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OMB Control No: 0938-1377	ICR Reference No: 202507-0938-001
Status: Received in OIRA	Previous ICR Reference No: 202105-0938-009
Agency/Subagency: HHS/CMS	Agency Tracking No: CPI
Title: Medicare Enrollment Application for Clinics/Group Practices and Other Suppliers (CMS-855B)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 07/03/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	167,978	0
Time Burden (Hours)	299,550	0
Cost Burden (Dollars)	0	0

Abstract: The primary function of the CMS 855B enrollment application for Clinics, Group Practices and Certain Other Suppliers is to gather information from the organization that tells us what it is, whether it meets certain qualifications to be a health care supplier, where it renders services and information necessary to establish the correct claims payment. The goal of evaluating and revising the CMS 855B enrollment application is to simplify and clarify the information collection without jeopardizing our need to collect specific information. The majority of the revisions are very minor in nature such as spelling and formatting corrections, removal of duplicate fields and instruction clarification for the organization/group. The Sections and Sub-Sections within the form are also being re-numbered and re-sequenced to create a more logical flow of the data collection. In addition, CMS is adding a data collection for an address to mail the periodic request for the revalidation of enrollment information (only if it differs from other addresses currently collected). Other than the revalidation mailing address described above, new data being collected in this revision package is a checkbox indicating whether or not an organization is wholly owned or operated by a hospital, the inclusion of a new supplier type (Centralized Flu Biller) and information on, if applicable, where the supplier stores its patient records electronically. The attachment for Opioid Treatment Programs (OTPs) is used to capture the OTP personnel and consists of limited data fields (name, Social Security Number, National Provider Identifier, and license number) in response to the “SUPPORT for Patients and Communities Act” that was signed into law on October 24, 2018. Section 2005 of the SUPPORT Act establishes a new Medicare Part B benefit for opioid use disorder (OUD) treatment services furnished by opioid treatment programs (OTPs) beginning on or after January 1, 2020.

Authorizing Statute(s): PL: Pub.L. 110 - 275 135(a) Name of Law: Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)
   PL: Pub.L. 115 - 271 2005 Name of Law: Substance Use Disorder Prevention Promotes Opioid Recovery Treatment for Patients and Communities Ac
   PL: Pub.L. 104 - 134 31001(1) Name of Law: Debt Collection Improvement Act of 1996 (DCIA)
   PL: Pub.L. 109 - 220 508 Name of Law: Rehabilitation Act of 1973 as incorporated with the Americans With Disabilities Act of 2005
   PL: Pub.L. 105 - 133 4313 Name of Law: Balanced Budget Act of 1997 (BBA)
   US Code: 42 USC 424.67 Name of Law: Enrollment requirements for opioid treatment programs (OTP)

Citations for New Statutory Requirements: PL: Pub.L. 109 - 220 508 Name of Law: Rehabilitation Act of 1973 as incorporated with the Americans With Disabilities Act of 2005
PL: Pub.L. 104 - 134 31001(1) Name of Law: Debt Collection Improvement Act of 1996 (DCIA)
PL: Pub.L. 105 - 133 4313 Name of Law: Balanced Budget Act of 1997 (BBA)
PL: Pub.L. 110 - 275 135(a) Name of Law: Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)
PL: Pub.L. 115 - 271 2005 Name of Law: Substance Use Disorder Prevention Promotes Opioid Recovery Treatment for Patients and Communities Ac
US Code: 42 USC 424.67 Name of Law: Enrollment requirements for opioid treatment programs (OTP)

ICR Summary of Burden

	Total Request	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	167,978	59,336	108,642
Annual Time Burden (Hours)	299,550	127,665	171,885
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: Current PECOS data suggests that the number of respondents in each of the categories that make up the 855 form have increased which resulted in a total increase of 59,336 respondents. In addition, several revisions are being made to the 855 form which also impacted the increase of burden. Thus, burden has increased from 171,885 to 299,550 hours.

Annual Cost to Federal Government: $2,351,818

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. Yes

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. Yes

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? No

Agency Contact: Jamaa Hill 301 492-4190