Medicare Enrollment Application (CMS-855ABI)

Forms and Documents

Document Name	Status
Form 855B Medicare Enrollment Applications Form and Instruction	Modified
CMS-855ABI - Supporting Statement A.docx Supporting Statement A	2016-10-21

IC Document Collections

IC ID	Document Title	Status
8284	Medicare Enrollment Applications Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0685	ICR Reference No: 201610-0938-005
Status: Historical Inactive	Previous ICR Reference No: 201605-0938-017
Agency/Subagency: HHS/CMS	Agency Tracking No: CPI
Title: Medicare Enrollment Application (CMS-855ABI)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Comment filed on proposed rule and continue	Conclusion Date: 11/01/2016
	Date Received in OIRA: 10/20/2016
Terms of Clearance: Terms of the previous clearance remain in effect. OMB is withholding approval at this time. Prior to publication of the final rule, the agency should provide a summary of any comments related to the information collection and their response, including any changes made to the ICR as a result of comments. In addition, the agency must enter the correct burden estimates.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2019	36 Months From Approved	08/31/2019
Responses	1,733,400	0	1,733,400
Time Burden (Hours)	289,391	0	289,391
Cost Burden (Dollars)	0	0	0

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Abstract: The primary function of the (CMS-855A,B,I) Medicare enrollment application is to gather information from a provider or supplier that tells us who it is, whether it meets certain qualifications to be a health care provider or supplier, where it practices or renders services, the identity of the owners of the enrolling entity, and other information necessary to establish correct claims payments. For reasons discussed below, CMS is revising the CMS-855 Medicare Enrollment Applications Package (OMB No. 0938-0685).

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Authorizing Statute(s): US Code: 42 USC 1395f Name of Law: Conditions of and Limitations on Payment for Services
   US Code: 42 USC 1395g Name of Law: Payment to Providers of Services
   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. 105 - 33 4313 Name of Law: Provision of certain identification numbers
   PL: Pub.L. 104 - 134 31001(I) Name of Law: Debt Collection Improvement Act of 1996
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AS81	Proposed rulemaking	81 FR 46162	07/15/2016

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 46162	07/15/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Medicare Enrollment Applications	CMS-855, 855B, 855I	Medicare Enrollment Application - Clinics/group Practices and Certain Other Suppliers ,   Medicare Enrollment Application -Physicians and Non-Physician Practitioners ,   Medicare Enrollment Application

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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 proposed rule would add 53,332 respondents which translates to an additional 223,932 hours. The CMS-855 forms remain unchanged from what is currently approved by OMB as does our per response estimates.

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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: 10/20/2016

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