate that it will take the supplier 5 minutes to furnish this information at a per hour labor cost of $20 (administrative wage). This results in an 18,333-hour burden (220,000 X .0833 hours) and a total annual cost of $366,660 (18,333 X $20).

2. Employing Physician EIN

In section 2, we are requesting the employer identification number (EIN) of a physician assistant’s employing physician. This is designed to reduce the time in which physician assistant enrollment applications are processed.

Of the estimated 220,000 individuals who will complete the CMS-855I each year, we believe that 12,000 will be physician assistants who will, in turn, submit the EIN of their employing physician. We estimate that it will take the supplier 5 minutes to furnish this information. This results in a 1,000-hour burden (12,000 X .0833) at a total annual cost of $20,000 (1,000 X $20 per hour).

3. Information on ADIs

In Section 2, we will request information from ADI suppliers regarding the services they provide and whether they are accredited.

Of the 220,000 aforementioned suppliers, we estimate that 12,000 will furnish this data. The estimated time involved will be 15 minutes. We therefore project a 3,000-hour burden (12,000 X .25 hours) at a total annual cost of $60,000 (3,000 X $20 per hour).

4. Indian Health Facilities

To ensure that CMS-855I enrollment applications are sent to the correct Medicare contractor, we will require the supplier in section 2 to indicate whether it is an Indian Health Facility that is enrolling with Trailblazer Health Enterprises.

Of the 220,000 suppliers that will complete the CMS-855I each year, we estimate that 60,000 will complete section 2 as a solely-owned corporation or LLC. We project that it will take the supplier 5 minutes to furnish this information. This results in a 5,000-hour burden (60,000 X .0833 hours) at a total annual cost of $100,000 (5,000 X $20 per hour).

5. Registration of Business

To ensure compliance with § 511 of TIPRA, the supplier will need to identify his/her business registration in section 2.

Of the 220,000 aforementioned suppliers, we estimate that 60,000 will complete section 2 as a solely-owned corporation or LLC. We project that it will take the supplier 5 minutes to furnish data about its business registration. This results in a 5,000-hour burden (60,000 X .0833 hours), with a total annual cost of $100,000 (5,000 X $20 per hour).

6. Effective Dates of Individuals in Section 6

We are inserting into section 6 a data element that asks for the effective date of an individual’s managing control of the business. This is to help verify the individual’s relationship with the practice.

We estimate that of the 220,000 suppliers that will complete the CMS-855I each year, 80,000 will have at least one managing employee. We project that it will take the supplier 10 minutes to furnish this information on the individual(s). This results in a 13,333-hour burden (80,000 X .1666 hours) and a total annual cost of $266,660 (13,333 X $20 per hour).

7. Places of Birth of Section 6 Officials

We are inserting into section 6 a data element that requests the birthplace of each person listed therein. This is to help verify the individual’s identity.

Using the 80,000-supplier and 10-minute figures mentioned in the previous data element, we project a 13,333-hour burden (80,000 X .1666 hours) at a total annual cost of $266,660 (13,333 X $20 per hour).

8. Billing Agent Date of Birth

For reasons already stated, we are requesting the billing agent’s date of birth if the supplier has a billing agent who is an individual.

Of the aforementioned 220,000 suppliers, we project that 44,000 of them will have an individual billing agent. We estimate that it will take the provider 10 minutes to furnish this information. This results in a 7,333-hour burden (44,000 X .1666 hours) at a total annual cost of $146,660 (7,333 X $20 hour).

9. Submission of Additional Documents

We are adding a statement to section 17 to the effect that the supplier may be required to submit additional documents not listed in section 17.

We estimate that 40,000 of the estimated 220,000 suppliers completing the CMS-855I each year will be required to submit this documentation. We project that it will take the supplier 10 minutes to produce this information. This results in a 6,667-hour burden (40,000 X .1666 hours) at a total annual cost of $133,340 (6,667 X $20).

10. Confirmation of LLC/Disregarded Entity Status

In section 17, we will require the supplier to, if applicable, confirm its status as a disregarded entity.

Of the above-referenced 220,000 suppliers, we project that 12,000 will furnish this information. We estimate that it will take the supplier 10 minutes to produce this data. This results in a 2,000-hour burden (12,000 X .1666 hours) at a total annual cost of $40,000 (2,000 X $20 per hour).

11. IRS Determination Letter

In section 17, we will require non-profit entities to submit a copy of their IRS-501(c) form.

We estimate that 8,000 of the aforementioned 220,000 suppliers will need to submit this information. We estimate that it will take the provider 10 minutes to do so. This results in a 1,333-hour burden (8,000 X .1666 hours) at a total annual cost of $26,660 (1,333 X $20 per hour).

12. Submission of TIN Documentation

In section 17, we will require certain suppliers to submit a copy of their CP-575 form. This is necessary to verify the business’s EIN.

We estimate that of the 220,000 suppliers that will annually complete the CMS-855I, 60,000 will submit this information. We estimate that it will take the supplier 10 minutes to do so. This results in a 10,000-hour burden (60,000 X .1666 hours), with a total annual cost of $200,000 (10,000 X $20 per hour).

13. Information about Advanced Diagnostic Imaging Suppliers

We will be adding an attachment to the CMS-855I that captures information on any ADIS services the supplier performs.

Of the aforementioned 220,000 suppliers, we estimate that 32,000 will complete this attachment and that it will take 15 minutes to do so. This results in an 8,000-hour burden (32,000 X .25 hours) at a total annual cost of $160,000 (8,000 X $20 per hour).

Table 3 below outlines the burden costs associated with furnishing the CMS-855I information outlined above:

Table 3 – Burden of Producing Information for CMS-855I Changes

Provision	OMB Control No.	Respondents	Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($)	Total Cost ($)
Acceptance of New Patients	0938-0685	220,000	220,000	.0833	18,333	20	366,660
Employing Physician EIN	0938-0685	12,000	12,000	.0833	1,000	20	20,000
ADI Information – Section 2	0938-0685	12,000	12,000	.25	3,000	20	60,000
Indian Health Facility Information	0938-0685	60,000	60,000	.0833	5,000	20	100,000
Registration of Business	0938-0685	60,000	60,000	.0833	5,000	20	100,000
Effective Date of Section 6 Individual	0938-0685	80,000	80,000	.1666	13,333	20	266,660
Birthplace of Section 6 Individual	0938-0685	80,000	80,000	.1666	13,333	20	266,660
Billing Agent Date of Birth	0938-0685	44,000	44,000	.1666	7,333	20	146,660
Submission of Additional Documents	0938-0685	40,000	40,000	.1666	6,667	20	133,340
Confirmation of LLC Status	0938-0685	12,000	12,000	.1666	2,000	20	40,000
IRS Determination Letter	0938-0685	8,000	8,000	.1666	1,333	20	26,660
Verification of EIN	0938-0685	60,000	60,000	.1666	10,000	20	200,000
Additional ADI Information	0938-0685	32,000	32,000	.25	8,000	20	160,000
TOTAL		720,000	720,000		94,332		$1,886,640

4. CMS-855R

We will require suppliers that are terminating a reassignment to identify a contact person in section 7 of the CMS-855R. This will reduce the time it takes to process the termination.

We estimate that 5,000 CMS-855R applications that terminate a reassignment will be submitted each year and that it will take the supplier 5 minutes to complete section 7. This results in a 416 hour burden (5,000 X .0833) at an annual cost of $8,320 (416 X $20 per hour).

5. Final Estimates

Table 4 summarizes the total hour and burden costs of this information collection:

Table 4 – Burden of Information Collection

Form	Respondents	Annual Burden Hours	Total Cost
CMS-855A	304,400	97,629	$14,644,350
CMS-855B	711,400	98,232	$14,734,800
CMS-855I	720,000	94,332	$1,886,640
CMS-855R	5,000	416	$8,320
TOTAL	1,740,800	290,609	$31,274,110

6. Other Changes

There are number of technical, editorial, and formatting changes being made to the CMS-855A, CMS-855B, CMS-855I and CMS-855R that either: (1) do not involve the collection of information, or (2) involve the addition of extra checkboxes (e.g., additional provider/supplier types or specialties) that the provider/supplier can use to identify itself. As these changes do not impose an additional burden of the provider/supplier, and were added for provider/supplier clarification of instructions, they will not be included with this submission.

13. Cost to Respondents (Capital)

There are no capital costs associated with this collection.

14. Cost to Federal Government

There is no additional cost to the Federal government. Applications will be processed in the normal course of Federal duties.

15. Changes in Burden/Program Changes

There are no changes or adjustments to the burden.

16. Publication/Tabulation

N/A.

17. Expiration Date

We are planning on displaying the expiration date.

18. Certification Statement

There are no exceptions to item 19 of OMB Form 83-I.

2. COLLECTIONS OF INFORMATION EMPLOYING STATISTICAL METHODS

N/A.

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