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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0938-0685
ICR Reference No:
201410-0938-008
Status:
Historical Active
Previous ICR Reference No:
201210-0938-009
Agency/Subagency:
HHS/CMS
Agency Tracking No:
Title:
Medicare Enrollment Application (CMS-855)
Type of Information Collection:
No material or nonsubstantive change to a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
11/13/2014
Retrieve Notice of Action (NOA)
Date Received in OIRA:
10/06/2014
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
05/31/2016
05/31/2016
05/31/2016
Responses
1,740,800
0
1,740,800
Time Burden (Hours)
290,609
0
290,609
Cost Burden (Dollars)
0
0
0
Abstract:
The primary function of the CMS-855 Medicare enrollment application is to gather information from a provider or supplier that tells us who it is, whether it meets certain qualifications to be a health care provider or supplier, where it practices or renders services, the identity of the owners of the enrolling entity, and other information necessary to establish correct claims payments. For reasons discussed below, CMS is revising the CMS-855 Medicare Enrollment Applications Package (OMB No. 0938-0685).
Authorizing Statute(s):
US Code:
42 USC 1395cc
Name of Law: AGREEMENTS WITH PROVIDERS OF SERVICES; ENROLLMENT PROCESSES
US Code:
42 USC 1395m
Name of Law: SPECIAL PAYMENT RULES FOR PARTICULAR ITEMS AND SERVICES
PL:
Pub.L. 105 - 33 4313
Name of Law: Provision of certain identification numbers
PL:
Pub.L. 104 - 134 31001(I)
Name of Law: Debt Collection Improvement Act of 1996
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
US Code:
42 USC 1395l
Name of Law: Payment of Benefits
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
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
77 FR 20403
04/04/2012
30-day Notice:
Federal Register Citation:
Citation Date:
77 FR 43288
07/24/2012
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Medicare Enrollment Applications
CMS-855, 855B, 855I, 855R
Medicare Enrollment Application - Clinics/group Practices and Certain Other Suppliers
,
Medicare Enrollment Application -Physicians and Non-Physician Practitioners
,
Reassignment of Medicare Benefits
,
Medicare Enrollment Application
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
1,740,800
1,740,800
0
0
0
0
Annual Time Burden (Hours)
290,609
290,609
0
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:
Annual Cost to Federal Government:
$0
Does this IC contain surveys, censuses, or employ statistical methods?
No
Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?
No
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?
Uncollected
Agency Contact:
William Parham 4107864669
Common Form ICR:
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:
(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:
10/06/2014
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