Information Collection

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

IC 8819 under ICR 202409-0938-030 · OMB 0938-0960.

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
Form CMS-10157 Medicare HIPAA Eligibility Transaction System (HETS) to Conduct the Health Care Eligibility Benefit Inquiry and Response HIPAA Eligibility Transaction System (HETS) Trading Partner Agreement (TPA)	Form
CMS-10157 Medicare HIPAA Eligibility Transaction System (HETS) to TPA-PRA-Form-Revision-V4.3-Final-.docx	Form
CMS-10157 Medicare HIPAA Eligibility Transaction System (HETS) to TPA-PRA-Form-Revision-V4.3-Final-.docx	Form
TPA_PRA_Form_Revision_4.2 to 4.3_CMS_7-08-24 with track changes-RS.docx TPA_PRA_Form_Revision_ track changes	IC Document
TPA_PRA_Form_Revision_4.2 to 4.3_CMS_7-08-24 with track changes-RS.docx TPA_PRA_Form_Revision_ track changes	IC Document

IC Title:

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				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
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,000	500	500
Annual IC Time Burden (Hours)	250	125	125
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
TPA_PRA_Form_Revision_ track changes		09/30/2024

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

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