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Federal forms, ICRs, and supporting documents

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

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

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HIPAA Eligibility Transaction System (HETS) Trading Partner Agreement (TPA)
 
No Modified
 
Required to Obtain or Retain Benefits
 
45 CFR 164.312(a)(2)(i)

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

Health Health Care Services

 

1,000 0
   
Private Sector Businesses or other for-profits
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,000 0 0 500 0 500
Annual IC Time Burden (Hours) 250 0 0 125 0 125
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.