Medicare Registration Application (CMS-855O)

Forms and Documents

Document Name	Status
Form CMS-855O Reporting Voluntary Withdrawal of Registration Information Form and Instruction	Modified
Form CMS-855O Change of Registration Information Form and Instruction	Modified
Form CMS-855O Initial Application Form and Instruction	Modified
CMS-855O - Supporting Statement A [rev 04-26-2018 by OSORA PRA].docx Supporting Statement A	2018-04-26
CMS 855O - Revisons Spreadsheet - 11202017.pdf Supplementary Document	2018-04-26

IC Document Collections

IC ID	Document Title	Status
202856	Reporting Voluntary Withdrawal of Registration Information Form and Instruction	Modified
197862	Change of Registration Information Form and Instruction	Modified
197861	Initial Application Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1135	ICR Reference No: 201804-0938-024
Status: Active	Previous ICR Reference No: 201612-0938-025
Agency/Subagency: HHS/CMS	Agency Tracking No: CPI
Title: Medicare Registration Application (CMS-855O)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/03/2018
	Date Received in OIRA: 04/26/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2021	36 Months From Approved	01/31/2020
Responses	95,200	0	515,200
Time Burden (Hours)	33,600	0	243,600
Cost Burden (Dollars)	0	0	0

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Abstract: The publication of the Patient Protection and Affordable Care Act (PPACA), section 6405 - "Physicians Who Order Items or Services Required to be Medicare Enrolled Physicians or Eligible Professionals" (regulation CMS 6010-F), contains a requirement for certain physicians and non-physician practitioners to enroll in the Medicare program for the sole purpose of ordering or referring items or services for Medicare beneficiaries. The PPACA has an effective date applicable to written orders and certifications made on or after July 1, 2010. The CMS 855O allows a physician to receive a Medicare identification number (without being approved for billing privileges) for the sole purpose of ordering and referring Medicare beneficiaries to Medicare approved providers and suppliers. This new Medicare application form allows physicians who do not provide services to Medicare beneficiaries to be given a Medicare identification number without having to supply all the data required for the submission of Medicare claims. It also allows the Medicare program to identify ordering and referring physicians without having to validate the amount of data necessary to determine claims payment eligibility (such as banking information), while continuing to identify the physician's credentials as valid for ordering and referring purposes.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 6405 Name of Law: Affordable Care Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AT08	Final or interim final rulemaking	83 FR 16440	04/16/2018

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 56336	11/28/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 16440	04/16/2018
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Initial Application	CMS-855O	Enrollment Application
Change of Registration Information	CMS-855O	Enrollment Application
Reporting Voluntary Withdrawal of Registration Information	CMS-855O	Enrollment Application

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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	95,200	515,200	0	-420,000	0	0
Annual Time Burden (Hours)	33,600	243,600	0	-210,000	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Changing Regulations

Short Statement: CMS-4182-F rescinds the Part D enrollment requirements in 42 CFR 423.120, therefore, all references to Part D enrollment for prescribers of Part D drugs have been eliminated from this PRA package and the CMS-855O Medicare Application Form. The burden hour and cost changes are shown in the table below. As demonstrated in the following table, we have revised our burden estimates associated with Initial Enrollment Application by -420,000 respondents/responses (515,200 – 95,200) and -210,000 hours (243,600 – 33,600).

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

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

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Common Form ICR:  No

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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: 04/26/2018

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