Medicare Enrollment Application (Form 855S)

Forms and Documents

Document Name	Status
Form CMS-855S Adding Information (New Business Data) Form and Instruction	New
Form CMS-855S Reactivation - Medicare Enrollment Application Form and Instruction	New
Form CM-855S Voluntary Withdrawing from Medicare Form and Instruction	New
Form CMS-855S Enrollment of MA Providers, Suppliers, and First-Tier, Downstream, and Related Entities (FDRs) (section 422.222) Form and Instruction	Removed
Form CMS-855S Revalidation of enrollment information Form and Instruction	Modified
Form CMS-855(S) Change of Enrollment Information Form and Instruction	Modified
Form CMS-855-S Initial Enrollment Form and Instruction	Modified
CMS-855S - Supporting Statement Final.pdf Supporting Statement A	2020-09-10

IC Document Collections

IC ID	Document Title	Status
243576	Adding Information (New Business Data) Form and Instruction	New
243574	Reactivation - Medicare Enrollment Application Form and Instruction	New
243573	Voluntary Withdrawing from Medicare Form and Instruction	New
224024	Enrollment of MA Providers, Suppliers, and First-Tier, Downstream, and Related Entities (FDRs) (section 422.222) Form and Instruction	Removed
197902	Revalidation of enrollment information Form and Instruction	Modified
197901	Change of Enrollment Information Form and Instruction	Modified
197900	Initial Enrollment Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1056	ICR Reference No: 202001-0938-004
Status: Received in OIRA	Previous ICR Reference No: 201611-0938-010
Agency/Subagency: HHS/CMS	Agency Tracking No: CPI
Title: Medicare Enrollment Application (Form 855S)
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 09/14/2020

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	45,115	0
Time Burden (Hours)	88,491	0
Cost Burden (Dollars)	0	0

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Abstract: The primary function of the CMS 855S Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) supplier enrollment application is to gather information from a supplier that tells us who it is, whether it meets certain qualifications to be a health care supplier, where it renders its services or supplies, the identity of the owners of the enrolling entity, and information necessary to establish correct claims payment. The goal of this revision of the CMS 855S is to simplify and clarify the current data collection and to remove obsolete and/or redundant questions. Grammar and spelling errors were corrected. Limited informational text has been added within the application form and instructions in conjunction with links to websites when greater detail is needed by the supplier. To clarify current data collection differentiations and to be in sync with accreditation coding, Section 3D (“Products and Services Furnished by This Supplier”) has been updated. This revision does not offer any new material data collection.

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Authorizing Statute(s): PL: Pub.L. 109 - 220 508 Name of Law: Rehabilitation Act of 1973 as incorporated with the Americans With Disabilities Act of 2005
   US Code: 42 USC 424.57 Name of Law: DMEPOS Supplier Standards
   US Code: 42 USC 455.460 Name of Law: Application fee
   PL: Pub.L. 105 - 33 4313 Name of Law: Balanced Budget Act of 1997
   PL: Pub.L. 104 - 134 31001(I) Name of Law: Debt Collection Improvement Act of 1996
   US Code: 42 USC 1395l Name of Law: Payment of Benefits
   US Code: 42 USC 1395f Name of Law: Requirements of Requests and Certifications
   US Code: 42 USC 1395g Name of Law: Requirements of Requests and Certifications
   US Code: 42 USC 1395cc Name of Law: AGREEMENTS WITH PROVIDERS OF SERVICES; ENROLLMENT PROCESSES
   US Code: 42 USC 1395m Name of Law: SPECIAL PAYMENT RULES FOR PARTICULAR ITEMS AND SERVICES
   US Code: 42 USC 424.58 Name of Law: DMEPOS Supplier Accreditation Requirements
   PL: Pub.L. 111 - 148 6201(3) Name of Law: Required Fingerprint Check as Part of Criminal History Background Check
   US Code: 42 USC 3004(b)(1) Name of Law: Public Health Service Act
   EO: EO 12600 Name/Subject of EO: Predisclosure Notification Procedures for Confidential Commercial Information
  

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:
	84 FR 32924	07/10/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 65396	11/27/2019
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 6

IC Title	Form No.	Form Name
Initial Enrollment	CMS-855-S, CMS-855S	Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers ,   Medicare Durable Medical Equipment Supplier Enrollment Application
Change of Enrollment Information	CMS-855(S), CMS-855-S	Medicare Durable Medical Equipment Supplier Enrollment Application ,   Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers
Revalidation of enrollment information	CMS-855S, CMS-855-S	Medicare Durable Medical Equipment Supplier Enrollment Application ,   Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers
Adding Information (New Business Data)	CMS-855S	Medicare Enrollment Application
Enrollment of MA Providers, Suppliers, and First-Tier, Downstream, and Related Entities (FDRs) (section 422.222)	CMS-855S, CMS-855S	Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers ,   Medicare Durable Medical Equipment Supplier Enrollment Application
Voluntary Withdrawing from Medicare	CM-855S	Medicare Enrollment Application
Reactivation - Medicare Enrollment Application	CMS-855S	Medicare Enrollment Application

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ICR Summary of Burden

	Total Request	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	45,115	0	0	0	-66,147	111,262
Annual Time Burden (Hours)	88,491	0	0	0	-8,186	96,677
Annual Cost Burden (Dollars)	0	0	0	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: Burden hours have decreased from 96,677 to 88,491 hours. With the use of the PECOS system, updated information technology allows CMS to accurately count the hours per submittal reason and consequently, total annual hours. There are six submission reasons for completion of the CMS-855S enrollment application (initial enrollment, enrolling another business location, revalidation, reactivation, a change of Medicare enrollment information, and voluntary termination of Medicare enrollment). Currently, the burden hours for the entirety of all submission reasons and respondents over a three year period is 265,471.5 hours.

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Annual Cost to Federal Government: $0

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

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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: 09/14/2020

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