Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers (Form 855S)

ICR 202201-0938-015

OMB: 0938-1056

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Form and Instruction
Modified
Form and Instruction
Modified
Form and Instruction
Modified
Form and Instruction
Modified
Form and Instruction
Modified
Justification for No Material/Nonsubstantive Change
2022-01-11
Supporting Statement A
2021-10-19
ICR Details
0938-1056 202201-0938-015
Received in OIRA 202001-0938-004
HHS/CMS CPI
Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers (Form 855S)
No material or nonsubstantive change to a currently approved collection   No
Regular 01/11/2022
  Requested Previously Approved
10/31/2024 10/31/2024
45,115 45,115
88,491 88,491
0 0

The primary function of the CMS 855S Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) supplier enrollment application is to gather information from a supplier that tells us who it is, whether it meets certain qualifications to be a health care supplier, where it renders its services or supplies, the identity of the owners of the enrolling entity, and information necessary to establish correct claims payment. The goal of this revision of the CMS 855S is to simplify and clarify the current data collection and to remove obsolete and/or redundant questions. Grammar and spelling errors were corrected. Limited informational text has been added within the application form and instructions in conjunction with links to websites when greater detail is needed by the supplier. To clarify current data collection differentiations and to be in sync with accreditation coding, Section 3D (“Products and Services Furnished by This Supplier”) has been updated. This revision does not offer any new material data collection.

US Code: 42 USC 1395cc Name of Law: AGREEMENTS WITH PROVIDERS OF SERVICES; ENROLLMENT PROCESSES
   PL: Pub.L. 109 - 220 508 Name of Law: Rehabilitation Act of 1973 as incorporated with the Americans With Disabilities Act of 2005
   US Code: 42 USC 424.57 Name of Law: DMEPOS Supplier Standards
   US Code: 42 USC 455.460 Name of Law: Application fee
   PL: Pub.L. 105 - 33 4313 Name of Law: Balanced Budget Act of 1997
   PL: Pub.L. 104 - 134 31001(I) Name of Law: Debt Collection Improvement Act of 1996
   US Code: 42 USC 1395l Name of Law: Payment of Benefits
   US Code: 42 USC 1395f Name of Law: Requirements of Requests and Certifications
   US Code: 42 USC 1395g Name of Law: Requirements of Requests and Certifications
   US Code: 42 USC 1395m Name of Law: SPECIAL PAYMENT RULES FOR PARTICULAR ITEMS AND SERVICES
   US Code: 42 USC 424.58 Name of Law: DMEPOS Supplier Accreditation Requirements
   PL: Pub.L. 111 - 148 6201(3) Name of Law: Required Fingerprint Check as Part of Criminal History Background Check
   US Code: 42 USC 3004(b)(1) Name of Law: Public Health Service Act
   EO: EO 12600 Name/Subject of EO: Predisclosure Notification Procedures for Confidential Commercial Information
  
None

Not associated with rulemaking

  84 FR 32924 07/10/2019
84 FR 65396 11/27/2019
No

  Total Request 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 45,115 45,115 0 0 0 0
Annual Time Burden (Hours) 88,491 88,491 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
    Yes
    Yes
No
No
No
No
Jamaa Hill 301 492-4190

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
01/11/2022


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