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

The HIPAA Eligibility Transaction System (HETS) (CMS-10157)

Documents and Forms

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-V4.3-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

Information Collection (IC) Details

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:

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-V4.3-Final-.docx		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 %

	Requested	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

Title	Document	Date Uploaded
TPA_PRA_Form_Revision_ track changes	TPA_PRA_Form_Revision_4.2 to 4.3_CMS_7-08-24 with track changes-RS.docx	09/30/2024

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