CMS-855O Supporting Statement

Supporting Statement for Paperwork Reduction Act Submissions

Medicare Enrollment Application - Registration for Eligible Ordering and Referring Physicians and Non-Physician Practitioners - CMS-855O/OMB Control Number: 0938-1135

A. BACKGROUND

The principal function of the Form CMS-855O is to gather information from a physician or other eligible professional to help CMS determine whether he or she meets certain qualifications to enroll in the Medicare program for the sole purpose of ordering, certifying, or referring certain Medicare items or services. The Form CMS-855O allows a physician or other eligible professional to enroll in Medicare without approval for billing privileges.

The purpose of this Paperwork Reduction Act (PRA) submission is to update the currently approved Form CMS-855O. Though described in more detail in Section 12 of this Supporting Statement, our general changes are as follows:

• Removal of gender question consistent with Executive Order 14168

• Removal of question regarding existing debt owed to CMS

• Adding instructions and a question regarding compact licenses

• Updating the list of physician and practitioner specialties

B. JUSTIFICATION

1. Need and Legal Basis

Various sections of the Social Security Act (Act), the United States Code (U.S.C.), Internal Revenue Service Code (Code) and the Code of Federal Regulations (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 allowing payment. These statutes and regulations include:

• 42 C.F.R. section 424.500, et al. states the requirements for enrollment, periodic resubmission and certification of enrollment information for revalidation, and timely reporting of updates and changes to enrollment information. Providers and suppliers must meet and maintain these enrollment requirements to bill either the Medicare program or its beneficiaries for Medicare covered services or item.

• Section 4313 of the Balanced Budget Act of 1997 (BBA) (Public Law 105-33) 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 an ownership or control interest in the provider or supplier, and any managing employees. The Secretary of Health and Human Services (the Secretary) signed and sent to the Congress a “Report to Congress on Steps Taken to Assure Confidentiality of Social Security Account Numbers as Required by the Balanced Budget Act” on January 26, 1999, with mandatory collection of SSNs and EINs effective on or about April 26, 1999.

• 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).

• Section 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.

• 42 C.F.R. section 424.502 defines enrollment and enrollment related terms.

• The Patient Protection and Affordable Care Act (PPACA), section 6405 ("Physicians Who Order Items or Services Required to be Medicare Enrolled Physicians or Eligible Professionals") contains a requirement for certain physicians and other eligible professionals to enroll in the Medicare program for the sole purpose of ordering, certifying, or referring certain items or services for Medicare beneficiaries.

• Sections 1102 and 1871 of the Act provide general authority for the Secretary to prescribe regulations for the efficient administration of the Medicare program

• Section 1866(j)(2)(A) of the Act requires the Secretary, in consultation with the Department of Health and Human Services' Office of the Inspector General, to establish procedures under which screening is conducted with respect to providers of medical or other items or services and suppliers under Medicare, Medicaid, and CHIP.

• Section 1866(j)(2)(B) of the Act requires the Secretary to determine the level of screening to be conducted according to the risk of fraud, waste, and abuse with respect to the category of provider or supplier.

• Section 1848(k)(3)(B) defines covered professional services and eligible professionals.

• 5 U.S.C. 522(b)(4) and Executive Order 12600 protect privileged or confidential commercial or financial information from public disclosure.

• Executive Order 14168 prohibits federal agencies from requesting gender identity.

The Form CMS-855 applications collect this information, including the information necessary to uniquely identify and enumerate the provider/supplier. Additional data needed to ensure that providers and suppliers meet all applicable Medicare requirements and to process claims accurately and timely are also collected on the Form CMS-855 applications.

2. Purpose and users of the information

Physicians and practitioners complete the Form CMS-855O if they are enrolling in Medicare strictly to order, certify, or refer particular Medicare items and services and not to obtain Medicare billing privileges. It is used by Medicare contractors to collect data that helps ensure the applicant has the necessary credentials to order, certify, or refer certain Medicare items and services.

The Medicare Administrative Contractor (MACs) establishes Medicare identification numbers. The MACs store Medicare identification numbers and other information in CMS’ Provider Enrollment, Chain and Ownership System (PECOS). The MACs collect data via the Form CMS-855O to ensure that the applicant has the necessary information for unique identification. The license numbers are validated against state licensing websites. Social Security Numbers (SSNs) are validated against the Social Security Administration database (SSA). The correspondence address and contact information are captured to contact the provider/supplier. 

The collection and verification of this information protects Medicare beneficiaries from illegitimate providers/suppliers. These procedures also protect the Medicare Trust Funds against fraud.  The Form CMS-855O gathers information that allow Medicare contractors to ensure that the physician or eligible professional is not sanctioned from the Medicare and/or Medicaid program(s), or debarred, or excluded from any other Federal agency or program. Furthermore, and as already stated, the data collected help to confirm that the applicant has the required credentials to order, certify, or refer various health care services. This is the sole instrument implemented for this purpose.

3. Improved Information Techniques

This collection lends itself to electronic collection methods. 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 provider/supplier enrollment activities. PECOS is an electronic Medicare enrollment system through which providers and suppliers can submit Medicare enrollment applications, view and print enrollment information, update enrollment information, complete the enrollment revalidation process, voluntarily withdraw from the Medicare program, and track the status of a submitted Medicare enrollment application. The data stored in PECOS mirrors the data collected on the various Form CMS-855 applications and is maintained indefinitely as both historical and current information. At present, approximately 67% of individual providers/suppliers use the electronic method of enrolling in Medicare via PECOS.

4. Duplication and Similar Information

There is no duplicative information collection instrument or process.

5. Small Business

The Form CMS-855O is not completed by small businesses and therefore will not affect them.

6. Less Frequent Collections

The information provided on the Form CMS-855O is necessary for identification of certain physician and other eligible professionals in the Medicare program. It is essential to collect this information for all ordering/certifying/referring physicians and other eligible professionals to verify the individual’s qualifications to order, certify, or refer particular Medicare items and services. In addition, Medicare contractors must ensure that the ordering/certifying/referring physicians or other eligible professionals meet all statutory and regulatory requirements and are properly credentialed.

After initial enrollment, this information is collected on an as needed basis; it is sometimes utilized by the individual to report a change of information. To ensure uniform data submissions, CMS requires that all changes to previously submitted enrollment data be reported via this enrollment application or its equivalent in PECOS.

7. Special Circumstances

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

• Report information to the agency more often than quarterly

• Prepare a written response to a collection of information in fewer than 30 days after receipt of it

• 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 is not supported by authority established in statute or regulation that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes 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

The 60-day notice published in the Federal Register on July 3, 2025 (90 FR 29551). A total of zero (0) comments were received.

A 30-day notice published in the Federal Register on September 24, 2025 (90 FR 45951).

9. Payment/Gift to Respondents

There are no payments or gifts to respondents as the respondents are merely ordering, certifying, or referring certain services or items for Medicare beneficiaries.

10. Confidentiality

Data will be kept private to the extent allowed by law.

The SORN title is Provider Enrollment, Chain and Ownership System (PECOS), number 09-70-0532 (71 FR 60536).

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 commonly considered private.

12. Burden Estimates (hours and cost)

This Section 12 outlines our proposed revisions to the Form CMS-855O and, as applicable, changes to the existing OMB-approved Form CMS-855O burden. For purposes of our calculations, we assume the following:

(a) Assumptions

(i) Wage Estimates

Although we have previously used the We will use the “Physicians, All Other” (29-1229) median wage category of the May 2023 Bureau of Labor Statistics National Occupational Employment and Wage Estimates for all salary estimates (https://www.bls.gov/oes/2023/may/oes_nat.htm). This median hourly wage is $113.46. With fringe benefits and overhead, the figure is $226.92.

(ii) Current Burden Estimates

The current OMB-approved annual burden estimates for the Form CMS-855O categories of initial enrollments, changes of information, and voluntary terminations are:

	Respondents	Responses	Hours Per Response	Total Hour Burden	Total Cost Burden
Initial Applications	45,558	45,558	0.5	22,779	$1,157,767
Changes of Information	2,250	2,250	0.5	1,125	$121,320
Reporting a Voluntary Withdrawal	6,190	6,190	0.5	3,095	$333,765

We believe our proposed Form CMS-855O changes would impact:

• Initially enrolling physicians and eligible professionals

• Physicians and eligible professionals who report a change in whether they owe a debt to CMS

We do not expect an increase or decrease in the number of annual applications submitted pursuant to our changes. As explained further below, however, we do anticipate a decrease in the number of reported changes of the individual’s debt status.

(b) Burden Changes:

(1) Removal of Gender Question

We are removing the question in Section 2(A) of the Form CMS-855O that asks the applicant’s gender. This question takes approximately 1 minute to answer (or .0167 hours). This would result in a reduction in our above “Initial Applications” annual burden of 761 hours (.0167 x 45,558) and $172,686 (761 x $226.92).

(2) Removal of Debt Question

We are removing an additional question in Section 2(A) that asks whether the applicant owes an existing debt to Medicare. This question takes approximately 2 minutes to answer (or .0333 hours). This would constitute a reduction in the “Initial Applications” annual burden of 1,517 hours (.0333 x 45,558) and $344,238 (1,517 x $226.92).

CMS data indicates that approximately 114 individuals per year report via the Form CMS-855O change in CMS debt status. This would reduce the annual “Changes of Information” burden by 57 hours (114 x 0.5 hours) and $12,934 (57 x $226.92).

(3) Compact Licenses

We are adding a question to Section 2(C) that asks whether the applicant’s license is a compact license. We believe this question would take approximately 1 minute to answer (or .0167 hours), resulting in an increase in the “Initial Applications” annual burden of 761 hours (.0167 x 45,558) and $172,686 (761 x $226.92).

As for changes of information, we are unable to establish a projected burden because this is a new data element on Form CMS-855O. We therefore have no precedent upon which to establish an estimate.

(4) Revisions to Specialties

Section 4 of the Form CMS-855O contains an extensive list of physician specialty, eligible professional, and other non-physician practitioner checkboxes via which the applicant indicates the supplier type. We are adding the following categories to this list:

• Dental Anesthesiology

• Dental Public Health

• Endodontics

• Epileptology

• Marriage and Family Therapists

• Mental Health Counselors

• Oral and Maxillofacial Pathology

• Oral and Maxillofacial Radiology

• Oral Medicine

• Orofacial Pain

• Orthodontics and Dentofacial Orthopedics

• Pediatric Dentistry

• Periodontics

• Prosthodontics

We are also changing the "Maxillofacial Surgery" category to "Oral and Maxillofacial Surgery".

None of these changes would involve additional or reduced burden. The revisions would simply give the applicant more options from which to choose.

(c) Final Burden Changes

Initial Applications -- Based on the foregoing, we estimate that the net annual burden reduction in this Form CMS-855O category would be 1,517 hours ((761) + (1,517) + 761) and $344,238 (($172,686) + ($344,238) + $172,686).

Changes of Information – We project that the net annual burden reduction would 57 hours (114 x 0.5 hours) and $12,934 (57 x $226.92).

13. Cost to Respondents (Capital)

There are no capital costs associated with this collection.

14. Cost to Federal Government

We do not anticipate our revisions imposing additional costs on the MACs with respect to processing (e.g., collecting, verifying) Form CMS-855O initial applications.

15. Changes in Burden/Program Changes

The chart below identifies the proposed new total hour and cost burdens associated with Form CMS-855O initial applications stemming from our revisions.

INITIAL APPLICATIONS	Respondents	Responses	Hours Per Response	Total Hour Burden	Total Cost Burden
Current	45,558	45,558	0.5	22,779	$1,157,767
New	45,558	45,558	0.5	21,262	$813,529
Change	0	0	N/A	(1,517)	($344,238)
	Respondents	Responses	Hours Per Response	Total Hour Burden	Total Cost Burden
Current	2,250	2,250	0.5	1,125	$121,320
New	2,136	2,136	0.5	1,068	$108,386
Change	(114)	(114)	N/A	(57)	($12,934)

16. Publication/Tabulation

There are no plans to publish the outcome of the data collection.

17. Expiration Date

The expiration date will be displayed on each instrument.