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: 0938-1056	ICR Reference No: 201512-0938-004
Status: Historical Active	Previous ICR Reference No: 201210-0938-010
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Enrollment Application (Form 855S)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 05/09/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/22/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2019	36 Months From Approved	05/31/2016
Responses	95,435	0	43,350
Time Burden (Hours)	54,013	0	113,550
Cost Burden (Dollars)	0	0	0

Authorizing Statute(s): 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
   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 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
   US Code: 42 USC 424.58 Name of Law: DMEPOS Supplier Accreditation Requirements
   US Code: 42 USC 455.460 Name of Law: Application fee
   EO: EO 12600 Name/Subject of EO: Predisclosure Notification Procedures for Confidential Commercial Information
   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

Citations for New Statutory Requirements: None

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	95,435	43,350	52,085
Annual Time Burden (Hours)	54,013	113,550	-59,537
Annual Cost Burden (Dollars)	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 burden hours and cost significantly decreased based on the new availability to use extremely accurate enrollment data (figures for respondents) gathered from the PECOS system and from the NSC MAC itself. In addition, new information technology collection techniques (specifically for revalidation information collection, electronic collection methods, the ability to send supporting documentation electronically and an electronic signature standard) allow DMEPOS suppliers to complete the CMS 855S online, rather than by hand, which greatly reduces the burden hours for completion. This, in turn, reduces the cost to the DMEPOS supplier. The new total annual burden hours associated with this information collection is approximately 54,013 hours. The total individual burden associated with this information collection ranges from approximately 4 hours to half an hour per application. The new total annual burden cost is $4,996,270. The total individual burden associated with the cost of this information ranges from approximately $600 to $10 per application.