Medicare Enrollment Applications (CMS-855A, B, and I)

Forms and Documents

Document Name	Status
Form CMS-855A Medicare Enrollment Applications Form and Instruction	Modified
CMS-855ABI - Supporting Statement A [rev 11-15-2016 by OSORA PRA].docx Supporting Statement A	2016-11-16

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: 201611-0938-009
Status: Historical Active	Previous ICR Reference No: 201610-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No: CPI
Title: Medicare Enrollment Applications (CMS-855A, B, and I)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/06/2017
	Date Received in OIRA: 11/16/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2019	36 Months From Approved	08/31/2019
Responses	1,786,732	0	1,733,400
Time Burden (Hours)	513,435	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.

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

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AS81	Final or interim final rulemaking	81 FR 80170	11/15/2016

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 46162	07/15/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 80170	11/15/2016
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-855A, CMS-855B, CMS-855I	Medicare Enrollment Application - Institutional Providers ,   Medicare Enrollment Application - Clinics/Group Practices and Certain Other Suppliers ,   Medicare Enrollment Application - Physicians and Non-Physician Practitioners

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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	1,786,732	1,733,400	0	53,332	0	0
Annual Time Burden (Hours)	513,435	289,391	0	224,044	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: Changing Regulations

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

Burden Reduction Due to:

Short Statement: The forms have been revised by removing the “Draft” watermark. Otherwise, there are no changes to any of the application forms. Based on the CMS-1654-F final rule, this iteration of the CMS-855A/B/I information collection request revises the burden estimates (number of respondents and hours) that are currently approved by OMB. In aggregate, the rule will add 53,332 respondents which translates to an additional 224,044 hours. The currently approved per hour response is unchanged.

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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: 11/16/2016

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