CMS-855B - Supporting Statement - 30-day

Supporting Statement for Paperwork Reduction Act Submissions

Medicare Enrollment Application for Clinics/Group Practices and Other Suppliers Form CMS-855B (OMB Control Number: 0938-1377) Revision and Reinstatement of Currently Approved Collection

BACKGROUND

The primary function of the Form CMS-855B Medicare enrollment application is to gather information from an organizational supplier that tells us who it is, whether it meets certain qualifications to be a health care supplier, where it practices or renders services, the identity of its owners, and other information necessary to establish correct claims payments.

This information collection request (ICR) seeks:

• Approval for revisions to the Form CMS-855B. In general, these changes will gather certain additional data to help: (1) Medicare Administrative Contractors (MAC) validate the accuracy and completeness of the information the supplier furnishes; and (2) ensure that payments are made only to qualified and legitimate organizational suppliers.

• To reinstate the Form CMS-855B, the OMB approval date for which expired on March 31, 2024.

1. JUSTIFICATION

1. Need and Legal Basis

Various sections of the Act, the United States Code (U.S.C.), Internal Revenue Service (IRS) Code, and the CFR require providers and suppliers to furnish information concerning the amounts due and the identification of individuals or entities that furnish medical services to beneficiaries before payment can be made.

• Sections 1814(a), 1815(a), and 1833(e) of the Act require the submission of information necessary to determine the amounts due to a provider or other person.

• Section 1842(r) of the Act requires us to establish a system for furnishing a unique identifier for each physician who furnishes services for which payment may be made. To do so, we need to collect information unique to that provider or supplier.

• The Balanced Budget Act of 1997 (BBA) (Public Law 105-33), section 4313, amended sections 1124(a)(1) and 1124A of the Act to require disclosure of both the employer identification number (EIN) and social security number (SSN) of each provider or supplier, each person with ownership or control interest in the provider or supplier, and any managing employees.

• Section 31001(I) of the Debt Collection Improvement Act of 1996 (DCIA) (Public Law 104-134) amended 31 U.S.C. 7701 by adding paragraph (c) to require that any person or entity doing business with the federal government provide their tax identification number (TIN).

• Sections 1866(b)(2)(D) and 1842(h)(8) of the Act require denial of enrollment (directly or indirectly) of persons convicted of a felony for a period not less than 10 years from the date of conviction.

• The IRS Code, section 3402(t), requires us to collect additional information about the proprietary/non-profit structure of a Medicare provider/supplier to allow exclusion of non-profit organizations from the mandatory 3% tax withholding.

• IRS section 501(c) requires each Medicare provider/supplier to report information about its proprietary/non-profit structure to the IRS for tax withholding determination.

• Section 6401 of the Affordable Care Act (which amended section 1866(j) of the Social Security Act) outlines requirements for the enrollment of providers and suppliers into the Medicare program.

• We are authorized to collect information on the Form CMS-855B (Office of Management and Budget (OMB) approval number 0938-1377) to ensure that correct payments are made to suppliers under the Medicare program as established by Title XVIII of the Act.

The Form CMS-855B application captures the foregoing information, including the data required to uniquely identify and enumerate the supplier. Additional information needed to process claims accurately and timely is also collected on the application.

2. Purpose and Users of the Information

The Form CMS-855B application is submitted when the applicant first requests Medicare enrollment. The application is used by the MACs to collect data to ensure the applicant has the necessary credentials to provide the health care services for which they intend to bill Medicare; this includes data that allows the Medicare contractor to correctly price, process, and pay the applicant’s claims. It also gathers information that enables MACs to ensure that the supplier is neither excluded from the Medicare program nor debarred, suspended, or excluded from any other federal agency or program. The application is also used by enrolled suppliers when they are reporting a change in their ownership, a change in their current Medicare enrollment information, or are revalidating or reactivating their Medicare enrollment.

3. Improved Information Techniques

This collection lends itself to electronic collection methods. The Provider Enrollment, Chain and Ownership System (PECOS) is a secure, intelligent, and interactive national data storage system maintained and housed within the CMS Data Center with limited user access through strict CMS systems access protocols.  Access to the data maintained in PECOS is limited to CMS and Medicare contractor employees responsible for supplier enrollment activities.  The data stored in PECOS mirrors the data collected on the Form CMS-855 (Medicare Enrollment Applications) and is maintained indefinitely as both historical and current information.  CMS also supports an internet-based supplier Form CMS-855 enrollment platform, which allows the supplier to complete an online Form CMS-855 enrollment application and transmit it to the Medicare contractor database for processing; the data is then transferred from the Medicare contractor processing database into PECOS by the MAC. Periodically, CMS will require adjustment to the format of the Form CMS-855 (either paper, electronic or both) for clarity or to improve form design.  These adjustments do not alter the current OMB data collection approval.

4. Duplication and Similar Information

There is no duplicative information collection instrument or process.

5. Small Business

The data collections associated with the Form CMS-855 application process impacts small businesses. However, because of the relative infrequency with which the information needs to be submitted, we believe the overall impact on small businesses is negligible.

6. Less Frequent Collections

This information is collected on an as needed basis. The information provided on the Form CMS-855 is required for enrollment in the Medicare program. It is essential to collect this data the first time a supplier enrolls with a Medicare contractor so that CMS’ contractors can ensure that the supplier meets all statutory and regulatory requirements necessary for enrollment and that claims are paid correctly.

In addition, to ensure uniform data submissions, CMS requires that all changes to previously submitted enrollment data be reported via the appropriate provider enrollment application.

7. Special Circumstances

There are no special circumstances that will require an information collection to be conducted in a manner that requires respondents to:

• Submit more than an original and two copies of any document.

• Retain records -- other than health, medical, government contract, grant-in-aid, or tax records -- for more than three years.

• Collect data in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study.

• Use a statistical data classification that has not been reviewed and approved by OMB.

• Include a pledge of confidentiality that: (1) is not supported by authority established in statute or regulation; (2) is not supported by disclosure and data security policies consistent with that pledge; and/or (3) unnecessarily impedes the sharing of data with other agencies for compatible confidential use.

• Submit proprietary trade secret or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.

8. Federal Register Notice/Outside Consultation

No rulemaking is associated with our requested Form CMS-855B revisions.

The 60-day notice for this information collect request was published in the Federal Register on July 9, 2024 (89 FR 56382). A 30-day Notice published on January 15, 2025. No public comments were submitted.

9. Payment/Gift to Respondents

No payments or gifts are being provided to respondents.

10. Confidentiality

Except as explained in Section 16 of this Supporting Statement: (1) all information collected will be kept private in accordance with 5 U.S.C. 552(b)(4), Executive Order 12600, and 45 CFR 155.260 (Privacy and Security of Personally Identifiable Information); and (2) privileged or confidential commercial or financial information is protected from public disclosure by federal law.

11. Sensitive Questions

There are no sensitive questions associated with this collection. Specifically, the collection does not solicit questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private.

12. Burden Estimate of Requested Form CMS-855B Changes

a. Introduction

This section 12 outlines our requested Form CMS-855B revisions that we believe will involve: (1) a change in burden for suppliers that complete this application; or (2) an explanation of why no burden change is involved. (Other application revisions not involving a burden change or requiring additional explanation are listed in the “Summary of Form CMS-855B Changes” Excel spreadsheet.)

We will use the following median wage category and hourly rate from the U.S. Bureau of Labor Statistics’ (BLS) May 2024 National Occupational Employment and Wage Estimates for all salary estimates (http://www.bls.gov/oes/current/oes_nat.htm):

TABLE 1: NATIONAL OCCUPATIONAL EMPLOYMENT AND WAGE ESTIMATES

Occupation Title	Occupation Code	Median Hourly Wage ($/hr)	Fringe Benefits and Overhead ($/hr)	Adjusted Hourly Wage ($/hr)
Office and Administrative Support Workers, All Other	43-9199	20.78	20.78	41.56
Healthcare Diagnosing or Treating Practitioners, All Other	29-1290	51.92	51.92	103.84
Physicians, All Other	29-1229	113.46	113.46	226.92

These wage categories reflect the following:

• The Form CMS-855B (including the new data/revised elements) will be completed by office/administrative staff and reviewed/signed by a practitioner within the supplier entity.

• The reassigning individual, typically a physician, will sign the certification statement in Section 15.

Along with these wage estimates, the burden below is based on the anticipated number of Form CMS-855B application receipts, which in turn is based on PECOS data. For purposes of this information collection request (ICR), there are several categories of Form CMS-855B transactions:

• Initial enrollment

• Enrolling with another MAC

• Revalidation

• Reactivation

• Reporting a change of information

• Voluntarily withdrawing from Medicare

Tables 2 and 3 break down the baseline per application hour and cost burdens. Our approach will mirror that utilized in previous Form CMS-855B supporting statements – specifically, office staff will complete the application while a physician or practitioner reviews and signs it. For purposes of this ICR, and as indicated above, we will use the physician rate when the individual must sign the application because he/she is reassigning his/her benefits to the organizational supplier. The practitioner rate will be applied in all other cases.

(Note that we do not anticipate any burden changes to the “Voluntarily Withdrawing from Medicare” category. This is because voluntarily withdrawing suppliers only complete a few data elements on the Form CMS-855B, none of which include the new/revised elements addressed in this Section 12. We thus will not include them in any tables in Section 12 or 15.)

TABLE 2 – PROJECTED BASE BURDEN/COST PER APPLICATION – HEALTH

DIAGNOSING & TREATING PRACTITIONER SIGNATURE

Reason for Submittal	Time for Completion by Administrative Staff (hours)	Time for a Health Diagnosing and Treating Practitioner to Review and Sign (hours)	Total Time for Completion Per Response (hours)*	Cost for Completion by Administrative Staff ($)	Cost for Review and Signature by a Health Diagnosing and Treating Practitioner ($)	Total Cost of Completion (per Response) *
Initial Enrollment	2.5	0.5	3	103.90 (2.5 x 41.56)	51.92 (0.5 x 103.84)	155.82
Enrolling with Another MAC	1.5	0.5	2	62.34 (1.5 x 41.56)	51.92 (0.5 x 103.84)	114.26
Revalidation	1.5	0.5	2	62.34 (1.5 x 41.56)	51.92 (0.5 x 103.84)	114.26
Reactivation	1.5	0.5	2	62.34 (1.5 x 41.56)	51.92 (0.5 x 103.84)	114.26
Reporting a Change of Medicare Enrollment Information	0.75	0.25	1	31.17 (0.75 x 41.56)	25.96 (0.25 x 103.84)	57.13

TABLE 3 – PROJECTED BASE BURDEN/COST PER APPLICATION RESPONSE –

PHYSICIAN SIGNATURE

Reason for Submittal	Time for Completion by Administrative Staff (hours)	Time for a Physician to Review and Sign (hours)	Total Time for Completion Per Response (hours)*	Cost for Completion by Administrative Staff ($)	Cost for Review and Signature by a Physician ($)	Total Cost of Completion (per Response) *
Initial Enrollment	2.5	0.5	3	103.90 (2.5 x 41.56)	113.46 (0.5 x 226.92)	217.36
Enrolling with Another MAC	1.5	0.5	2	62.34 (1.5 x 41.56)	113.46 (0.5 x 226.92)	175.80
Revalidation	1.5	0.5	2	62.34 (1.5 x 41.56)	113.46 (0.5 x 226.92)	175.80
Reactivation	1.5	0.5	2	62.34 (1.5 x 41.56)	113.46 (0.5 x 226.92)	175.80
Reporting a Change of Medicare Enrollment Information	0.75	0.25	1	31.17 (0.75 x 41.56)	56.73 (0.25 x 226.92)	87.90

b. Revisions to Current Figures

In our most recent Form CMS-855B ICR, we outlined the following number of Form CMS-855B submissions we receive on average each year for the five above-mentioned categories. The sixth approved category involves home infusion therapy (HIT) supplier enrollment. Burdens are included.

TABLE 4 – MOST RECENT FORM CMS-855B AVERAGE ANNUAL RECEIPT

TOTALS

Reason for Submittal	Total Number of Respondents	Total Number of Responses	Time per Response (hours)	Total Annual Time (hours)	Total Annual Cost ($)
Initial Enrollment	15,797	15,797	3	47,391	2,283,301
Enrolling with Another MAC	37	37	2	74	3,953
Revalidation	31,211	31,211	2	62,422	3,334,271
Reactivation	1,316	1,316	2	2,632	140,588
Reporting a Change of Information	55,650	55,650	1	55,650	2,972,823
HIT Supplier Enrollment	700	700	2.5	1,750	106,744
Total	104,711	104,711	Varies	169,919	8,841,680

We are in this ICR updating these categories and totals as follows:

(i) HIT Suppliers

• The respondent/response, total annual time, and total annual cost figures for HIT suppliers in Table 4 are the combined totals over 3 years rather than the annual amounts (e.g., 700/3). These figures should instead be, respectively, 233 respondents/responses, 583 annual hours, and $35,581.

• Since these HIT supplier enrollments were effectively initial enrollments, we believe a 3-hour per response figure, instead of 2.5 hours, is more appropriate.

• For this same reason, we will merge the HIT Supplier Enrollment category (with the above-mentioned modified annual figures) into the Initial Enrollment category. The HIT Supplier Enrollment category will be eliminated.

This revises Table 4’s categories and totals as follows:

TABLE 5 –FORM CMS-855B ANNUAL BURDEN FIGURES WITH HIT

SUPPLIER CATEGORY MERGED INTO INITIAL ENROLLMENTS

Reason for Submittal	Total Number of Respondents	Total Number of Responses	Time per Response (hours)	Total Annual Time (hours)	Total Annual Cost ($)
Initial Enrollment	16,030	16,030	3	47,974	2,318,882
Enrolling with Another MAC	37	37	2	74	3,953
Revalidation	31,211	31,211	2	62,422	3,334,271
Reactivation	1,316	1,316	2	2,632	140,588
Reporting a Change of Information	55,650	55,650	1	55,650	2,972,823
Total	104,244	104,244	Varies	168,752	8,770,517

(ii) Updated Annual Totals

Based on new PECOS data, we believe the actual number of several categories of annual application receipts is higher than that shown in Tables 4/5. We are therefore revising them for accuracy in Table 6 as part of this ICR. We will use these updated totals as the baseline for our requested revised estimates.

TABLE 6 – FORM CMS-855B REVISED CURRENT BURDEN FIGURES

BASED ON PECOS DATA

Reason for Submittal	Number of Respondents	Total Number of Responses *	Time per Response (hours)	Total Annual Time (hours)	Total Annual Cost ($) **
Initial Enrollment	42,083 *	42,083 *	3	126,249 *	6,557,794 *
Enrolling with Another MAC	37	37	2	74	4,228
Revalidation	41,608	41,608	2	83,216	4,754,130
Reactivation	5,761	5,761	2	11,522	658,252
Reporting a Change of Information	78,489	78,489	1	78,489	4,484,077
Total	167,978	167,978	Varies	299,550	16,458,481

* Includes all HIT supplier applications.

** Applies the Table 2 (Practitioner) wage estimates for each application category (e.g., for initial applications, $155.82 x 42,083; for revalidations, $114.26 x 41,608; etc.)

c. New/Revised Data Elements

Most of the changes addressed below are to isolated sections of the Form CMS-855B. Except as otherwise indicated, the burden will only pertain to the specific section of the application that is being revised. For such situations involving initial, revalidation, and reactivation submissions (as well as those involving enrollment with another MAC), we will use the above-referenced $41.56 wage for administrative staff alone rather than the higher, combined administrative staff/practitioner total (e.g., $114.26 for reactivations). This is because the signature burden for practitioners is already included in the current OMB-approved burden; the only changed burden will, again, involve the revised section of the application that administrative staff will complete. To illustrate, suppose a supplier is submitting a Form CMS-855B revalidation application. As part of this, it must complete a new data element in Section 4. The new burden will only involve administrative staff’s furnishing of this information; the practitioner will not have additional burden, for he or she will still sign the application regardless of whether the new data element was added to the form.

Unless noted otherwise, the change of information (COI) category will use the combined administrative staff/practitioner figure of $57.13 because: (1) the COI will involve a change to the new/revised data; and (2) this will constitute a new COI submission and, hence, require a practitioner signature.

(i) Section 1(A) (Reason for Submitting This Application)

Enrolling and enrolled suppliers must check the applicable box in Section 1A to identify the reason it is submitting the application. We are adding a new submittal reason: “You are solely enrolling in Medicare to participate in Medicaid or another health care program and will not bill Medicare.” This will not implicate any new burden. It is merely another option via which the supplier can identify its submittal reason.

(ii) Section 1(A) (Reason for Submitting This Application)

For the voluntary termination submittal reason/checkbox, we are adding Sections 2A3 and 4B as optional sections that the supplier may complete. As the supplier is not required to complete them, there is no burden associated with this change.

(iii) Section 2(A)(1) (Supplier Identification Information – Business Information)

In the business structure portion of Section 2(A)(1) in which the supplier identifies its organizational type, we are adding checkboxes for "sole owner", “general partnership”, “limited partnership”, and government-owned supplier. These checkboxes are merely additional options via which the supplier can identify its business type and will involve no burden change.

(iv) Section 2(B)(1) (Type of Supplier)

In Section 2(B)(1), the supplier checks which type of supplier it is. We are adding the following new checkboxes to this section: “home infusion therapy”; “physical therapy group in private practice”; and “occupational therapy group in private practice”. This will not impose any new burden, for the additional checkboxes merely give the supplier additional checkbox options.

(v) Section 2(E) (Accreditation for Ambulatory Surgical Centers (ASCs) Only)

In Section 2(E), the ASC checks whether it is accredited. We are adding the following new checkbox to this section: “The ASC applied for or is pending accreditation”. This checkbox will impose no new burden; it simply gives the ASC an additional checkbox option in Section 2(E).

(vi) Deletion of Section 2(F) (Employer Terminating Employment Arrangement with One or More Physician Assistants (PAs))

Employers need no longer report whether they are terminating an employment arrangement with a PA. This is because PAs may now bill Medicare directly for the services they perform. They no longer need to bill the program through their employer.

When Section 2(F) was required, we roughly estimate that 5,000 employers per year (typically a Form CMS-855B-enrolled group practice that employed the PA) reported the termination of a PA arrangement via a Form CMS-855B COI. Section 2(F)’s removal means the burden estimate for the COI category will be reduced. The initial enrollment, enrolling with another MAC, revalidation, and reactivation categories are unaffected.

TABLE 7 – BURDEN CHANGE FOR REMOVAL OF SECTION 2(F)

Reason for Submittal	Number of Respondents	Total Number of Responses	Time per Response (hours)	Total Annual Time (hours)	Cost of Completion Per Response (See Table 3)	Total Annual Cost ($)
Initial Enrollment	N/A	N/A	N/A	N/A	N/A	N./A
Enrolling with Another MAC	N/A	N/A	N/A	N/A	N/A	N/A
Revalidation	N/A	N/A	N/A	N/A	N/A	N/A
Reactivation	N/A	N/A	N/A	N/A	N/A	N/A
Reporting a Change of Information	(5,000)	(5,000)	0.333	(1,667)	19.02 (57.13 x 0.333)	(95,100)
Total	(5,000)	(5,000)	N/A	(1,667)	N/A	(95,100)

(vii) Section 3 (Final Adverse Actions)

We are revising Section 3’s list of final adverse actions (FAAs) to require the following to be reported:

• Any felony conviction of the supplier’s managing organization, officer, or director.

• Revising the FAA currently listed in Section 3(B)(2) to read: “Any crime, under Federal or State law, where an individual or entity has entered into participation in a first offender, deferred adjudication or other program or arrangement where judgment of conviction has been withheld, or the criminal conduct has been expunged or otherwise removed, or there is a post-trial motion or appeal pending, or the court has made a finding of guilt or accepted a plea of guilty or nolo contendere.”

• Any misdemeanor conviction, under federal or state law, related to sexual abuse, sexual misconduct, inappropriate physical contact of another, or child pornography.

Since these FAAs are new to Section 3 and have not been previously reported, we have no historical data upon which we can accurately estimate of the burden of disclosure. For purposes of this ICR request only, we project that each year approximately 100 initially enrolling suppliers, 98 revalidating suppliers, 2 reactivating suppliers, and 25 enrolled suppliers (via a COI) will report one of these FAAs via the Form CMS-855B. We estimate that each disclosure will take 30 minutes. Table 8 outlines the burden change associated with our revision to Section 3.

TABLE 8 – BURDEN CHANGE FOR SECTION 3 REVISION – FINAL

ADVERSE ACTIONS

Reason for Submittal	Number of Respondents	Total Number of Responses	Time per Response (hours)	Total Annual Time (hours)	Cost of Completion Per Response	Total Annual Cost ($)
Initial Enrollment	100	100	0.5	50	20.78 (41.56 x 0.5)	2,078
Enrolling with Another MAC	0	0	N/A	0	N/A	0
Revalidation	98	98	0.5	49	20.78 (41.56 x 0.5)	2,036
Reactivation	2	2	0.5	1	20.78 (41.56 x 0.5)	42
Reporting a Change of Information	25	25	0.5	13	28.57 (57.13 x 0.5)	714
Total	225	225	0.5	113	N/A	4,870

(viii) Section 4(A) (Practice Location Information)

Section 4(A) requires the supplier to identify via checkbox the type of facility in which it is located. A current checkbox option is “Home/Business Office for Administrative Use Only.” We are splitting this into separate “Home Office for………” and “Business Office for………” checkboxes. As we are merely dividing this checkbox into two options, no new burden is implicated.

(ix) Section 4(C)(2) (Practice Location Information – Electronic Records)

The supplier currently must disclose in Section 4(C)(2) the website at which any electronic records are stored. We are removing this data box and instead requiring the supplier to list the address and tax identification number of the company via which (if applicable) electronic records are stored. We believe that furnishing this address will take the supplier 15 minutes (0.25 hours) longer than furnishing the website address. Table 9 below outlines the projected burden associated with this change.

TABLE 9 – BURDEN CHANGE FOR SECTION 4(C) REVISION –

ELECTRONIC MEDICAL RECORDS

Reason for Submittal	Number of Respondents	Total Number of Responses	Time per Response (hours)	Total Annual Time (hours)	Cost of Completion Per Response (See Table 3)	Total Annual Cost ($)
Initial Enrollment	13,578	13,578	0.25	3,395	10.39 (41.56 x 0.25)	141,075
Enrolling with Another MAC	14	14	0.25	4	10.39 (41.56 x 0.25)	145
Revalidation	8,100	8,100	0.25	2,025	10.39 (41.56 x 0.25)	84,159
Reactivation	2,535	2,535	0.25	634	10.39 (41.56 x 0.25)	26,339
Reporting a Change of Information	24,223	24,223	0.25	6,056	14.25 (57.13 x 0.25)	345,178
Total	48,450	48,450	0.25	12,114	N/A	596,896

(x) Section 4(H) (Reassignment of Benefits Information)

Reassignment information was previously collected via the Form CMS-855R. With the Form CMS-855R’s discontinuance, this data is now captured through the Form CMS-855I (for the physician/practitioner reassigning his/her benefits) and in new Section 4(H) of the Form CMS-855B (for the entity to which the individual is reassigning his/her benefits). Although the supplier burden associated with completing the Form CMS-855R has been eliminated, there will now be a Form CMS-855B burden for completing Section 4(H).

Section 4(H)(1) will capture the reassignor’s name, social security number, Medicare identification number, and National Provider Identifier (NPI). (Section 4(H)(2) will collect the primary and secondary practice locations at which the reassignor will render services on the reassignee’s behalf. These sections are optional, however, so no burden is involved.) We estimate that completion of Section 4(H)(1) will take 10 minutes (0.167 hours). Table 10 below addresses our burden estimates.

TABLE 10 – BURDEN CHANGE FOR SECTION 4(H) REVISION –

REASSIGNMENTS

Reason for Submittal	Number of Respondents	Total Number of Responses	Time per Response (hours)	Total Annual Time (hours)	Cost of Completion Per Response (See Table 3)	Total Annual Cost ($)
Initial Enrollment	17,744	17,744	0.167	2,963	6.94 (41.56 x 0.167)	123,143
Enrolling with Another MAC	21	21	0.167	4	6.94 (41.56 x 0.167)	146
Revalidation	34,991	34,991	0.167	5,843	6.94 (41.56 x 0.167)	242,838
Reactivation	4,418	4,418	0.167	738	6.94 (41.56 x 0.167)	30,661
Reporting a Change of Information	33,014	33,014	0.167	5,513	9.54 (57.13 x 0.167)	314,954
Total	90,188	90,188	0.167	15,061	N/A	711,742

(xi) Section 5(A) (Organization with Ownership Interest and/or Managing Control – Identification Information)

Section 5(A) collects information regarding organizations that own or manage the supplier. The section currently has checkboxes via which the supplier must identify the organization’s interest in the supplier (e.g., managing control, partnership interest). We are adding more checkboxes to Section 5(A) that will help further clarify the organization’s interest. This will not impose additional burden on the supplier, for our change only affords the supplier more options for identifying its relationship with the supplier. It does not involve the submission of additional data.

(xii) Section 5(A) (Organization with Ownership Interest and/or Managing Control – Identification Information)

Section 5(A) currently captures the Medicare identification number (if issued) of the owning/managing organization(s). We are removing this data element from the Form CMS-855B because we believe it is no longer necessary. This will result in a burden reduction. We project that reporting this data took suppliers 15 minutes (0.25 hours). Table 11 outlines our burden reduction projections.

TABLE 11 – BURDEN CHANGE FOR SECTION 5(A) REVISION –

OWNERSHIP/MANAGEMENT

Reason for Submittal	Number of Respondents	Total Number of Responses	Time per Response (hours)	Total Annual Time (hours)	Cost of Completion Per Response (See Table 3)	Total Annual Cost ($)
Initial Enrollment	(20,295)	(20,295)	0.25	(5,074)	10.39 (41.56 x 0.25)	(210,865)
Enrolling with Another MAC	(4)	(4)	0.25	(1)	10.39 (41.56 x 0.25)	(42)
Revalidation	(6,599)	(6,599)	0.25	(1,650)	10.39 (41.56 x 0.25)	(68,564)
Reactivation	(685)	(685)	0.25	(171)	10.39 (41.56 x 0.25)	(7,117)
Reporting a Change of Information	(21,755)	(21,755)	0.25	(5,439)	14.25 (57.13 x 0.25)	(310,009)
Total	(49,338)	(49,338)	0.25	(12,335)	N/A	(596,597)

(xiii) Section 6(A) (Individual with Ownership Interest and/or Managing Control – Identification Information – Telephone/Fax/E-mail Number)

Section 6(A) collects information regarding individuals who own or manage the supplier. We are adding the following data elements the supplier must furnish about these individuals’ telephone number, fax number, and email address. We estimate that it will take a supplier approximately 25 minutes to furnish this data. Table 12 outlines our burden estimates.

TABLE 12 – BURDEN CHANGE FOR SECTION 6(A) REVISION –

OWNERSHIP/MANAGEMENT

Reason for Submittal	Number of Respondents	Total Number of Responses	Time per Response (hours)	Total Annual Time (hours)	Cost of Completion Per Response (See Table 3)	Total Annual Cost ($)
Initial Enrollment	42,083	42,083	0.4167	17,536	10.39 (41.56 x 0.4167)	437,242
Enrolling with Another MAC	37	37	0.4167	15	10.39 (41.56 x 0.4167)	384
Revalidation	41,608	41,608	0.4167	17,338	10.39 (41.56 x 0.4167)	432,307
Reactivation	5,761	5,761	0.4167	2,401	10.39 (41.56 x 0.4167)	59,857
Reporting a Change of Information	26,893	26,893	0.4167	11,206	14.25 (57.13 x 0.4167)	383,225
Total	116,382	116,382	0.4167	48,496	Varies	1,313,015

(xiv) Section 6(A) (Individual with Ownership Interest and/or Managing Control – Identification Information)

The section currently has checkboxes via which the supplier must identify its interest in the supplier (e.g., managing control, partnership interest). We are splitting the “Partnership Interest” checkbox into separate general partner and limited partner checkboxes to better identify the type of partnership interest. This will involve no new burden for suppliers.

(xv) Section 12 (Supporting Documentation Information)

Section 12 outlines certain documents the supplier must submit with their applications. We are adding several document types to this list. These newly listed documents are already typically submitted even though they are not specifically listed in Section 12. For this reason, we do not project an increased burden for our Section 12 additions.

(xvi) Section 13 (Contact Person Information)

Section 13, which is optional, permits the supplier to report an individual to whom the MAC can direct questions regarding the application submission. We are adding the following new data element to Section 13: “Relationship or Affiliation to Individual or Organization/Group (Spouse, Secretary, Attorney, Billing Agent, etc.)” However, as Section 13 is, again, optional, we are not projecting a burden estimate for this data element.

(xv) Section 15 (Certification Statement)

Consistent with the Form CMS-855R’s discontinuance and the collection of certain reassignment data via the Form CMS-855B, Section 15 now includes new data elements for the reassignor’s name, signature, and date of signature. We estimate that 17,798 reassignors per year will furnish their signature on the supplier’s initial enrollment application. It will take the reassignor three minutes to do so.

TABLE 13 – BURDEN CHANGE FOR SECTION 15 REVISION –

REASSIGNOR SIGNATURE

Reason for Submittal	Number of Respondents	Total Number of Responses	Time per Response (hours)	Total Annual Time (hours)	Cost of Completion Per Response (See Table 3)	Total Annual Cost ($)
Initial Enrollment	17,798	17,798	0.05	890	11.35 (226.92 * x 0.05)	202,007
Enrolling with Another MAC	N/A	N/A	N/A	N/A	N/A	N/A
Revalidation	N/A	N/A	N/A	N/A	N/A	N/A
Reactivation	N/A	N/A	N/A	N/A	N/A	N/A
Reporting a Change of Information	N/A	N/A	N/A	N/A	N/A	N/A
Total	17,798	17,798	0.05	890	11.35	202,007

* Current Physician BLS wage.

(xvi) Attachment 2 (Independent Diagnostic Testing Facilities) (IDTFs)

We are adding a new element to Section B of Attachment 2 that requires the IDTF to list the serial numbers of the testing equipment it uses. We estimate that it will take each IDTF 20 minutes to do so. Table 14 outlines our burden estimates.

TABLE 14 – BURDEN CHANGE FOR ATTACHMENT 2 REVISION –

IDTF SERIAL NUMBERS

Reason for Submittal	Number of Respondents	Total Number of Responses	Time per Response (hours)	Total Annual Time (hours)	Cost of Completion Per Response (See Table 3)	Total Annual Cost ($)
Initial Enrollment	339	339	0.333	113	13.84 (41.56 x 0.333)	4,692
Enrolling with Another MAC	1	1	0.333	0	13.84 (41.56 x 0.333)	0
Revalidation	337	337	0.333	112	13.84 (41.56 x 0.333)	4,664
Reactivation	47	47	0.333	16	13.84 (41.56 x 0.333)	650
Reporting a Change of Information	636	636	0.333	212	19.02 (57.13 x 0.333)	12,097
Total	1,360	1,360	0.33	453	Varies	22,103

(xvii) Attachment 2 (Independent Diagnostic Testing Facilities) (IDTFs)

We are adding a new element to Section D of Attachment 2 that requires the IDTF to identify the state in which their technicians are licensed or certified. We estimate that it will take each IDTF 8 minutes to report this information. Table 15 outlines our burden estimates.

TABLE 15 – BURDEN CHANGE FOR ATTACHMENT 2 REVISION –

IDTF TECHNICIAN LICENSURE

Reason for Submittal	Number of Respondents	Total Number of Responses	Time per Response (hours)	Total Annual Time (hours)	Cost of Completion Per Response (See Table 3)	Total Annual Cost ($)
Initial Enrollment	339	339	0.133	45	5.53 (41.56 x 0.133)	1,875
Enrolling with Another MAC	1	1	0.133	0	5.53 (41.56 x 0.133)	0
Revalidation	337	337	0.133	45	5.53 (41.56 x 0.133)	1,864
Reactivation	47	47	0.133	6	5.53 (41.56 x 0.133)	260
Reporting a Change of Information	636	636	0.133	85	7.60 (57.13 x 0.133)	4,834
Total	1,360	1,360	0.133	181	Varies	8,833

d. Total Burden Change

Table 16 outlines the total, combined burden change associated with the revisions described in Section 12(c) above.

TABLE 16 – TOTAL BURDEN CHANGE FOR ALL REVISIONS ADDRESSED

IN SECTION 12(C)

	Number of Respondents	Number of Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits) *	Total Cost ($)
Deletion of Section 2(F) – Physician Assistant Employer	(5,000)	(5,000)	0.333	(1,667)	19.02	(95,100)
Section 3 – Additional of Final Adverse Actions	225	225	0.50	113	Varies	4,870
Section 4(C)(2) – Electronic Records	48,450	48,450	0.25	12,114	Varies	596,896
Section 4(H)(1) – Reassignment of Benefits Information	90,188	90,188	0.167	15,061	Varies	711,742
Section 5(A) – Removal of Medicare Identification Number	(49,338)	(49,338)	0.25	(12,335)	Varies	(596,597)
Section 6(A) – Addition of Telephone/E-mail/Fax	116,382	116,382	0.4167	48,496	Varies	1,313,015
Section 15 – Reassignor Signature	17,798	17,798	0.05	890	11.35	202,007
Attachment 2 – IDTF Serial Numbers	1,360	1,360	0.333	453	Varies	22,103
Attachment 2 – IDTF Technician State of Licensure or Certification	1,360	1,360	0.133	181	Varies	8,833
Total	221,425	221,425	Varies	63,306	Varies	2,167,769

Table 17 breaks down by application submission reason the total, combined burden change associated with the revisions described in Section 12(c) above.

TABLE 17 – TOTAL FORM CMS-855B BURDEN CHANGE BREAKDOWN BY

APPLICATION SUBMISSION REASON

	Number of Respondents	Number of Responses	Burden per Response (hours)	Total Annual Burden (hours)	Hourly Labor Cost of Reporting ($) (includes 100% fringe benefits) *	Total Cost ($)
Initial Enrollment	71,686	71,686	Varies	19,918	Varies	701,247
Enrolling with Another MAC	70	70	Varies	22	Varies	633
Revalidation	78,872	78,872	Varies	23,762	Varies	699,304
Reactivation	12,125	12,125	Varies	3,625	Varies	110,692
Reporting a Change of Information	58,672	58,672	Varies	15,979	Varies	655,893
TOTAL	221,425	221,425	Varies	63,306	Varies	2,167,769

We emphasize with respect to the “Respondents” category, however, that the 221,425 figure therein does not mean that our changes will result in, for instance, the submission of 71,686 additional initial enrollment applications and 12,125 reactivations each year – in both cases roughly twice what we receive as reflected in Table 6 above. The Respondents category simply reflects the number of instances where a supplier will furnish one of the newly requested or revised data elements.

13. Cost to Respondents (Capital)

There are no capital costs associated with this collection.

14. Cost to Federal Government

14.1 MACs

We anticipate costs for the MACs for processing the above-mentioned Form CMS-855B changes. We projected in Table 16 an annual supplier burden of 63,306 hours. Given our experience, we estimate it will take the MACs a similar amount of time to process this data.

The applicable MAC hourly is wage equivalent to a GS-9, Step 5 (Washington/Baltimore/Arlington locality), which is $37.15. (See https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/24Tables/html/DCB_h.aspx.) This results in an annual increase in MAC costs of $2,351,818 (or 63,306 x $37.15).

15. Annual Changes in Burden/Program Changes

Current PECOS data suggests that the number of respondents in each of the categories that make up the 855 form have increased which resulted in a total increase of 59,336 respondents. In addition, several revisions are being made to the 855 form which also impacted the increase of burden. Thus, burden has increased from 171,885 to 299,550 hours. As shown in Table 17, we project the following increases in annual burden for the following Form CMS-855B application categories:

Form CMS-855B	Respondents	Responses	Hours	Costs
Initial Enrollment	71,686	71,686	19,918	701,247
Enrolling with Another MAC	70	70	22	633
Revalidation	78,872	78,872	23,762	699,304
Reactivation	12,125	12,125	3,625	110,692
Reporting a Change of Information	58,672	58,672	15,979	655,893

16. Publication/Tabulation

All information collected will be kept private in accordance with 5 U.S.C. 552(b)(4), Executive Order 12600, and 45 CFR 155.260 (Privacy and Security of Personally Identifiable Information). Privileged or confidential commercial or financial information is protected from public disclosure by federal law.

17. Expiration Date

We are planning on displaying the expiration date.

18. Certification Statement

There are no exceptions to the certification statement.

B. Collections of Information Employing Statistical Methods

This collection does not employ statistical methods.

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