Medicare Enrollment Application for Clinics/Group Practices and Other Suppliers (CMS-855B)

Forms and Documents

Document Name	Status
Form CMS-855B Change of Enrollment Information Form and Instruction	New
Form CMS-855B Enrolling with a Administrative Contractor (MAC) Form and Instruction	New
Form CMS-855B Medicare Enrollment Application (Initial Enrollment) Form and Instruction	New
Form CMS-855B Medicare Enrollment Application (Reactivation) Form and Instruction	New
Form CMS-855B Medicare Enrollment Application - Revalidation Form and Instruction	New
Form CMS-855B Voluntarily Withdrawal (from the Medicare Program) Form and Instruction	New
CMS-855B - Supporting Statement - Final.docx Supporting Statement A	2020-07-14

IC Document Collections

IC ID	Document Title	Status
240713	Change of Enrollment Information Form and Instruction	New
240712	Enrolling with a Administrative Contractor (MAC) Form and Instruction	New
240711	Medicare Enrollment Application (Initial Enrollment) Form and Instruction	New
240710	Medicare Enrollment Application (Reactivation) Form and Instruction	New
240709	Medicare Enrollment Application - Revalidation Form and Instruction	New
240708	Voluntarily Withdrawal (from the Medicare Program) Form and Instruction	New

ICR Details

OMB Control No: 0938-1377	ICR Reference No: 202001-0938-007
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CPI - 855B
Title: Medicare Enrollment Application for Clinics/Group Practices and Other Suppliers (CMS-855B)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/14/2020
	Date Received in OIRA: 03/20/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2023	36 Months From Approved
Responses	109,232	0	0
Time Burden (Hours)	174,005	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The primary function of the CMS 855B enrollment application for Clinics, Group Practices and Certain Other Suppliers is to gather information from the organization that tells us what it is, whether it meets certain qualifications to be a health care supplier, where it renders services and information necessary to establish the correct claims payment. The goal of evaluating and revising the CMS 855B enrollment application is to simplify and clarify the information collection without jeopardizing our need to collect specific information. The majority of the revisions are very minor in nature such as spelling and formatting corrections, removal of duplicate fields and instruction clarification for the organization/group. The Sections and Sub-Sections within the form are also being re-numbered and re-sequenced to create a more logical flow of the data collection. In addition, CMS is adding a data collection for an address to mail the periodic request for the revalidation of enrollment information (only if it differs from other addresses currently collected). Other than the revalidation mailing address described above, new data being collected in this revision package is a checkbox indicating whether or not an organization is wholly owned or operated by a hospital, the inclusion of a new supplier type (Centralized Flu Biller) and information on, if applicable, where the supplier stores its patient records electronically. The attachment for Opioid Treatment Programs (OTPs) is used to capture the OTP personnel and consists of limited data fields (name, Social Security Number, National Provider Identifier, and license number) in response to the “SUPPORT for Patients and Communities Act” that was signed into law on October 24, 2018. Section 2005 of the SUPPORT Act establishes a new Medicare Part B benefit for opioid use disorder (OUD) treatment services furnished by opioid treatment programs (OTPs) beginning on or after January 1, 2020.

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Authorizing Statute(s): PL: Pub.L. 110 - 275 135(a) Name of Law: Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)
   PL: Pub.L. 115 - 271 2005 Name of Law: Substance Use Disorder Prevention Promotes Opioid Recovery Treatment for Patients and Communities Ac
   PL: Pub.L. 109 - 220 508 Name of Law: Rehabilitation Act of 1973 as incorporated with the Americans With Disabilities Act of 2005
   PL: Pub.L. 104 - 134 31001(1) Name of Law: Debt Collection Improvement Act of 1996 (DCIA)
   PL: Pub.L. 105 - 133 4313 Name of Law: Balanced Budget Act of 1997 (BBA)
  

Citations for New Statutory Requirements: PL: Pub.L. 109 - 220 508 Name of Law: Rehabilitation Act of 1973 as incorporated with the Americans With Disabilities Act of 2005
PL: Pub.L. 104 - 134 31001(1) Name of Law: Debt Collection Improvement Act of 1996 (DCIA)
PL: Pub.L. 105 - 133 4313 Name of Law: Balanced Budget Act of 1997 (BBA)
PL: Pub.L. 110 - 275 135(a) Name of Law: Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)
PL: Pub.L. 115 - 271 2005 Name of Law: Substance Use Disorder Prevention Promotes Opioid Recovery Treatment for Patients and Communities Ac

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 50846	09/26/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 2136	01/14/2020
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 6

IC Title	Form No.	Form Name
Voluntarily Withdrawal (from the Medicare Program)	CMS-855B	Medicare Enrollment Application with Opioid Treatment Program
Medicare Enrollment Application - Revalidation	CMS-855B	Medicare Enrollment Application with Opioid Treatment Program
Medicare Enrollment Application (Reactivation)	CMS-855B	Medicare Enrollment Application with Opioid Treatment Plan
Medicare Enrollment Application (Initial Enrollment)	CMS-855B, CMS-855B	Enrollment Opioid Treatment Program ,   Medicare Enrollment Application with Opioid Treatment Program
Enrolling with a Administrative Contractor (MAC)	CMS-855B	Medicare Enrollment Application with Opioid Treatment Program
Change of Enrollment Information	CMS-855B	Medicare Enrollment Application with Opioid Treatment Program

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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	109,232	0	109,232	0	0	0
Annual Time Burden (Hours)	174,005	0	174,005	0	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: No

Burden Reduction Due to:

Short Statement: This is a new collection of information.

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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.     Yes

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? No

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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: 03/20/2020

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