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OMB Control No: 0938-0685	ICR Reference No: 201605-0938-017
Status: Historical Active	Previous ICR Reference No: 201410-0938-008
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Enrollment Application (CMS-855ABI)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/15/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/31/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2019	36 Months From Approved	08/31/2016
Responses	1,733,400	0	1,740,800
Time Burden (Hours)	289,391	0	290,609
Cost Burden (Dollars)	0	0	0

Abstract: The primary function of the (CMS-855A,B,I) 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 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 1395cc Name of Law: AGREEMENTS WITH PROVIDERS OF SERVICES; ENROLLMENT PROCESSES
   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:
	81 FR 18855	04/01/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 34343	05/31/2016
Did the Agency receive public comments on this ICR? No

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	1,733,400	1,740,800	-7,400
Annual Time Burden (Hours)	289,391	290,609	-1,218
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: CMS is removing the CMS-855R application from the CMS-855 Medicare Enrollment Applications Package (OMB No. 0938-0685). On May 22, 2013, in accordance with the Paperwork Reduction Act, OMB approved a reinstatement without change of a previously approved collection of the Medicare enrollment applications (specifically, the CMS-855A, CMS-855B, CMS-855I and CMS-855R Medicare enrollment application bundle, OMB number 0938-0685, ICR reference number 201210-0938-009). This was necessary in order to allow the CMS-855A, CMS-855B and CMS-855I to remain active. That collection expires on May 31, 2016. While the CMS-855R enrollment form was included in that collection, it was not active and was not being used by the public as CMS now uses the revised CMS-855R, OMB number 0938-1179, approved by OMB on November 1, 2012 (ICR reference number 201206-0938-007) and renewed via approval by OMB on April 15, 2016 (ICR reference number 201509-0938-008). The CMS-855R application under OMB number 0938-0685 is now being removed from the Medicare application bundle collection. There is no duplication of CMS-855R Medicare application forms as only the CMS-855R Medicare application form under OMB approval number 0938-1179 is active. Therefore, CMS is seeking to redefine the CMS-855 Medicare Enrollment Applications Package (OMB No. 0938-0685) to include only the CMS-855A, CMS-855B, and CMS-855I enrollment applications. The adjustments to the total burden (number 12, Table 4) reflect the removal of the CMS-855R from this CMS-855 enrollment package. The total respondents were reduced by 7,400, making the new total 1,733,400. The annual burden hours were reduced by 1,218, making the new total 289,393 hours. The small amount of burden hours removed by the CMS-855R does not significantly impact the burden hours of this collection. The total cost was reduced by $12,879,435, which reflects the $8,320 reduction from the CMS-855R removal as well as the reduction from using the Bureau of Labor Statistics (BLS) wage rates, making the new total $18,386,355. This significant reduction is due to CMS estimation of using a wage rate of $150 per hour for professional staff rather than $81.84 as reported by the BLS. As previously mentioned, CMS determined the wage rates based on the most recent data from the Bureau of Labor Statistics, which include fringe benefits and overhead.

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]? 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? Uncollected

Agency Contact: Jamaa Hill 301 492-4190

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