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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:
201611-0938-009
Status:
Historical Active
Previous ICR Reference No:
201610-0938-005
Agency/Subagency:
HHS/CMS
Agency Tracking No:
CPI
Title:
Medicare Enrollment Applications (CMS-855A, B, and I)
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:
03/06/2017
Retrieve Notice of Action (NOA)
Date Received in OIRA:
11/16/2016
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
08/31/2019
36 Months From Approved
08/31/2019
Responses
1,786,732
0
1,733,400
Time Burden (Hours)
513,435
0
289,391
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.
Authorizing Statute(s):
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
PL:
Pub.L. 105 - 33 4313
Name of Law: Provision of certain identification numbers
US Code:
42 USC 1395g
Name of Law: Payment to Providers of Services
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
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:
0938-AS81
Final or interim final rulemaking
81 FR 80170
11/15/2016
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
81 FR 46162
07/15/2016
30-day Notice:
Federal Register Citation:
Citation Date:
81 FR 80170
11/15/2016
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-855A, CMS-855B, CMS-855I
Medicare Enrollment Application - Clinics/Group Practices and Certain Other Suppliers
,
Medicare Enrollment Application - Physicians and Non-Physician Practitioners
,
Medicare Enrollment Application - Institutional Providers
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
1,786,732
1,733,400
0
53,332
0
0
Annual Time Burden (Hours)
513,435
289,391
0
224,044
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
Yes
Burden Increase Due to:
Changing Regulations
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
The forms have been revised by removing the “Draft” watermark. Otherwise, there are no changes to any of the application forms. Based on the CMS-1654-F final rule, this iteration of the CMS-855A/B/I information collection request revises the burden estimates (number of respondents and hours) that are currently approved by OMB. In aggregate, the rule will add 53,332 respondents which translates to an additional 224,044 hours. The currently approved per hour response is unchanged.
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:
Mitch Bryman 410 786-5258 Mitch.Bryman@cms.hhs.gov
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:
11/16/2016
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