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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:
202305-0938-003
Status:
Active
Previous ICR Reference No:
202103-0938-010
Agency/Subagency:
HHS/CMS
Agency Tracking No:
CPI
Title:
Medicare Enrollment Application for Institutional Providers (CMS-855A)
Type of Information Collection:
Reinstatement with change of a previously approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
09/21/2023
Retrieve Notice of Action (NOA)
Date Received in OIRA:
05/05/2023
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
09/30/2026
36 Months From Approved
Responses
217,493
0
0
Time Burden (Hours)
41,143
0
0
Cost Burden (Dollars)
0
0
0
Abstract:
The primary function of the CMS-855A Medicare enrollment application is to gather information from a certified provider or certified supplier (hereafter occasionally and collectively referenced as “provider(s)”) that tells us who it is, whether it meets certain qualifications to be a health care provider, where it practices or renders services, the identity of its owners, 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 1395g
Name of Law: Payment to Providers of Services
PL:
Pub.L. 105 - 33 4313
Name of Law: Provision of certain identification numbers
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
PL:
Pub.L. 116 - 260 125 (Division CC)
Name of Law: Consolidated Appropriations Act of 2021
US Code:
42 USC 1395f
Name of Law: Conditions of and Limitations on Payment for Services
Citations for New Statutory Requirements:
PL: Pub.L. 116 - 260 125 (Division CC) Name of Law: Consolidated Appropriations Act of 2021
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:
87 FR 76626
12/15/2022
30-day Notice:
Federal Register Citation:
Citation Date:
88 FR 28554
05/04/2023
Did the Agency receive public comments on this ICR?
Yes
Number of Information Collection (IC) in this ICR:
2
IC Title
Form No.
Form Name
Medicare Enrollment Application for Institutional Providers
CMS-855A
Medicare Enrollment Application - Institutional Providers
REH Completion of CMS-855A Change of Information
CMS-855A
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
217,493
0
23
-85,328
0
302,798
Annual Time Burden (Hours)
41,143
0
23
-56,006
0
97,126
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:
Yes
Burden Reduction Due to:
Miscellaneous Actions
Short Statement:
There will be a burden increase associated with this request for reinstatement, addition of data elements, and burden changes pursuant to two final rules. We proposed that the number of: (1) respondents and responses would increase by 45,473; (2) hours would increase by 9,356; and (3) cost would increase by $383,022.
Annual Cost to Federal Government:
$9,125
Does this IC contain surveys, censuses, or employ statistical methods?
No
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
No
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
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?
No
Agency Contact:
William Parham 410 786-4669 william.parham@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:
05/05/2023
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