Medicare Enrollment Application (Form 855S)

Forms and Documents

Document Name	Status
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-855S Initial Enrollment Form and Instruction	Modified
CMS-855S - Comment and Response document .pdf Supplementary Document	2015-12-22
CMS-855S PRA Supporting Statement - Final 050916.docx Supporting Statement A	2016-05-09

IC Document Collections

IC ID	Document Title	Status
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: 201512-0938-004
Status: Historical Active	Previous ICR Reference No: 201210-0938-010
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Enrollment Application (Form 855S)
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: 05/09/2016
	Date Received in OIRA: 12/22/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2019	36 Months From Approved	05/31/2016
Responses	95,435	0	43,350
Time Burden (Hours)	54,013	0	113,550
Cost Burden (Dollars)	0	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
   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
   US Code: 42 USC 455.460 Name of Law: Application fee
   EO: EO 12600 Name/Subject of EO: Predisclosure Notification Procedures for Confidential Commercial Information
   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
  

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 54793	09/11/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 79045	12/18/2015
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Initial Enrollment	CMS-855-S, CMS-855S	Medicare Durable Medical Equipment Supplier Enrollment Application ,   Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers
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

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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	95,435	43,350	0	0	52,085	0
Annual Time Burden (Hours)	54,013	113,550	0	0	-59,537	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 burden hours and cost significantly decreased based on the new availability to use extremely accurate enrollment data (figures for respondents) gathered from the PECOS system and from the NSC MAC itself. In addition, new information technology collection techniques (specifically for revalidation information collection, electronic collection methods, the ability to send supporting documentation electronically and an electronic signature standard) allow DMEPOS suppliers to complete the CMS 855S online, rather than by hand, which greatly reduces the burden hours for completion. This, in turn, reduces the cost to the DMEPOS supplier. The new total annual burden hours associated with this information collection is approximately 54,013 hours. The total individual burden associated with this information collection ranges from approximately 4 hours to half an hour per application. The new total annual burden cost is $4,996,270. The total individual burden associated with the cost of this information ranges from approximately $600 to $10 per application.

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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: 12/22/2015

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