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HETS_Trading_Partner_Agreement_Form HETS Trading Partner Agreement Form

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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
This Trading Partner Agreement (“Agreement”) is made as of ______________ between the
Centers for Medicare & Medicaid Services and ____________________________________.
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. 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
mcare@cms.hhs.gov.
I. 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:
o To maintain an historical account of processing activity
o In accordance with procedures (e.g., routine system backups) to support data restoration
in the event of a disaster
o 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 per failure to comply with a Privacy Rule
requirement, up to an annual calendar year limit of $1,500,000 for multiple violations of
the identical Privacy Rule requirement. A person
who knowingly
obtains or discloses
individually identifiable health information in violation of HIPAA faces criminal penalties
ranging from $50,000 and up to one-year imprisonment 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 and up to ten years imprisonment. 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 $5,500 to $11,000
per false claim.
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 and/ 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. Trading Partners are allowed to use both forms of
connectivity, but must select a primary approach. 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:
All Submitters
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.
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. 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.
4. Every Submitter must be an active enrolled Medicare provider or a Business Associate
working on behalf of active enrolled Medicare providers 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 providers 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.
5. Submitters shall notify CMS of a change in Business Associate representation consistent
with the HETS Rules of Behavior.
6. 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.
7. 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.
8. 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.
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
APPENDIX A
REFERENCES
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-Information-
Technology/HETSHelp/Downloads/EligibilityTransactionSystemInquiriesRulesofBehavior.pdf
HETS Companion Guide
This document defines the Medicare eligibility request sent from Medicare-authorized Trading
Partners and the corresponding response from the Medicare Health Insurance Portability and
Accountability Act (HIPAA) Eligibility Transaction System (HETS) 270/271 application.
http://cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-
Technology/HETSHelp/Downloads/HETS270271CompanionGuide5010.pdf
APPENDIX B
INFORMATION REQUIRED TO REQUEST ACCESS FOR THE CONNECTIVITY TO
THE HIPAA ELIGIBILITY TRANSACTION SYSTEM
Security Officer Contact Information (Optional):
(fields marked with * are optional, all others are required)
*Name: (Optional) ___________________________________________________________
*Title: (Optional)_____________________________________________________________
*Telephone number: (Optional)__________________________________________________
*E-mail address: (Optional) _____________________________________________________
Submitter’s
Information:
Name: _____________________________________________________________________
Legal Busin
ess Name: _________________________________________________________
Medicare Provider’s Name: _____________________________________________________
Billing Address:______________________________________________________________
City ______________________State _______Zip Code _______________________
Physical Address:_____________________________________________________________
City ______________________State _______Zip Code ________________________
Technical Representative Name: _________________________________________________
Technical Representative Telephone Number: ______________________________________
Technical Representative E-mail Address: _________________________________________
NPI(s): Note: only one NPI for an active enrolled Medicare provider must be indicated on this form. Any
additional NPIs for whom the trading partner submits transactions must be shared with CMS in
accordance with item 4 in the Assurances section of the Agreement.
_________________________
Please indicate the primary and secondary (if appropriate) forms of connectivity used by the
Trading Partner.
Extranet: Yes __ No __ If yes, Primary __ Secondary __
If yes, Name of Network Service Vendor (NSV) used ___________________________
Internet: Yes __ No __ If yes, Primary __ Secondary __
If yes, Message Envelope Used SOAP + WSDL __ HTTP MIME Multipart __
Trading Partner IP Address (es) for SOAP/MIME transactions:
_______________
X.509 Digital Certificate Issuer Name: __________________________________
X.509 Digital Certificate Type: ________________________________________
X.509 Digital Certificate Serial Number: ________________________________
For Disproportionate Share Hospital Information Trading Partners:
CMS has 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 verify
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 have a separate Submitter ID in order to request this view.
Is the Trading Partner requesting a Submitter ID for the limited DSH view? Yes ___ No___
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Completed 18 September 2019

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