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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-855B Medicare Enrollment Application	Form and Instruction	Unchanged	Available
Form CMS-855B Home Infusion Therapy (HIT) Supplier Enrollment	Form and Instruction	Unchanged	Repair queued
Form CMS-855B Medicare Enrollment Application with Opioid Treatment Program	Form and Instruction	Unchanged	Available
Form CMS-855B Change of Enrollment Information	Form and Instruction	Unchanged	Repair queued
Form CMS-855B Medicare Enrollment Application with Opioid Treatment Program	Form and Instruction	Unchanged	Available
Form CMS-855B Enrolling with a Administrative Contractor (MAC)	Form and Instruction	Unchanged	Repair queued
Form CMS-855B Enrollment Opioid Treatment Program	Form and Instruction	Unchanged	Available
Form CMS-855B Medicare Enrollment Application (Initial Enrollment)	Form and Instruction	Unchanged	Repair queued
Form CMS-855B Medicare Enrollment Application with Opioid Treatment Program	Form and Instruction	Unchanged	Repair queued
Form CMS-855B Medicare Enrollment Application with Opioid Treatment Plan	Form and Instruction	Unchanged	Repair queued
Form CMS-855B Medicare Enrollment Application (Reactivation)	Form and Instruction	Unchanged	Repair queued
Form CMS-855B Medicare Enrollment Application with Opioid Treatment Program	Form and Instruction	Unchanged	Repair queued
Form CMS-855B Medicare Enrollment Application - Revalidation	Form and Instruction	Unchanged	Repair queued
Form CMS-855B Medicare Enrollment Application with Opioid Treatment Program	Form and Instruction	Unchanged	Repair queued
Form CMS-855B Voluntarily Withdrawal (from the Medicare Program)	Form and Instruction	Unchanged	Repair queued
CMS-855B - Response to comments (CMS-1730P).docx	Supplementary Document	Uploaded 2020-11-23	Repair queued
CMS-855B - Supporting Statement A (CMS-1730-F).docx	Supporting Statement A	Uploaded 2020-11-23	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
243317	Home Infusion Therapy (HIT) Supplier Enrollment	Form and Instruction	Unchanged	Medicare Enrollment Application
243317	Home Infusion Therapy (HIT) Supplier Enrollment	Form and Instruction	Unchanged
240713	Change of Enrollment Information	Form and Instruction	Unchanged	Medicare Enrollment Application with Opioid Treatment Program
240713	Change of Enrollment Information	Form and Instruction	Unchanged
240712	Enrolling with a Administrative Contractor (MAC)	Form and Instruction	Unchanged	Medicare Enrollment Application with Opioid Treatment Program
240712	Enrolling with a Administrative Contractor (MAC)	Form and Instruction	Unchanged
240711	Medicare Enrollment Application (Initial Enrollment)	Form and Instruction	Unchanged	Enrollment Opioid Treatment Program
240711	Medicare Enrollment Application (Initial Enrollment)	Form and Instruction	Unchanged
240711	Medicare Enrollment Application (Initial Enrollment)	Form and Instruction	Unchanged	Medicare Enrollment Application with Opioid Treatment Program
240710	Medicare Enrollment Application (Reactivation)	Form and Instruction	Unchanged	Medicare Enrollment Application with Opioid Treatment Plan
240710	Medicare Enrollment Application (Reactivation)	Form and Instruction	Unchanged
240709	Medicare Enrollment Application - Revalidation	Form and Instruction	Unchanged	Medicare Enrollment Application with Opioid Treatment Program
240709	Medicare Enrollment Application - Revalidation	Form and Instruction	Unchanged
240708	Voluntarily Withdrawal (from the Medicare Program)	Form and Instruction	Unchanged	Medicare Enrollment Application with Opioid Treatment Program
240708	Voluntarily Withdrawal (from the Medicare Program)	Form and Instruction	Unchanged

ICR Details

OMB Control No: 0938-1377	ICR Reference No: 202011-0938-012
Status: Historical Active	Previous ICR Reference No: 202008-0938-006
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: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/19/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/24/2020
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2024	36 Months From Approved	07/31/2023
Responses	109,932	0	109,232
Time Burden (Hours)	175,755	0	174,005
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)
   US Code: 42 USC 424.67 Name of Law: Enrollment requirements for opioid treatment programs (OTP)
  

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
US Code: 42 USC 424.67 Name of Law: Enrollment requirements for opioid treatment programs (OTP)

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AU06	Final or interim final rulemaking	85 FR 70298	11/04/2020

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 7

table that charts list of burden

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

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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	109,932	109,232	700	0	0	0
Annual Time Burden (Hours)	175,755	174,005	1,750	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: The proposed changes in this revision request is associated with the June 30, 2020 (85 FR 39408) Notice of Proposed Rulemaking (Medicare and Medicaid Programs; CY 2021 Home Health Prospective Payment System Rate Update; Home Health Quality Reporting Requirements; and Home Infusion Therapy Services Requirements” (CMS-1730-P)). As a result of implementing a new requirement of Home Infusion Therapy (HIT) suppliers, the burden hours have increased by a total of 583 hours annually (1,750 for 3-years).

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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: 11/24/2020

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