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Federal forms, ICRs, and supporting documents

Information Collection Request

Medicare Enrollment Application for Institutional Providers (CMS-855A)

ICR 202008-0938-001 · OMB 0938-0685 · Received in OIRA

Forms and Documents
Document
Name
Status
Form and Instruction
 Modified
Supporting Statement A
2020-08-18
IC Document Collections
IC ID
Document
Title
Status
8284 Modified
ICR Details
0938-0685 202008-0938-001
Received in OIRA 201803-0938-002
HHS/CMS CPI
Medicare Enrollment Application for Institutional Providers (CMS-855A)
Revision of a currently approved collection   No
Regular 08/18/2020
  Requested Previously Approved
36 Months From Approved 12/31/2021
302,999 1,733,400
97,342 289,393
0 0
The CMS-855A application is submitted at the time the applicant first requests a Medicare billing number. The application is used by Medicare contractors to collect data to ensure that the applicant has the necessary credentials to provide the health care services for which they intend to bill Medicare, including information that allows the Medicare contractor to correctly price, process and pay the applicant’s claims. It also gathers information that allows Medicare contractors to ensure that the provider/supplier is not sanctioned from the Medicare program, or debarred, suspended or excluded from any other Federal agency or program.
PL: Pub.L. 104 - 134 31001(I) Name of Law: Debt Collection Improvement Act of 1996
   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
   PL: Pub.L. 105 - 33 4313 Name of Law: Provision of certain identification numbers
   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
   US Code: 42 USC 1395f Name of Law: Conditions of and Limitations on Payment for Services
  
None
0938-AU10 Proposed rulemaking 85 FR 50074 08/17/2020
  85 FR 50074 08/17/2020
No
1
IC Title Form No. Form Name
Medicare Enrollment Application for Institutional Providers CMS-855A Medicare Enrollment Application - Institutional Providers
  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 302,999 1,733,400 0 -1,430,401 0 0
Annual Time Burden (Hours) 97,342 289,393 0 -192,051 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes
Miscellaneous Actions
The proposed changes in this 2020 collection of information request is associated with our August 17, 2020 (85 FR 50074) proposed rule (CMS-1734-P, RIN 0938-AU10). Overall, the changes amount to a reduction of 1,430,401 responses, 192,051 hours, and $17,136,173. Please see section 15 of the attached Supporting Statement for details.
$0
No
    No
    No
Yes
No
No
No
Mitch Bryman 410 786-5258 Mitch.Bryman@cms.hhs.gov
  No
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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
08/18/2020