Medicare Enrollment Application for Clinics/ Group Practice and Certain Other Suppliers

Forms and Documents

Document Name	Status
Form CMS-855B Change of Information Form and Instruction	New
Form CMS-855B Revalidation of Enrollment Form and Instruction	New
Form CMS-855B Initial Enrollment Form and Instruction	New
855B PECOS Screen Shots for PRA Package - 04192012.DOCX Supplementary Document	2013-02-11
CMS 855B - Revisons Spreadsheet - 04182012.xlsx Supplementary Document	2013-02-11
CMS 855B - section mapping - 04182012.xlsx Supplementary Document	2013-02-11
CMS-855B Supporting Statement.docx Supporting Statement A	2013-02-11

IC Document Collections

IC ID	Document Title	Status
205742	Change of Information Form and Instruction	New
205741	Revalidation of Enrollment Form and Instruction	New
205740	Initial Enrollment Form and Instruction	New

ICR Details

OMB Control No: 0938-1198	ICR Reference No: 201302-0938-005
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: 18804
Title: Medicare Enrollment Application for Clinics/ Group Practice and Certain Other Suppliers
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/10/2013
	Date Received in OIRA: 02/12/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2016	36 Months From Approved
Responses	31,000	0	0
Time Burden (Hours)	103,000	0	0
Cost Burden (Dollars)	0	0	0

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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.

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Authorizing Statute(s): US Code: 31 USC 7701(c) Name of Law: Tax Payer Identification Number
   US Code: 26 USC 501 Name of Law: Exemption from tax on corporations, certain trusts, etc.
   US Code: 26 USC 3402(t) Name of Law: Income tax collected at source
   US Code: 42 USC 1395g Name of Law: PAYMENT TO PROVIDERS OF SERVICES
   US Code: 42 USC 1320a-3 Name of Law: DISCLOSURE OF OWNERSHIP AND RELATED INFORMATION
   US Code: 42 USC 1320a-3a Name of Law: DISCLOSURE REQUIREMENTS FOR OTHER PROVIDERS UNDER PART B OF MEDICARE
   US Code: 42 USC 1395f Name of Law: CONDITIONS OF AND LIMITATIONS ON PAYMENT FOR SERVICES
   US Code: 42 USC 1395l Name of Law: PAYMENT OF BENEFITS
   US Code: 42 USC 1395cc Name of Law: AGREEMENTS WITH PROVIDERS OF SERVICES; ENROLLMENT PROCESSES
   US Code: 42 USC 1395u Name of Law: PROVISIONS RELATING TO THE ADMINISTRATION OF PART B
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 32118	05/31/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 75634	12/12/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Initial Enrollment	CMS-855B	Medicare Enrollment Application for Clinics/ Group Practice and Certain Other Suppliers
Revalidation of Enrollment	CMS-855B	Medicare Enrollment Application for Clinics/ Group Practice and Certain Other Suppliers
Change of Information	CMS-855B	Medicare Enrollment Application for Clinics/ Group Practice and Certain Other Suppliers

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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	31,000	0	0	31,000	0	0
Annual Time Burden (Hours)	103,000	0	0	103,000	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: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a request for a new control number. However, the CMS-855B is also approved under 0938-0685. Once the new contorl number is issued, the burden assigned under 0938-0685 will be removed.

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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

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Common Form ICR:  No

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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: 02/12/2013

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