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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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_V4.1_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 %

	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

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.