OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Medicare Enrollment Application for Clinics/Group Practices and Other Suppliers (CMS-855B)

ICR 202103-0938-020 · OMB 0938-1377 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form CMS-855B Home Infusion Therapy (HIT) Supplier Enrollment Form and Instruction Unchanged Repair queued
Form CMS-855B Change of Enrollment Information Form and Instruction Unchanged Repair queued
Form CMS-855B Enrolling with a Administrative Contractor (MAC) Form and Instruction Unchanged Repair queued
Form CMS-855B Medicare Enrollment Application (Initial Enrollment) Form and Instruction Unchanged Repair queued
Form CMS-855B Medicare Enrollment Application (Reactivation) Form and Instruction Unchanged Repair queued
Form CMS-855B Medicare Enrollment Application - Revalidation Form and Instruction Unchanged Repair queued
Form CMS-855B Voluntarily Withdrawal (from the Medicare Program) Form and Instruction Unchanged Repair queued
CMS-855B - Supporting Statement A (CMS-1734-P version 6).docx Supporting Statement A Uploaded 2021-03-24 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
243317 Home Infusion Therapy (HIT) Supplier Enrollment Form and Instruction Unchanged
240713 Change of Enrollment Information Form and Instruction Unchanged
240712 Enrolling with a Administrative Contractor (MAC) Form and Instruction Unchanged
240711 Medicare Enrollment Application (Initial Enrollment) Form and Instruction Unchanged
240710 Medicare Enrollment Application (Reactivation) Form and Instruction Unchanged
240709 Medicare Enrollment Application - Revalidation Form and Instruction Unchanged
240708 Voluntarily Withdrawal (from the Medicare Program) Form and Instruction Unchanged
ICR Details
0938-1377 202103-0938-020
Received in OIRA 202011-0938-012
HHS/CMS CPI
Medicare Enrollment Application for Clinics/Group Practices and Other Suppliers (CMS-855B)
Revision of a currently approved collection   No
Regular 03/24/2021
  Requested Previously Approved
36 Months From Approved 03/31/2024
109,932 109,932
175,755 175,755
0 0
The primary function of the CMS 855B enrollment application for Clinics, Group Practices and Certain Other Suppliers is to gather information from the organization that tells us what it is, whether it meets certain qualifications to be a health care supplier, where it renders services and information necessary to establish the correct claims payment. The goal of evaluating and revising the CMS 855B enrollment application is to simplify and clarify the information collection without jeopardizing our need to collect specific information. The majority of the revisions are very minor in nature such as spelling and formatting corrections, removal of duplicate fields and instruction clarification for the organization/group. The Sections and Sub-Sections within the form are also being re-numbered and re-sequenced to create a more logical flow of the data collection. In addition, CMS is adding a data collection for an address to mail the periodic request for the revalidation of enrollment information (only if it differs from other addresses currently collected). Other than the revalidation mailing address described above, new data being collected in this revision package is a checkbox indicating whether or not an organization is wholly owned or operated by a hospital, the inclusion of a new supplier type (Centralized Flu Biller) and information on, if applicable, where the supplier stores its patient records electronically. The attachment for Opioid Treatment Programs (OTPs) is used to capture the OTP personnel and consists of limited data fields (name, Social Security Number, National Provider Identifier, and license number) in response to the “SUPPORT for Patients and Communities Act” that was signed into law on October 24, 2018. Section 2005 of the SUPPORT Act establishes a new Medicare Part B benefit for opioid use disorder (OUD) treatment services furnished by opioid treatment programs (OTPs) beginning on or after January 1, 2020.
PL: Pub.L. 110 - 275 135(a) Name of Law: Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)
   PL: Pub.L. 115 - 271 2005 Name of Law: Substance Use Disorder Prevention Promotes Opioid Recovery Treatment for Patients and Communities Ac
   PL: Pub.L. 109 - 220 508 Name of Law: Rehabilitation Act of 1973 as incorporated with the Americans With Disabilities Act of 2005
   PL: Pub.L. 104 - 134 31001(1) Name of Law: Debt Collection Improvement Act of 1996 (DCIA)
   PL: Pub.L. 105 - 133 4313 Name of Law: Balanced Budget Act of 1997 (BBA)
   US Code: 42 USC 424.67 Name of Law: Enrollment requirements for opioid treatment programs (OTP)
  
PL: Pub.L. 109 - 220 508 Name of Law: Rehabilitation Act of 1973 as incorporated with the Americans With Disabilities Act of 2005
PL: Pub.L. 104 - 134 31001(1) Name of Law: Debt Collection Improvement Act of 1996 (DCIA)
PL: Pub.L. 105 - 133 4313 Name of Law: Balanced Budget Act of 1997 (BBA)
PL: Pub.L. 110 - 275 135(a) Name of Law: Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)
PL: Pub.L. 115 - 271 2005 Name of Law: Substance Use Disorder Prevention Promotes Opioid Recovery Treatment for Patients and Communities Ac
US Code: 42 USC 424.67 Name of Law: Enrollment requirements for opioid treatment programs (OTP)
0938-AU10 Proposed rulemaking 85 FR 50074 08/17/2020
  85 FR 50074 08/17/2020
No
  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 109,932 109,932 0 0 0 0
Annual Time Burden (Hours) 175,755 175,755 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$0
No
    Yes
    Yes
No
No
No
No
Mitch Bryman 410 786-5258 [email protected]
  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.
03/24/2021