In a recent MedLearn Matters article, the Centers for Medicare Services (CMS) advised health care providers, suppliers and their vendors that the Common Working File (CWF) that is currently used to obtain Medicare health insurance eligibility information will be replaced with the Medicare Health Insurance Portability and Accountability (HIPAA) Eligibility Transaction System (HETS). By April 2013, access to CWF eligibility query functions implemented in the Fiscal Intermediary Standard System (FISS) will be terminated. Providers should begin to take steps to prepare for this change.
Although providers may choose to use a Medicare Contractor’s IVR or Internet portal to obtain beneficiary eligibility information, it is not recommended by CMS. Providers that use software vendors and clearinghouses to check beneficiary eligibility should direct any questions about HETS to their vendors. Answers about HETS are also available by contacting the MCARE Help Desk at 1-866-324-7315.
HETS applies search logic that uses a combination of four data elements: Health Insurance Claim Number (HICN), Medicare Beneficiary’s Date of Birth, Medicare Beneficiary’s Full Last Name (including Suffix, if applicable), and Medicare Beneficiary’s Full First Name. The Date of Birth and First Name are optional, but at least one must be present. HETS provides all of the information now provided by CWF, although some will be in a different format than CWF.
The HETS 270/271 Companion Guide provides specific details about the eligibility information that is returned in the HETS 271 response. The guide is available at http://www.cms.gov/ on the CMS website.
The HETS Companion Guide has two purposes: to educate the user on how to access the HETS 270/271 application, and to educate the user on how to send eligibility requests and interpret responses, using the 270/271 formats. Requests are handled in real-time mode for the following purposes:
- Verify eligibility, after screening the patient to determine Medicare eligibility, for Part A and/or Part B coverage;
- Determine Medicare Beneficiary payment responsibility with regard to deductible/co-payment;
- Determine eligibility for other services, such as preventive;
- Determine if Medicare is the primary or secondary payer;
- Determine if the Medicare Beneficiary is in the original Medicare plan, MA plan or Part D plan;
- Determine proper billing.
CMS refers to Providers, Clearinghouses, and/or Third Party Vendors as “Trading Partners.” To obtain access to the HETS 270/271 application via the CMS Extranet, a potential Trading Partner will be required to access the appropriate form located on the CMS HETS Help website. Instructions to complete the sign-up process can be found at the following link: Instructions to complete the sign-up process can be found at the following link:http://www.cms.gov/Research-Statistics-Data-and-Systems/.
Trading Partners are also required to submit test transactions to ensure that their systems are HIPAA and X12 compliant. Each Trading Partner may submit up to 50 test transactions during the testing phase. Details about sign-up, testing, and information for each provider type is available in the Companion Guide. Further, refinements to HETS, such as additional information on hospice eligibility status will be forthcoming.