Medicare Enrollment Application- Reassignment of Medicare Benefits (CMS-855R)

Forms and Documents

Document Name	Status
Form CMS-855R Terminating a Reassignment Form	Modified
Form CMS-855-R Establishing or adding a reassignment of benefits enrollment application Form and Instruction	Modified
CMS-855R Supporting Statement_04112016.docx Supporting Statement A	2016-04-11

IC Document Collections

IC ID	Document Title	Status
202867	Terminating a Reassignment Form	Modified
202866	Establishing or adding a reassignment of benefits enrollment application Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1179	ICR Reference No: 201509-0938-008
Status: Historical Active	Previous ICR Reference No: 201206-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Enrollment Application- Reassignment of Medicare Benefits (CMS-855R)
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: 04/15/2016
	Date Received in OIRA: 09/17/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2019	36 Months From Approved	04/30/2016
Responses	379,619	0	200,000
Time Burden (Hours)	94,905	0	50,000
Cost Burden (Dollars)	0	0	0

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Abstract: The primary function of the CMS 855R enrollment application is to allow physicians and non-physician practitioners to reassign their Medicare benefits to a group practice and to gather information from the individual that tells us who he/she is, where he or she renders services, and information necessary to establish correct claims payment. The goal of evaluating and revising the CMS 855R enrollment application is to require the physician or non-physician practitioner to identify a primary group location where the physician or non-physician practitioner will render most of his or her services. This identification does not add any additional burden to the physicians or non-physician practitioners.

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Authorizing Statute(s): PL: Pub.L. 104 - 134 31001(l) Name of Law: Debt Collection Improvement Act of 1996
   PL: Pub.L. 105 - 133 4313 Name of Law: Balanced Budget Act of 1997
  

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:
	80 FR 6726	02/06/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 21721	04/20/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Establishing or adding a reassignment of benefits enrollment application	CMS-855-R	Reasignment of Medicare Benefits Application
Terminating a Reassignment	CMS-855R	Reassignment of Medicare Benefits

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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	379,619	200,000	0	0	179,619	0
Annual Time Burden (Hours)	94,905	50,000	0	0	44,905	0
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: The currently approved total annual hour burden for the respondents for the CMS 855R is 50,000 hours. Due to better reporting methods and more accurate data collection via PECOS, CMS is seeking approval of new burden estimates based on current data collection information. CMS estimates the new total burden hours for this information collection to be 83,936 hours to establish a reassignment and 10,969 hours to terminate a reassignment, a total increase of 44,905 hours.

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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]? 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? 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: 09/17/2015

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