CMS Real-Time Eligibility Agreement and MDCN Access Request

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10157 HIPAA Eligibility Transaction System (HETS) Trading Partner Agreement (TPA)	Form	Modified	Available
CMS_10157_Supporting_Statement_Part_A_02082017_Passback2_cm_Final.docx	Supporting Statement A	Uploaded 2017-02-10	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8819	HIPAA Eligibility Transaction System (HETS) Trading Partner Agreement (TPA)	Form	Modified

ICR Details

OMB Control No: 0938-0960	ICR Reference No: 201702-0938-002
Status: Historical Active	Previous ICR Reference No: 201608-0938-008
Agency/Subagency: HHS/CMS	Agency Tracking No: CMS-10157
Title: CMS Real-Time Eligibility Agreement and MDCN Access Request
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/03/2017
	Date Received in OIRA: 02/15/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2020	36 Months From Approved	05/31/2017
Responses	1,000	0	1,000
Time Burden (Hours)	250	0	250
Cost Burden (Dollars)	0	0	0

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Abstract: The Centers for Medicare and Medicaid Services (CMS) is requesting the Office of Management and Budget's (OMB) approval of a revised HIPAA Eligibility Transaction System (HETS) Trading Partner Agreement form. CMS created the HETS application to provide Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant 270/271 health care eligibility inquiries (270) and responses (271) on a real-time basis. In creating the HETS application, federal law requires that CMS take precautions to minimize the security risk to federal information systems. Accordingly, CMS is requiring that trading partners who wish to connect to the HETS 270/271 application via the CMS Extranet and/or Internet agree to specific trading partner terms as a condition of receiving access to Medicare eligibility information. Applicants will complete the entire Trading Partner Agreement form to indicate agreement with CMS trading partner terms and provide sufficient information to establish connectivity to the service and assure that those entities that access the Medicare eligibility information are aware of applicable provisions and penalties for the misuse of information.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: PUBLIC HEALTH SERVICE
  

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:
	81 FR 30308	05/16/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 46925	07/19/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
HIPAA Eligibility Transaction System (HETS) Trading Partner Agreement (TPA)	CMS-10157	Medicare HIPAA Eligibility Transaction System (HETS) to Conduct the Health Care Eligibility Benefit Inquiry and Response

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ICR Summary of Burden

table that charts list 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	1,000	1,000	0	0	0	0
Annual Time Burden (Hours)	250	250	0	0	0	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:

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Annual Cost to Federal Government: $50,000

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: 02/15/2017

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