CMS-855S - Supporting Statement Final

Supporting Statement for Paperwork Reduction Act Submissions
Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
(DMEPOS) Suppliers
CMS-855S/OMB Control Number: 0938-1056)

A. BACKGROUND
The primary function of the CMS-855S Medicare enrollment application for suppliers, also known as
durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers, is to gather
information from the supplier that tells us who the supplier is, whether the supplier meets certain
qualifications to be a Medicare health care DMEPOS supplier, where the supplier practices or renders
services, and other information necessary to establish correct claims payments.
There are two principal facets of this submission:
1. Re-sequencing and re-numbering of sections - This revision includes a re-sequencing and renumbering of the sections and sub-sections of the application to create a more logical flow of the data
to make it easier for the supplier to complete (for example, by putting most address collection
information in one section). The re-sequencing and re-numbering of the application was also
necessary to maintain continuity with other CMS-855 applications. One example of the resequencing and re-numbering is the CMS-855A, CMS-855B, and CMS-855I all have organizational
and individual ownership information collection in sections five and six of the applications. The
CMS-855S was re-sequenced to also have organizational and individual ownership information
collection in sections five and six of the application. The sections of the applications have been reordered to be consistent with the other CMS-855 enrollment applications.

2. Corrections to the content of the CMS-855S - The goal of evaluating and revising the CMS-855S
enrollment application is to simplify and clarify the information collection without jeopardizing our
need to collect specific information. In addition, periodically new congressional legislation or
regulations require CMS to update the Medicare Provider Enrollment Applications (CMS-855s). The
majority of these changes are in content and minor in nature for the purposes of supplier enrollment,
such as instruction clarification for the supplier, adding new specialty codes for the supplier to choose
from, questions with “Yes/No” check boxes, spelling and formatting corrections, removal of
duplicate fields, and indicating which addresses the suppliers wish to use for different types of
correspondence.
In this revision of the CMS-855S, some of the main revisions include an exemption from
accreditation option for the supplier to check one of three checkboxes for the reason of the
exemption, if applicable. An expanded definition of managing control was added. The contact
person section was made optional to reduce the reporting burden for suppliers. Additional
information, including a link to the website, was added regarding the application fee. Additionally,
some obsolete questions were removed. Other minor editorial and clerical corrections were made to
better clarify the current data collection. Some of the instructions were simplified for the suppliers

completing this application in response to comments received by the NSC MAC and suppliers during
focus groups discussing the current version of this application.

JUSTIFICATION
1. Need and Legal Basis
Various sections of the Social Security Act (Act), the United States Code (U.S.C.), Internal Revenue Service
Code (Code) and the Code of Federal Regulations (C.F.R.) 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. The CMS-855S application collect this information,
including the information necessary to uniquely identify and enumerate the supplier. Additional information
necessary to ensure that suppliers meet all applicable Medicare requirements and to process claims
accurately and timely are also collected on the CMS-855S application. This information also ensures that the
data collected allows CMS to make correct payments to suppliers.
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C.F.R. section 424.500 state the requirements for enrollment, periodic resubmission and certification of
enrollment information for revalidation, and timely reporting of updates and changes to enrollment
information. These requirements apply to all providers and suppliers. Providers and suppliers must meet
and maintain these enrollment requirements to bill either the Medicare program or its beneficiaries for
Medicare covered services or supplies.
Title XVII of the Act ensures that the data collected allows CMS to make correct payments to providers
and suppliers in the Medicare program.
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
provider/supplier 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 1866(j)(1)(C) of the Act requires us to consult with providers and suppliers of services before
making changes in provider enrollment forms.
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.
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 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.
Section 1834(a)(20)(G)(i) of the Act allows certain Medicare supplier types to be exempt from the

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accreditation requirement.
Section 1866(j)(2)(A) of the Act requires the Secretary, in consultation with the Department of Health
and Human Services' Office of the Inspector General, to establish procedures under which screening is
conducted with respect to providers of medical or other items or services and suppliers under Medicare,
Medicaid, and CHIP.
Section 1866(j)(2)(B) of the Act requires the Secretary to determine the level of screening to be
conducted according to the risk of fraud, waste, and abuse with respect to the category of provider or
supplier.
Section 1848(k)(3)(B) defines covered professional services and eligible professionals.
Section 3004(b)(1) of the Public Health Service Act (PHSA) requires the Secretary to adopt an initial set
of standards, implementation guidance, and certification criteria and associated standards and
implementation specifications will be used to test and certify complete EHRs and EHR modules in order
to make it possible for eligible professionals and eligible hospitals to adopt and implement Certified EHR
Technology.
Section 1834(j) of the Act states that no payment may be made for items furnished by a supplier of
durable medical equipment, prosthetics, and supplies (DMEPOS) unless that supplier obtains, and renews
at such intervals as we may require, a billing number. In order to issue a billing number, we need to
collect information unique to that supplier.
Section 6401(2) of the Affordable Care Act (ACA) requires the Secretary to impose a fee on each
"institutional provider of medical or other items or services and suppliers." The fee is to be used by the
Secretary to cover the cost of program integrity efforts including the cost of screening associated with
provider enrollment processes, including those under section 1866(j) and section 1128(J) of the Social
Security Act.
Section 1866(j) of the Act requires the revalidation of all provider and supplier enrollment data every
five years – every three years for DMEPOS suppliers.
42 C.F.R. Section 424.57 requires DMEPOS suppliers comply with 30 specific standards in order to
receive and maintain Medicare billing privileges.
42 C.F.R. Section 424.58 requires accreditation in order to qualify for the Medicare program.
Section 6201(c), of the Affordable Care Act (ACA) Subtitle C, requires DHHS to obtain state and
national background checks on prospective employees, including national fingerprint-based criminal
history record checks.
The Patient Protection and Affordable Care Act, section 3109(a) allows certain Medicare supplier types
to be exempt from the accreditation requirement.
Section 3004(b)(1) of the Public Health Service Act (PHSA) requires the Secretary to adopt an initial set
of standards, implementation guidance, and certification criteria and associated standards and
implementation specifications will be used to test and certify complete EHRs and EHR modules in order
to make it possible for eligible professionals and eligible hospitals to adopt and implement Certified EHR
Technology.
Executive Order 12600 requires the pre-disclosure of notification procedures for confidential commercial
information.
5 U.S.C. 522(b)(4) requires privileged or confidential commercial or financial information be protected
from public disclosure.
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.

2. Purpose and users of the information
The C.F.R. section 424.500 state the requirements for enrollment, periodic resubmission and certification of
enrollment information for revalidation, and timely reporting of updates and changes to enrollment
information. These requirements apply to all providers and suppliers except for physicians and practitioners
who have entered into a private contract with a beneficiary as described in part 405, subpart D of this
chapter. Providers and suppliers must meet and maintain these enrollment requirements to bill either the
Medicare program or its beneficiaries for Medicare covered services or supplies. 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, supplier, or other person.
The CMS-855S is submitted by an applicant to the National Supplier Clearinghouse Medicare
Administrative Contractor (NSC MAC) to initially apply for a Medicare billing number, and thereafter
to add a new business location, revalidate Medicare enrollment, reactivate Medicare enrollment,
to report a change to current Medicare enrollment information, changing the tax identification
number, and to voluntary terminate the supplier’s Medicare enrollment, as applicable. It is used
by new applicants as well as suppliers already enrolled in Medicare but need to submit the form for a
reason other than initial enrollment into the Medicare program. A DMEPOS supplier that will
bill for DMEPOS complete this form for the submittal reasons above.
The NSC MAC establishes Medicare Identification Numbers, also known as Medicare Billing Numbers, for
suppliers of DMEPOS. The NSC MAC stores these numbers and information in CMS’ Provider Enrollment,
Chain and Ownership System (PECOS). The application is used by the CMS’ contractor (NSC MAC) to
collect data to ensure that the applicant has the necessary information for unique identification. The license
numbers that come through paper applications are validated against state licensing websites. All the license
numbers are captured and stored in the NSC MAC database. Social Security Numbers (SSNs) are validated
against the Social Security Administration database (SSA) and only the valid entries are allowed to proceed
in the process of getting a Medicare billing number. International Tax Identification Numbers (ITINs) are
not validated. However, if a user enters ITIN, additional forms of identification (e.g., driver’s license,
passport or birth certificate) are required. Both ITINs and SSNs are captured in the NSC MAC database and
disseminated only to approved CMS stakeholders. Mailing address, practice location address and contact
information is captured to contact the supplier. Specialty type is captured to identify the specialty of the
supplier. The information obtained is to help prevent fraud by allowing vetting of the suppliers as well as to
ensure a supplier is not illegitimately attempting to get a Medicare billing number. In addition, the
information collected allows CMS and the NSC MAC to determine relationships among those with Medicare
billing numbers. For example, a supplier who enrolls as a group practice may also have an individual
Medicare billing number for private practice as well as part ownership in a hospital. This information is
determined during the enrollment process. If any relationship is prohibited by CMS regulation, the supplier
would be denied a Medicare billing number and other measures may be taken, such as revocation of the
supplier’s individual Medicare billing number or an enrollment bar so the supplier will not get a Medicare
billing number for a set number of years, depending on the enrollment bar issued to the supplier.
The collection and verification of this information defends and protects our beneficiaries from illegitimate
suppliers. These procedures also protect the Medicare Trust Fund against fraud. It gathers information that
allow Medicare contractors to ensure that the supplier is not sanctioned from the Medicare and/or Medicaid

program(s), or debarred, or excluded from any other Federal agency or program. The data collected also
ensures 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. This is sole instrument implemented for this purpose.

3. Improved Information Techniques
This collection lends itself to electronic collection methods and is currently available through the CMS
website. 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
supplier has access to its own records. PECOS is an electronic Medicare enrollment system through which
providers and suppliers can: submit Medicare enrollment applications, view and print enrollment
information, update enrollment information, complete the enrollment revalidation process, voluntarily
withdraw from the Medicare program, and track the status of a submitted Medicare enrollment application.
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 Internetbased provider/supplier CMS-855 enrollment platform which allows the provider/supplier to complete an
online CMS-855 enrollment application and transmit it to the Medicare contractor database for processing.
Then the data is transferred from the Medicare contractor processing database into PECOS by the Medicare
contractor. CMS also has the ability to allow suppliers to upload supporting documentation (required for
enrollment) electronically. CMS has also adopted an electronic signature standard; however, suppliers will
have the choice to e-sign via the CMS website or to submit a hard copy of the CMS-855S certification page
with an original signature. 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. Currently, approximately 60% of DMEPOS suppliers use the
electronic method of enrolling in the Medicare program via the PECOS system.

4. Duplication and Similar Information
There is no duplicative information collection instrument or process.

5. Small Business
A Medicare billing number is required of all health care suppliers/providers who wish to submit claims for
payment to the Medicare Trust Fund so it will affect small businesses who wish to have a Medicare billing
number. However, these businesses have always been required to provide CMS with the same information in
order to enroll in the Medicare program to submit information for CMS to ensure the providers and suppliers
are legitimate and to collect information to successfully process their Medicare claims.

6. Less Frequent Collections
This information is collected on an as needed basis. The information provided on these forms is necessary
for initial 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 uniquely identify the
provider/supplier, ensure the provider’s/supplier’s eligibility and legitimacy, to determine if the
provider/supplier meets all statutory and regulatory requirements, are properly credentialed in their specialty
(if applicable), and to collect relevant information to process the provider’s/supplier’s claims in a timely and
accurate manner.
After the initial enrollment and approval, the information collected is less frequent and often initialized by
the supplier for reasons such as a change of information, adding a business location, and to voluntarily
withdraw from the Medicare program. It will be collected to complete the enrollment revalidation process
every three years. In addition, to ensure uniform data submissions, CMS requires that all changes to
previously submitted enrollment data be reported via this enrollment application.

7. Special Circumstances
There are no special circumstances associated with this collection.

8. Federal Register Notice/Outside Consultation
A 60-day Notice published in the Federal Register on July 10, 2019 (84 FR 32924). No comments were
received. No outside consultation was sought.

9. Payment/Gift to Respondents
No payments and/or gifts will be provided to respondents.

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.
The SORN title is Provider Enrollment, Chain and Ownership System (PECOS), number 09-70-0532.

11. Sensitive Questions
There are no sensitive questions associated with this collection. Specifically, the collection does not solicit
questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that

are commonly considered private.

12. Burden Estimate (hours and cost)
A. Burden Estimate (hours)
HOURS ASSOCIATED WITH COMPLETING THE CMS-855S ENROLLMENT APPLICATION
For this proposed revision of the CMS-855S, CMS has recalculated the estimated burden hours. CMS
believes this recalculation is necessary because the number of affected users, actual data collected and
the collection methods have changed significantly. CMS believes these new burden hours accurately
reflects the current burden for the purposes of this application when completing this proposed revision
of the CMS-855S. CMS is basing the new burden amounts on data compiled from PECOS and the NSC
MAC. The new estimates for completing the CMS-855S Medicare enrollment application form for the
six submission reasons shown in the burden tables (initial enrollment, adding a new business
location, reactivation, revalidation, reporting a change of Medicare enrollment information, and
voluntary termination of Medicare enrollment) are taken directly from the actual applications
processed for calendar year 2017. The new figures of processed applications are exact and therefore
more accurate than the prior estimates. CMS contacted the NSC MAC through conference calls to
determine how the application was typically completed (by chief executives of large organizations,
physicians, or retail store managers).
The hour burden to the respondents is calculated based on the following assumptions:
• The NSC MAC currently processes approximately 45,117 CMS-855S applications per
year (as seen in Table 1).
• Completion of the CMS-855S hour burden depends on the reason for submittal.
• Hour burden of the respondents is calculated as follows based on the following assumptions:
o The CMS-855S will likely be completed by large organizations (50%), physicians (25%),
or retail store managers (25%) (BLS category = Chief Executives (50%), Physicians and
Surgeons (25%), and General and Occupational Managers (25%)),
o The record keeping burden is included in the time determined for completion, and
o The CMS-855S applications are signed by the enrolling or enrolled supplier (BLS
categories listed above).
• The hours are calculated based on the respondent’s submission reason, which also determines the
time it takes for completion and submission to the NSC MAC as well as the cost per individual
submission completion (as seen in Table 2).
Table 1 – Total Number of CMS-855S’ Processed per Year by Reason for Submittal (2017)
Reason for Submittal
Initial Enrollment
Adding a New Business Location
Reactivation
Revalidation

Total Number of CMS-855S’ Processed per year (2017)
3,429
1,242
2,378
25,956

Reporting a Change of Medicare Enrollment
Information
Voluntary Termination of Medicare Enrollment
GRAND TOTAL (Total Processed CMS855S’ for All Reasons for Submission)

12,105
7
45,117

Table 2 – Individual Burden Hours and Costs for Completion of the CMS-855S per Reason for
Submittal*
* For Table 2 - CMS adjusted the employee hourly wage estimates by a factor of 100 percent. Additional
information on cost can be found in 12 B.

B. Burden Estimate (costs)
For this proposed revision of the CMS-855S, CMS has recalculated the estimated burden costs. CMS
Reason for
Submittal

Initial
Enrollment
Adding a
New
Business
Location
Reactivation
Revalidation
Reporting a
Change of
Medicare
Enrollment
Information
Voluntary
Termination
of Medicare
Enrollment

Hours to
Complete by
a Chief
Executive of
a Large
Organization
per CMS855S

Hours to
Complete
by a
Physician
per CMS855S

Hours to
Complete by
a General and
Occupational
Manager per
CMS-855S

Total
Hours to
Complete
per CMS855S

Cost to
Complete by
a Chief
Executive of a
Large
Organization
per CMS855S

Cost to
Complete
by a
Physician
per CMS855S

Cost to
Complete by
a General and
Occupational
Manager per
CMS-855S

4

4

4

4

$754.00

$825.76

$474.80

1

1

1

1

$188.50

$206.44

$118.70

4
2

4
2

4
2

4
2

$754.00
$377.00

$825.76
$412.88

$474.80
$237.40

1

1

1

1

$188.50

$206.44

$118.70

0.5

0.5

0.5

0.5

$94.25

$103.22

$59.35

believes this recalculation is necessary because the number of affected users, actual data collected and
the collection methods have changed significantly. CMS believes these new burden costs accurately
reflects the current burden for the purposes of this application when completing this proposed revision

of the CMS-855S. CMS is basing the new burden amounts on data compiled from PECOS and the NSC
MAC. The new estimates for completing the CMS-855S Medicare enrollment application form for the
six submission reasons shown above in table 2 (initial enrollment, adding a new business location,
reactivation, revalidation, reporting a change of Medicare enrollment information, and voluntary
termination of Medicare enrollment) are taken directly from the actual applications processed for
calendar year 2017. The new figures of processed applications are exact and therefore more accurate
than the prior estimates. CMS contacted the NSC MAC through conference calls to determine how the
application was typically completed (by chief executives of large organizations, physicians, or retail store
managers).
To derive average costs, CMS used data from the U.S. Bureau of Labor Statistics’ (BLS) May 2017
National Occupational Employment and Wage Estimates for all salary estimates
(http://www.bls.gov/oes/current/oes_nat.htm). For the purposes of this application, CMS used the wages
under the general categories of “Chief Executives,” “Physicians and Surgeons,” and “General and
Occupational Managers.” In this regard, CMS adjusted the employee hourly wage estimates by a factor
of 100 percent. This is necessarily an estimated adjustment, both because fringe benefits and overhead
costs vary significantly from employer to employer, and because methods of estimating these costs vary
widely from study to study. Nonetheless, there is no practical alternative and CMS believes that doubling
the hourly wage to estimate total cost is an accurate estimation method that has been used successfully in
previous burden calculations.
The cost burden to the respondents is calculated based on the following assumptions:
• The NSC MAC currently processes approximately 45,117 DMEPOS supplier CMS-855S
applications per year.
• Completion of the CMS-855S costs burden depends on the reason for submittal and respondent.
o The reason for submittal of the CMS-855S determines the hour burden.
o The hour burden multiplied by the cost per hour of the respondents determine the cost
burden, as seen in Table 2 (above).
• Cost to the respondents is calculated as follows based on the following assumptions:
o The CMS-855S will likely be completed by large organizations (50%), physicians (25%),
or retail store managers (25%) (BLS category = Chief Executives (50%), Physicians and
Surgeons (25%), and General and Occupational Managers (25%)).
o The record keeping burden is included in the time determined for completion.
o The most recent wage data provided by the Bureau of Labor Statistics (BLS) for May
2017, the mean hourly wage for the general category of "Chief Executive" is $94.25 per
hour (see http://www.bls.gov/oes/current/oes_nat.htm). With fringe benefits and overhead,
the total per hour rate is $188.50
o The most recent wage data provided by the BLS for May 2017 (see
http://www.bls.gov/oes/current/oes_nat.htm), the mean hourly wage for the category of
"Physicians and Surgeons” is $103.22. With fringe benefits and overhead, the total hourly
rate is $206.44.
o The most recent wage data provided by the Bureau of Labor Statistics (BLS) for May
2017, the mean hourly wage for the general category of "General and Occupational
Manager” is $59.35 per hour (see http://www.bls.gov/oes/current/oes_nat.htm). With
fringe benefits and overhead, the total per hour rate is $118.70

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•

The total number of respondents is calculated by the percentage of the type of respondent.
For example, there were 3,429 initial enrollment applications processed. Chief Executives
are 50% of the respondents, therefore, the number of Chief Executives respondents is 50% of
3,429 = 1,715.
Numbers will be rounded to the closest full number when necessary.

The three year summary of all burden hours and costs are reflected in Table 3 (below).
Table 3 – Summary of Burden Hours and Costs for Three Years

Regulation
Section(s)
Initial
Enrollments Medicare
Enrollment
Application
for Durable
Medical
Equipment,
Prosthetics,
Orthotics, and
Supplies
(DMEPOS)
(CMS-855S)

Adding a New
Business
Location –
Medicare
Enrollment
Application
for Durable
Medical
Equipment,
Prosthetics,
Orthotics, and
Supplies
(DMEPOS)
(CMS-855S)

Reactivation Medicare
Enrollment
Application
for Durable
Medical
Equipment,
Prosthetics,
Orthotics, and
Supplies
(DMEPOS)
(CMS-855S)

OMB
Control
No.
09381056

Number
of
Respondents
Chief
Executives
(50%)
1,715 total

Number
of
Responses
3,429
per year

Burden
per Response
(hours)
4 hours

Total
Annual
Burden
(hours)
13,716
hours

General and
Occupational
Managers (25%)
$474.80 total

General and
Occupational
Managers
(25%)
857 total

3,429 total
Chief
Executives
(50%)
622 total

$2,055.00 total

1,242
per year

1 hour

1,242
hours

Physicians
and Surgeons
(25%)
594 total
General and
Occupational
Managers
(25%)
594 total

$638,388.00

General and
Occupational
Managers (25%)
$118.70 total

General and
Occupational
Managers
(25%)
310 total

1,242 total
Chief
Executives
(50%)
1,190 total

Chief Executives
(50%)
$188.50
Physicians and
Surgeons (25%)
$206.44 total

Physicians
and Surgeons
(25%)
310 total

09381056

Total Cost
($)
$28,186,380.00

Physicians and
Surgeons (25%)
$825.76 total

Physicians
and Surgeons
(25%)
857 total

09381056

Hourly Labor
Cost of
Reporting ($)
includes 100%
fringe benefits
Chief Executives
(50%)
$754.00

$514.00 total

2,378
per year

4 hours

9,512
hours

Chief Executives
(50%)
$754.00
Physicians and
Surgeons (25%)
$825.76 total
General and
Occupational
Managers (25%)
$474.80 total

$2,055.00 total

$19,547,160.00

Revalidation Medicare
Enrollment
Application
for Durable
Medical
Equipment,
Prosthetics,
Orthotics, and
Supplies
(DMEPOS)
(CMS-855S)

Reporting a
Change of
Information Medicare
Enrollment
Application
for Durable
Medical
Equipment,
Prosthetics,
Orthotics, and
Supplies
(DMEPOS)
(CMS-855S)

Voluntarily
Withdrawing
from
Medicare Medicare
Enrollment
Application
for Durable
Medical
Equipment,
Prosthetics,
Orthotics, and
Supplies
(DMEPOS)
(CMS-855S)

09381056

2,378 total
Chief
Executives
(50%)
12,978 total

25,956
per year

2 hours

51,912
hours

General and
Occupational
Managers (25%)
$237.40 total

General and
Occupational
Managers
(25%)
6,489 total

25,956 total
Chief
Executives
(50%)
6,053 total

$1,028.00 total

12,105
per year

1 hour

12,105
hours

Physicians
and Surgeons
(25%)
1.5 total
General and
Occupational
Managers
(25%)
1.5 total

$6,221,970.00

General and
Occupational
Managers (25%)
$118.70 total

General and
Occupational
Managers
(25%)
3,026 total

12,105 total
Chief
Executives
(50%)
4 total

Chief Executives
(50%)
$188.50
Physicians and
Surgeons (25%)
$206.44 total

Physicians
and Surgeons
(25%)
3,026 total

09381056

$53,365,536.00

Physicians and
Surgeons (25%)
$412.88 total

Physicians
and Surgeons
(25%)
6,489 total

09381056

Chief Executives
(50%)
$377.00

$514.00 total

7
per year

0.5 hours

3.5
hours

Chief Executives
(50%)
$94.25
Physicians and
Surgeons (25%)
$103.22 total
General and
Occupational
Managers (25%)
$59.35 total

$257.00 total

$900.00

3-year total

09381056

7 total
135,351
Respondents

135,351
Responses

37.5 hours
total

265,471.5
hours

Chief
Executives
(50%)
$7,068.75

$323,881,002.00

Physicians and
Surgeons (25%)
$7,741.50 total
General and
Occupational
Managers
(25%)
$1,483.75 total

$16,294.00 total

13. Cost to Respondents (Capital)
There are no capital costs associated with this collection.

14. Cost to Federal Government
The application form revisions will not result in any additional cost to the federal government because the
application revisions are designed for better flow and to reduce the burden on the supplier and the contractor.
Medicare contractors currently finalize approximately 1.3 million provider/supplier enrollment applications a
year. The CMS-855S form changes will not result in any additional cost to the federal government because
Medicare contractors are already processing applications from suppliers who are enrolling or enrolled in the
Medicare program. Applications will continue to be processed in the normal course of Federal duties.

15. Changes in Burden/Program Changes
The changes in burden since the last revision of this collection instrument cannot accurately be
assessed. The previous burden statement was written to include additional suppliers enrolling due to
regulation RIN: 0938-AS75 (CMS-1654-F). This rule required providers and suppliers to enroll in the
Medicare program as a prerequisite to enrolling with a Medicare Advantage plan. The enrollment
requirements in that regulation were replaced with the preclusion list requirements in RIN: 0938-AT08
(CMS-4182-F). CMS-4182-F has no enrollment requirements pertaining to the CMS-855S application.
In addition, the previous burden statement was inadvertently calculated using only singular data from the
above regulation, RIN: 0938-AS75 (CMS-1654-F). Burden was calculated at only four hours and was not
separated out per submission reason as previously done with past approvals. The CMS-855S hour and cost
burden depends on the submission reason as well as the individual completing the application. The previous
burden only calculated organizations to be DMEPOS suppliers. Organizations constitute approximately 50%

of the respondents. Physicians and retail managers are the other 50% of respondents. To that end, this
burden statement calculated the burden using all parameters, both the individual completing the application
and the submission reason for the completion of this application.
With the use of the PECOS system, updated information technology allows CMS to accurately count the
hours per submittal reason and consequently, total annual hours. There are six submission reasons for
completion of the CMS-855S enrollment application (initial enrollment, enrolling another business
location, revalidation, reactivation, a change of Medicare enrollment information, and voluntary
termination of Medicare enrollment). Currently, the burden hours for the entirety of all submission
reasons and respondents over a three year period is 265,471.5 hours, with approximately 135,351
respondents. A breakdown of this burden hour count is shown in the three tables in #12 above. Both the
burden hour per submission reason as well as the respondent are valued and calculated in this burden
estimate.
This revision of the CMS-855S includes a re-sequencing and re-numbering of the sections and sub-sections
of the application to create a more logical flow of the data to make it easier for the supplier to complete (for
example, by putting most address collection information in one section). The re-sequencing and renumbering of the application was also necessary to maintain continuity with other CMS-855 applications.
Additionally, in this revision of the CMS-855S, some of the main revisions include an exemption from
accreditation option for the supplier to check one of three checkboxes for the reason of the exemption, if
applicable. An expanded definition of managing control was added. The contact person section was made
optional to reduce the reporting burden for suppliers. Additional information, including a link to the website,
was added regarding the application fee. Also, some obsolete questions were removed. Other minor
editorial and clerical corrections were made to better clarify the current data collection. Some of the
instructions were simplified for the suppliers completing this application in response to comments received
by the NSC MAC during meetings discussing the current version of this application.
16. Publication/Tabulation
There are no plans to publish the outcome of the data collection.

17. Expiration Date
The expiration date will be displayed on the top, right-hand corner of page 1 of the CMS-855S application.