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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:
0938-1056
ICR Reference No:
201611-0938-010
Status:
Historical Active
Previous ICR Reference No:
201610-0938-004
Agency/Subagency:
HHS/CMS
Agency Tracking No:
CPI
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:
03/24/2017
Retrieve Notice of Action (NOA)
Date Received in OIRA:
11/18/2016
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
05/31/2019
36 Months From Approved
05/31/2019
Responses
111,262
0
95,435
Time Burden (Hours)
96,677
0
54,013
Cost Burden (Dollars)
0
0
0
Abstract:
The primary function of the CMS 855S Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) supplier enrollment application is to gather information from a supplier that tells us who it is, whether it meets certain qualifications to be a health care supplier, where it renders its services or supplies, the identity of the owners of the enrolling entity, and information necessary to establish correct claims payment. The goal of this revision of the CMS 855S is to simplify and clarify the current data collection and to remove obsolete and/or redundant questions. Grammar and spelling errors were corrected. Limited informational text has been added within the application form and instructions in conjunction with links to websites when greater detail is needed by the supplier. To clarify current data collection differentiations and to be in sync with accreditation coding, Section 3D (“Products and Services Furnished by This Supplier”) has been updated. This revision does not offer any new material data collection.
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
US Code:
42 USC 455.460
Name of Law: Application fee
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
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
EO: EO 12600 Name/Subject of EO: Predisclosure Notification Procedures for Confidential Commercial Information
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:
4
IC Title
Form No.
Form Name
Change of Enrollment Information
CMS-855(S), CMS-855-S
Medicare Durable Medical Equipment Supplier Enrollment Application
,
Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers
Enrollment of MA Providers, Suppliers, and First-Tier, Downstream, and Related Entities (FDRs) (section 422.222)
CMS-855S, CMS-855S
Medicare Durable Medical Equipment Supplier Enrollment Application
,
Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers
Initial Enrollment
CMS-855-S, CMS-855S
Medicare Durable Medical Equipment Supplier Enrollment Application
,
Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers
Revalidation of enrollment information
CMS-855S, CMS-855-S
Medicare Durable Medical Equipment Supplier Enrollment Application
,
Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers
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
111,262
95,435
0
10,666
5,161
0
Annual Time Burden (Hours)
96,677
54,013
0
42,664
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:
In aggregate, the rule will add 10,666 CMS-855S respondents, which translates to an additional 63,996 hours. The CMS-855S form remains unchanged as does our 6-hour per response estimate. For the initial application, the currently approved information collection request inadvertently set out 5,162 respondents when it should have been 10,323 respondents. 10,323 was set out in the Supporting Statement, but 5,162 was entered into the ROCIS system. This correction is also discussed under section 12 of this Supporting 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:
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:
11/18/2016
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