Medicare Enrollment Application- Reassignment of Medicare Benefits (CMS-855R)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-855R Terminating a Reassignment	Form	Modified	Available
Form CMS-855-R Establishing or adding a reassignment of benefits enrollment application	Form and Instruction	Modified	Available
CMS-855R - Response to Public Comments Received.docx	Supplementary Document	Uploaded 2019-06-19	Repair queued
CMS-855R Supporting Statement 30-day CPI.docx	Supporting Statement A	Uploaded 2020-01-03	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
202867	Terminating a Reassignment	Form	Modified
202866	Establishing or adding a reassignment of benefits enrollment application	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1179	ICR Reference No: 201906-0938-008
Status: Active	Previous ICR Reference No: 201509-0938-008
Agency/Subagency: HHS/CMS	Agency Tracking No: CPI
Title: Medicare Enrollment Application- Reassignment of Medicare Benefits (CMS-855R)
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/06/2020
	Date Received in OIRA: 06/21/2019
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2023	36 Months From Approved
Responses	357,628	0	0
Time Burden (Hours)	89,408	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The primary function of the CMS 855R enrollment application is to allow physicians and non-physician practitioners to reassign their Medicare benefits to a group practice and to gather information from the individual that tells us who he/she is, where he or she renders services, and information necessary to establish correct claims payment. The goal of evaluating and revising the CMS 855R enrollment application is to require the physician or non-physician practitioner to identify a primary group location where the physician or non-physician practitioner will render most of his or her services. This identification does not add any additional burden to the physicians or non-physician practitioners.

---

Authorizing Statute(s): PL: Pub.L. 104 - 134 31001(l) Name of Law: Debt Collection Improvement Act of 1996
   PL: Pub.L. 105 - 133 4313 Name of Law: Balanced Budget Act of 1997
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 5690	02/22/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 26877	06/10/2019
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Establishing or adding a reassignment of benefits enrollment application	CMS-855-R	Reasignment of Medicare Benefits Application
Terminating a Reassignment	CMS-855R	Reassignment of Medicare Benefits

---

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	357,628	0	0	0	-21,991	379,619
Annual Time Burden (Hours)	89,408	0	0	0	-5,497	94,905
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: No

Burden Reduction Due to:

Short Statement: The total burden is 89,408 hours. Due to better reporting methods and more accurate data collection via PECOS, CMS is seeking approval of new burden estimates based on current data collection information. As a result of the decrease in the number of respondents, the burden hours decreased by 5,497 hours (from 94,905 to 89,408 hours). Based numbers derived from PECOS, the total number of respondents decreased by 21,991 (from 379,619 to 367,628).

---

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.     Yes

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: 06/21/2019

---