Medicare Enrollment Application (Form 855S)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-855S Enrollment of MA Providers, Suppliers, and First-Tier, Downstream, and Related Entities (FDRs) (section 422.222)	Form and Instruction	Modified	Available
Form CMS-855-S Revalidation of enrollment information	Form and Instruction	Modified	Available
Form CMS-855(S) Change of Enrollment Information	Form and Instruction	Modified	Available
Form CMS-855-S Initial Enrollment	Form and Instruction	Modified	Available
CMS-855S - Supporting Statement A - Passback2 - 03202017 CLEAN.docx	Supporting Statement A	Uploaded 2017-03-20	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
224024	Enrollment of MA Providers, Suppliers, and First-Tier, Downstream, and Related Entities (FDRs) (section 422.222)	Form and Instruction	Modified
197902	Revalidation of enrollment information	Form and Instruction	Modified
197901	Change of Enrollment Information	Form and Instruction	Modified
197900	Initial Enrollment	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1056	ICR Reference No: 201611-0938-010
Status: Historical Active	Previous ICR Reference No: 201610-0938-004
Agency/Subagency: HHS/CMS	Agency Tracking No: CPI
Title: Medicare Enrollment Application (Form 855S)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/24/2017
	Date Received in OIRA: 11/18/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2019	36 Months From Approved	05/31/2019
Responses	111,262	0	95,435
Time Burden (Hours)	96,677	0	54,013
Cost Burden (Dollars)	0	0	0

---

Abstract: The primary function of the CMS 855S Durable Medical Equipment, Prosthetics, Orthotics and Supplies (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 correct claims payment. The goal of this revision of the CMS 855S is to simplify and clarify the current data collection and to remove obsolete and/or redundant questions. Grammar and spelling errors were corrected. Limited informational text has been added within the application form and instructions in conjunction with links to websites when greater detail is needed by the supplier. To clarify current data collection differentiations and to be in sync with accreditation coding, Section 3D (“Products and Services Furnished by This Supplier”) has been updated. This revision does not offer any new material data collection.

---

Authorizing Statute(s): PL: Pub.L. 109 - 220 508 Name of Law: Rehabilitation Act of 1973 as incorporated with the Americans With Disabilities Act of 2005
   US Code: 42 USC 424.57 Name of Law: DMEPOS Supplier Standards
   US Code: 42 USC 455.460 Name of Law: Application fee
   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
   US Code: 42 USC 424.58 Name of Law: DMEPOS Supplier Accreditation Requirements
   PL: Pub.L. 111 - 148 6201(3) Name of Law: Required Fingerprint Check as Part of Criminal History Background Check
   US Code: 42 USC 3004(b)(1) Name of Law: Public Health Service Act
   EO: EO 12600 Name/Subject of EO: Predisclosure Notification Procedures for Confidential Commercial Information
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AS81	Final or interim final rulemaking	81 FR 80170	11/15/2016

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 46162	07/15/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 80170	11/15/2016
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Initial Enrollment	CMS-855-S, CMS-855S	Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers ,   Medicare Durable Medical Equipment Supplier Enrollment Application
Change of Enrollment Information	CMS-855(S), CMS-855-S	Medicare Durable Medical Equipment Supplier Enrollment Application ,   Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers
Revalidation of enrollment information	CMS-855S, CMS-855-S	Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers ,   Medicare Durable Medical Equipment Supplier Enrollment Application
Enrollment of MA Providers, Suppliers, and First-Tier, Downstream, and Related Entities (FDRs) (section 422.222)	CMS-855S, CMS-855S	Medicare Durable Medical Equipment Supplier Enrollment Application ,   Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers

---

ICR Summary of Burden

table that charts list 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	111,262	95,435	0	10,666	5,161	0
Annual Time Burden (Hours)	96,677	54,013	0	42,664	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: Changing Regulations

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

Burden Reduction Due to:

Short Statement: In aggregate, the rule will add 10,666 CMS-855S respondents, which translates to an additional 63,996 hours. The CMS-855S form remains unchanged as does our 6-hour per response estimate. For the initial application, the currently approved information collection request inadvertently set out 5,162 respondents when it should have been 10,323 respondents. 10,323 was set out in the Supporting Statement, but 5,162 was entered into the ROCIS system. This correction is also discussed under section 12 of this Supporting Statement.

---

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: 11/18/2016

---