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Statement of Need: The Medicare program is currently the principal payer for health care for 39.2 million enrolled beneficiaries. Under section 1802 of the Act, a beneficiary may obtain health services from any institution, agency, or person qualified to participate in Medicare. Some qualifications to participate are specified in statute, such as in sections 1819, 1834, 1861, 1866, and 1891 of the Act. Many more are in our regulations, especially at 42 CFR subchapter E, which concerns standards and certification requirements.

Summary of the Legal Basis: Because we are intending to use the form HCFA 855 as the principal information collection instrument, we provide the following information about the data request on the forms. In addition to the legal authority cited, the following additional cites grant us the authority to collect the information required to complete the form HCFA 855: Section 1814(a) of the Act states that payment for services furnished to an individual may only be made to providers and only if a written request is filled in such a form and manner as the Secretary may prescribe. Sections 1815 and 1833(e) of the Act authorize the Secretary to withhold Medicare payments until the provider or supplier furnishes such information as may be necessary to determine amounts due. Section 1866(a)(1) of the Act establishes provider agreement requirements, including a requirement not to charge the beneficiary if the provider would have been entitled to Medicare payment had the provider compiled with procedural requirements.

Alternatives: If this rule is not published, we would weaken our authority to prevent fraudulent or abusive providers and suppliers from billing the Medicare program.

Anticipated Costs and Benefits: This is an administrative initiative that may result in Medicare program saving but at this time those savings are inestimable. We believe the probable costs providers or suppliers would incur as a result of this rule would be negligible.

Risks: This rule will potentially improve the information and documentation collection used to determine if a provider or supplier should be granted billing privileges. This rule will promote compliance with Medicare requirements, and also prevent abuse of the Medicare program and inappropriate uses of Medicare funds by ensuring that payment is made only for services furnished by qualified individuals or entities by requiring that the providers and suppliers of those services prove their qualifications and identity. If the provider or supplier failed to meet the requirements or submit the required information, we would not enroll them in the Medicare program or we would remove them if they were currently in the program.