Information Collection

HIPAA Eligibility Transaction System (HETS) Trading Partner Agreement (TPA)

IC 8819 under ICR 202201-0938-019 · OMB 0938-0960.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0960 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10157 HIPAA Eligibility Transaction System (HETS) Trading Partner Agreement (TPA)	Form
CMS-10157 Medicare HIPAA Eligibility Transaction System (HETS) to TPA_PRA_Form_Revision_V4.1_BESST_HETS_2021-10-21-fillable.pdf	Form
CMS-10157 Medicare HIPAA Eligibility Transaction System (HETS) to TPA_PRA_Form_Revision_V4.1_BESST_HETS_2021-10-21-fillable.pdf	Form

IC Title:

HIPAA Eligibility Transaction System (HETS) Trading Partner Agreement (TPA)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 164.312(a)(2)(i)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10157	Medicare HIPAA Eligibility Transaction System (HETS) to Conduct the Health Care Eligibility Benefit Inquiry and Response	TPA_PRA_Form_Revision_V4.1_BESST_HETS_2021-10-21-fillable.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.