Medicare Enrollment Application for Institutional Providers (CMS-855A)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-855A Medicare Enrollment Application - Institutional Providers	Form and Instruction	Modified	Available
Form CMS-855A Medicare Enrollment Application for Institutional Providers	Form and Instruction	Modified	Repair queued
Form CMS-855A Medicare Enrollment Application - Institutional Providers	Form and Instruction	Modified	Available
Form CMS-855A REH Completion of CMS-855A Change of Information	Form and Instruction	Modified	Repair queued
0938-0685. CMS-855A Compare Document.docx	Supplementary Document	Uploaded 2024-09-03	Repair queued
855A COMMENTS RESPONSES 082024 815.docx	Supplementary Document	Uploaded 2024-09-03	Repair queued
CMS-855A - 2024 Revisions Spreadsheet.xlsx	Supplementary Document	Uploaded 2024-09-03	Repair queued
Form CMS-855A Update Notice_SNF Additional Disclosable Parties_AHCA Comments_08.02.2024.pdf	Public Comments	Uploaded 2024-08-02	Available
CMS-855A - Supporting Statement - final.docx	Supporting Statement A	Uploaded 2024-09-03	Repair queued
CMS-855A - Supporting Statement.docx	Supporting Statement A	Uploaded 2024-08-01	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8284	Medicare Enrollment Application for Institutional Providers	Form and Instruction	Modified	Medicare Enrollment Application - Institutional Providers
8284	Medicare Enrollment Application for Institutional Providers	Form and Instruction	Modified
260074	REH Completion of CMS-855A Change of Information	Form and Instruction	Modified	Medicare Enrollment Application - Institutional Providers
260074	REH Completion of CMS-855A Change of Information	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0685	ICR Reference No: 202408-0938-001
Status: Active	Previous ICR Reference No: 202305-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No: CPI
Title: Medicare Enrollment Application for Institutional Providers (CMS-855A)
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: 09/04/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/01/2024
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2027	36 Months From Approved	09/30/2026
Responses	424,092	0	217,493
Time Burden (Hours)	117,128	0	41,143
Cost Burden (Dollars)	0	0	0

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Abstract: The primary function of the CMS-855A Medicare enrollment application is to gather information from a certified provider or certified supplier (hereafter occasionally and collectively referenced as “provider(s)”) that tells us who it is, whether it meets certain qualifications to be a health care provider, where it practices or renders services, the identity of its owners, and other information necessary to establish correct claims payments.

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Authorizing Statute(s): US Code: 42 USC 1395f Name of Law: Conditions of and Limitations on Payment for Services
   US Code: 42 USC 1395g Name of Law: Payment to Providers of Services
   PL: Pub.L. 105 - 33 4313 Name of Law: Provision of certain identification numbers
   US Code: 42 USC 1395m Name of Law: SPECIAL PAYMENT RULES FOR PARTICULAR ITEMS AND SERVICES
   US Code: 42 USC 1395cc Name of Law: AGREEMENTS WITH PROVIDERS OF SERVICES; ENROLLMENT PROCESSES
   US Code: 42 USC 1395l Name of Law: Payment of Benefits
   PL: Pub.L. 104 - 134 31001(I) Name of Law: Debt Collection Improvement Act of 1996
   US Code: 42 USC 1395u Name of Law: Provisions related to the Administration of Part B
   PL: Pub.L. 111 - 148 6001 Name of Law: Affordable Care Act
   PL: Pub.L. 116 - 260 125 (Division CC) Name of Law: Consolidated Appropriations Act of 2021
  

Citations for New Statutory Requirements: PL: Pub.L. 116 - 260 125 (Division CC) Name of Law: Consolidated Appropriations Act of 2021

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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:
	89 FR 12350	02/16/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 55727	07/03/2024
Did the Agency receive public comments on this ICR? Yes

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

table that charts list of burden

IC Title	Form No.	Form Name
Medicare Enrollment Application for Institutional Providers	CMS-855A	Medicare Enrollment Application - Institutional Providers
REH Completion of CMS-855A Change of Information	CMS-855A	Medicare Enrollment Application - Institutional Providers

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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	424,092	217,493	0	0	206,599	0
Annual Time Burden (Hours)	117,128	41,143	0	0	75,985	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: Burden hours have increased by +75,985 hours as a result of additional requirements associated with 2024 Home Health Prospective Payment System Final Rule (CMS-1780-F), The burden increase is mainly due to the completion of the initial enrollment application rather than the change of ownership form.

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Annual Cost to Federal Government: $9,609

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.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

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: 08/01/2024

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