Form CMS-10157 Medicare HIPAA Eligibility Transaction System (HETS) to

MEDICARE HIPAA ELIGIBILITY TRANSACTION
SYSTEM (HETS) TRADING PARTNER
AGREEMENT (TPA)
CMS-Version 4.1

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-0960

TABLE OF CONTENTS
Form Instructions ................................................................................................................. 1
CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) TRADING PARTNER
AGREEMENT ......................................................................................................................... 1
I.
II.
III.
IV.
V.

BACKGROUND ......................................................................................................... 2
AUTHORIZED USES ................................................................................................. 2
SYSTEM INTEGRITY................................................................................................. 2
CONNECTIVITY......................................................................................................... 3
ASSURANCES........................................................................................................... 3

APPENDIX A – REFERENCES – Required ........................................................................... 6
APPENDIX B - INFORMATION REQUIRED TO REQUEST ACCESS TO THE HIPAA
ELIGIBILITY TRANSACTION SYSTEM – Required ............................................................... 7
APPENDIX C – CONNECTIVITY – Required ......................................................................... 8
APPENDIX D – DSH – Situational ......................................................................................... 9
APPENDIX E – OFFSHORE DATA PROTECTION – Situational.......................................... 10

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

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FORM INSTRUCTIONS
Please check one (1) box to indicate the type of Agreement being submitted:
Initial Trading Partner Application
Annual TPA Recertification
Other TPA Update

CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
TRADING PARTNER AGREEMENT
For Use of the Medicare HIPAA Eligibility Transaction System (HETS) to Conduct the Health
Care Eligibility Benefit Inquiry and Response transactions.
This Trading Partner Agreement (“Agreement”) is made on
of Medicare & Medicaid Services and

between the Centers for
.

The Trading Partner (also known as the Submitter), intends to conduct eligibility transactions
with CMS in electronic form. Both parties acknowledge and agree that the privacy and security
of data held by or exchanged between them is of utmost priority. Each party agrees to take all
steps reasonably necessary to ensure that all electronic transactions between them conform to
the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and regulations
promulgated thereunder. Unless defined herein, all terms have the same meaning as in the
regulations promulgated to implement the Administrative Simplification provisions of HIPAA at
45 CFR Parts 160-164.
PAPERWORK REDUCTION ACT (PRA) DISCLOSURE STATEMENT
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-0960 expires January 31, 2023. The
time required to complete this information collection is estimated to average 15 minutes per
response, including the time to review instructions, search existing data resources, gather
the data needed, and complete and review the information collection. If you have
comments concerning the accuracy of the time estimate(s) or suggestions for improving
this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance
Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Please do not send
applications, claims, payments, medical records or any documents containing sensitive
information to the PRA Reports Clearance Office. Please note that any correspondence not
pertaining to the information collection burden approved under the associated OMB control
number listed on this form will not be reviewed, forwarded, or retained. If you have
questions or concerns regarding where to submit your documents, please contact the
MCARE Help Desk at 1-866-324-7315 or [email protected].

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

I.

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BACKGROUND

The Centers for Medicare & Medicaid Services (CMS) is committed to maintaining the integrity
and security of health care data in accordance with applicable laws and regulations. Disclosure
of Medicare beneficiary eligibility data is restricted under the provisions of the Privacy Act of
1974 (Privacy Act) and HIPAA. The Medicare beneficiary eligibility transaction is to be used for
conducting Medicare business only.
In its administration of the Medicare Fee-For-Service (FFS) program, CMS is a covered entity
under the HIPAA rules. This Trading Partner Agreement serves to identify entities external to
CMS that will exchange HIPAA compliant electronic transactions with CMS software
applications. The HIPAA Eligibility Transaction System (HETS) supports the ASC X12 270/271.
The information collected by the HETS system will enable CMS and the Trading Partner to
establish connectivity, define the data exchange requirements, and stipulate the responsibilities
of the entities receiving CMS-supplied beneficiary eligibility information.

II.

AUTHORIZED USES

Medicare eligibility data are only to be used for Medicare business done on behalf of Medicare
FFS providers, including preparing accurate Medicare claims or determining eligibility for
specific services. Authorized and unauthorized uses are provided in the HETS Rules of
Behavior referenced in Appendix A, available on the CMS website, and incorporated by
reference herein.
Trading Partners cannot electronically store or reuse Medicare beneficiary protected health
information (PHI) obtained from HETS, except for the following purposes expressly authorized
by CMS:

•

To maintain an historical account of processing activity

•

In accordance with procedures (e.g., routine system backups) to support data restoration
in the event of a disaster

•

To update patient account records in the record management system of the FFS
Medicare provider requesting the data

Any data storage by Trading Partner or its Business Associates, as defined by 45 CFR
§160.103, must be compliant with the HETS Rules of Behavior.

III.

SYSTEM INTEGRITY

CMS monitors beneficiary eligibility inquiries. Submitters demonstrating behavior that suggests
improper use of the data (e.g., high inquiry error rate or, for provider submitters, high ratio of
eligibility inquiries to claims submitted) may be suspended, placed on a corrective action plan
(CAP) or, when appropriate, be referred for investigation. Civil and/or criminal enforcement may
be pursued where appropriate.
1. HIPAA Violation
The U.S. Department of Health and Human Services (HHS) may impose civil money penalties
on a covered entity of up to $50,000 for failure to comply with a provision in the Privacy,
Security, and Breach Notification Rules, with maximum annual limits for violations of identical
provisions, which are set forth at 42 U.S.C. 1320d-5(a). A person who knowingly obtains or
discloses individually identifiable health information in violation of HIPAA faces criminal

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
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penalties ranging from $50,000, up to one-year imprisonment, or both, to, in circumstances
where the wrongful conduct involves the intent to sell, transfer, or use individually identifiable
health information for commercial advantage, personal gain, or malicious harm, up to $250,000,
up to ten years imprisonment, or both Criminal enforcement is conducted by the Department of
Justice.
2. Civil False Claims Act Violation and Criminal Violations
The False Claims Act, 31 U.S.C. §§ 3729-3733, provides that one who knowingly submits, or
causes another person or entity to submit, false claims for payment of government funds is
liable for three times the government’s damages plus civil penalties of $11,181 to $22,363 per
false claim (note that the civil penalty amounts are subject to an inflation adjustment; these were
the amounts for calendar year 2018).
Various federal criminal provisions authorize imposition of criminal penalties, including fines and
imprisonment, against individuals who, with respect to Government or health care benefit
programs, engage in conduct including, but not limited to, falsifying or concealing a material fact
or making materially false, fictitious, or fraudulent statement.

IV.

CONNECTIVITY

Connectivity to CMS eligibility systems is supported by the use of the Extranet and/or the
Internet. A Trading Partner may submit a request using the 270 standard to HETS using
Transmission Control/Internet Protocol (TCP/IP) for extranet access or Simple Object Access
Protocol (SOAP) + Web Services Description Language (WSDL) or Hypertext Transfer Protocol
(HTTP)/Multipart Internet Mail Extensions (MIME) Multipart communication protocols for public
Internet access. For additional information, including connectivity options, refer to the HETS
Rules of Behavior. All Submitters shall submit the information required in Appendix B to request
connectivity and be compliant with the guidance referenced in Appendix A.

V.

ASSURANCES

Provision by CMS of access to HETS, both Extranet and Internet, is subject to Submitter’s
assurances as set forth below. Access to HETS may be terminated by CMS, without prior notice
to the Submitter, in the event that CMS determines based on information from the Submitter or
otherwise, that Submitter has not complied with one or more of the assurances hereafter
provided by Submitter.
In consideration of the foregoing, and in order to obtain access to the HETS system, the
Submitter hereby agrees and assures as follows:
No.

Assurance

1.

Submitter agrees to abide by all applicable federal laws, regulations, and
guidance governing access to, and use and disclosure of, CMS data,
Protected Health Information (PHI) as defined in 45 CFR §160.103, and
Personally Identifiable Information (PII) as defined in OMB Memorandum
M-07-16 (May 22, 2007) and understands that individuals or entities may
be subject to civil and/or criminal penalties for failing to abide by such
provisions.

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Agreement

Agree
Disagree

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

No.

Assurance

2.

Before initiating any transmission in HIPAA standard 270/271 transaction
format, and thereafter through the term of this Agreement, the Trading
Partner will cooperate with CMS and any contractors representing CMS in
testing of the transmission and processing systems used in connection
with CMS as deemed appropriate to ensure the accuracy, timeliness,
completeness, and security of each data transmission.

3.

4.

5.

6.

7.

8.

9.

Submitter will take reasonable care to ensure that the information
submitted in each electronic transaction is timely, complete, accurate, and
secure, and will take reasonable precautions to prevent unauthorized
access of the party’s transmission and processing systems. The Submitter
will ensure that each electronic transaction submitted to CMS conforms
with the requirements applicable to the transaction.
Every Submitter must be an active enrolled Medicare provider or a
Business Associate working on behalf of active enrolled Medicare
provider(s) before any submission of electronic transactions is allowed.
The Submitter agrees to notify CMS when its relationship with a Medicare
provider both begins and terminates. Business Associate Submitters are
responsible for providing current information about the provider(s) for
whom they are submitting transactions in accordance with the HETS
Rules of Behavior. CMS reserves the right to confirm the status of a
Business Associate relationship with a provider directly.
Submitters shall notify CMS of a change in Business Associate
representation consistent with the HETS Rules of Behavior.
All Submitters must comply with and follow the HETS Rules of Behavior,
referenced in Appendix A, in all areas not specifically listed in this
Agreement, including how to address making changes to the information
supplied in Appendix B.
This Agreement shall take effect and be binding on the Trading Partner
and CMS when signed by the Trading Partner and reviewed and signed
by an authorized CMS representative.
Termination or expiration of this Agreement or any other contract between
the parties does not relieve either party of its obligations under this
Agreement and under federal and state laws and regulations pertaining to
the privacy and security of PHI and PII, nor its obligations regarding the
confidentiality of CMS proprietary information.
Submitters who perform Medicare work offshore (any location outside of
the United States where U.S. law is non-binding) must attest that
safeguards to protect Medicare Beneficiary Information are actively
enforced. Any Submitters who perform work or either directly or indirectly
employ offshore labor must attest to the terms specified in Appendix E.
Submitters who do not perform any Medicare work offshore (or directly or
indirectly employ any offshore labor should mark this assurance as ‘Not
Applicable.’

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Agreement
Agree
Disagree

Agree
Disagree

Agree
Disagree

Agree
Disagree
Agree
Disagree
Agree
Disagree

Agree
Disagree

Agree
Disagree
Not Applicable

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-0960

The Authorized Representative whose name is supplied below is authorized to bind the Trading
Partner as a HETS Submitter to the undertakings of this Agreement. By completing the section
below, you are agreeing that your organization will be in compliance with the provisions of this
Agreement.
Trading Partner Authorized Representative Signature

Title

Printed Name of Trading Partner Authorized Signer

Date Signed

Telephone Number

E-Mail Address

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

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APPENDIX A – REFERENCES – REQUIRED
HETS Rules of Behavior
This document details the Submitter’s responsibilities in obtaining, disseminating, and using
beneficiary’s Medicare eligibility data. It further explains the expectations for using HETS.
Compliance with these HETS Rules of Behavior is necessary in order to gain and maintain
continued access to the system.
http://cms.gov/Research-Statistics-Data-and-Systems/CMS-InformationTechnology/HETSHelp/Downloads/EligibilityTransactionSystemInquiriesRulesofBehavior.pdf
HETS Authorized Representative Roles and Responsibilities
This document details the Authorized Representatives HETS roles and responsibilities. It is
written confirmation that the Submitter’s Authorized Representative understands his/her
responsibility for the organization’s use of HETS and compliance with the HETS Rules of
Behavior.
https://www.cms.gov/files/document/tpaarroleresponsibilities.pdf

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-0960

APPENDIX B - INFORMATION REQUIRED TO REQUEST ACCESS TO THE HIPAA
ELIGIBILITY TRANSACTION SYSTEM – REQUIRED
(fields marked with * are optional, all others are required)
Submitter Organization Security Officer Contact Information (Optional):
*Name: (Optional)

*Title: (Optional)

*Telephone number: (Optional)

*E-mail address: (Optional)

Submitter Organization’s Information:
Submitter Organization Name:

Submitter Organization Legal Business Name:

Submitter Organization Billing Address:
City

State

Zip Code

State

Zip Code

Submitter Organization Physical Address:
City

Submitter Organization Technical Representative Name:
Submitter Organization Technical
Representative Telephone Number:

Submitter Organization Technical Representative
E-mail Address:

CMS requires only one NPI from an active/valid enrolled Medicare provider(s) on this form. In
accordance with item 4 in the Assurances section of the Agreement, submitter organization must later
share any/all additional NPIs with CMS.
Medicare Provider’s Name:

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Medicare Provider’s NPI:

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-0960

APPENDIX C – CONNECTIVITY – REQUIRED
Please indicate the type of connectivity used by the Trading Partner.
Extranet:

Yes

No

Internet:

Yes

No

If yes, Message Envelope Used

SOAP + WSDL

If yes, Name of Network Service Vendor (NSV) used
HTTP MIME Multipart

Trading Partner IP Address (es) for SOAP/MIME transaction (Note: If sending multiple IP addresses,
please use a Classless Inter-Domain Routing [CIDR] notation, i.e., 192.0.1.0/24)
IP Address(es):
X.509 Digital Certificate Issuer Name:
X.509 Digital Certificate Type:
X.509 Digital Certificate Serial Number:
Note: If using SOAP + WSDL or HTTP MIME Multipart, applicants must send a copy of their
organization’s public x.509 digital certificate. The Trading Partner Agreement will not be processed
without a copy of the public digital certificate.

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
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APPENDIX D – DSH – SITUATIONAL
For Disproportionate Share Hospital (DSH) Information Trading Partners:
CMS developed a limited view of the HIPAA Eligibility Transaction System (HETS) to allow
hospitals that receive Medicare Disproportionate Share Hospital (DSH) payments to view
Medicare enrollment information for their hospital inpatients. This data assists hospitals when
verifying CMS’ determination of the hospital’s SSI ratio (i.e., the total number of Medicare days
compared to the number of Medicare/SSI days). This information may be disclosed to Medicare
HETS DSH Trading Partners under routine use of the ‘Medicare Provider Analysis and Review
(MEDPAR), HHS/CMS/OIS, 09-70-0514’ Privacy Act system of records, published at 71 Fed.
Reg. 17470 (April 06, 2006).
Eligible Trading Partners must request a separate DSH Submitter ID in order to utilize this view.
Specify the type of HETS Submitter ID(s) being requested:
DSH view only

DSH view and standard HETS 270/271

DSH Hospital NPI(s):

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APPENDIX E – OFFSHORE DATA PROTECTION – SITUATIONAL (IF YOU HAVE
OFFSHORE ARRANGEMENT)
Offshore Data Protection Safeguards
The Authorized Representative must positively affirm that all of the following safeguards are
actively in place.
Attestation of Safeguards to Protect Beneficiary Information Offshore
No.

Assurance

1.

Offshore arrangement has policies and procedures in place to ensure the
privacy and security of Medicare beneficiary Protected Health Information
(PHI), Personal Identifiable information (PII), and confidentiality of CMS
proprietary information.

2.

3.

4.

5.

Agreement
Agree
Disagree

Offshore arrangement prohibits access to Medicare data not associated
with the offshore agreement.

Agree

Offshore arrangement has policies and procedures in place that allow for
immediate termination of the offshore work upon discovery of a significant
security breach.

Agree

Offshore arrangement will take reasonable precautions to prevent
unauthorized access to the parties’ transmission and processing systems.

Agree

Offshore arrangement must comply with and follow HETS Rules of
Behavior referenced in Appendix A.

Agree

Disagree

Disagree

Disagree

Disagree

The Authorized Representative named below must be authorized to attest to the Offshore Data
Protection Safeguards Appendix E of the HETS Trading Partner Agreement. CMS requires
applicants to complete all of the fields below, including signature. By completing and signing the
section below, the Authorized Representative is agreeing that the organization will be in
compliance with the provisions of this section.

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Offshore Work Site
Organization Name*

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Offshore Work Site Organization
Address including Country
Name*

Offshore Work Site
Organization Originating
IP Address(es)*

Trading Partner Authorized Representative Signature

Title

Printed Name of Trading Partner Authorized Signer

Date Signed

Telephone Number

E-Mail Address

*if multiple Organizations, then provide all
Note: Enter each/every Offshore Work Site’s non-US Originating IP Address(es)

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