HETS EDI Enrollment Form User Guide

The HETS EDI Enrollment Form allows providers to attest their relationship with a 3rd party entity to exchange the ANSI X12 270/271 Beneficiary Eligibility transaction on their behalf.

Step 1 – Authorization
Step 2 – Attestation
Step 3 – Confirmation

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Step 1 – Authorization

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Getting Started

Please note, the person entering data on this form MUST be the Authorized or Delegated Official on behalf of the NPIs and PTANs being entered. If the person entering the data is a 3rd party entity (Clearinghouse/Billing Service), do not proceed any further.

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Terms and Conditions

Review and accept the terms and conditions.
Select ‘Yes’ or ‘No’ for the question regarding organizations outside the United States.

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Authorized Signer Information

Name – The authorized signer on the Enrollment Form is the person who is authorized or delegated to sign on behalf of the supplier as they are enrolled in PECOS. This person agrees to all terms and conditions on the form. Enter the signer’s First Name, Middle Name/Initial, Last Name and Suffix, exactly as reflected in PECOS.
Email Address – The email address entered in this field will be used by EDI to send communication regarding the Enrollment Form and annual recertification. Please be sure to use an email address which is frequently checked.
Secondary Email Address – the alternate email address entered in this field will be used by EDI to send communication regarding the Enrollment Form and annual recertification. Please be sure to use an email address which is frequently checked.

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PTAN/NPI Information

PTAN

Enter the PTAN. The PTAN is a Medicare-only number issued to providers by MACs upon enrollment to Medicare. MACs issue an approval/notification letter, including the PTAN when enrollment is approved. The PTAN can be referred to as the supplier or provider number.

NPI

Enter the NPI. The NPI is assigned by the National Plan and NPPES.
The NPI is a 10-digit number.
To apply for an NPI, providers contact the NPPES at 800-465-3203 or visit them online at https://nppes.cms.hhs.gov/NPPES/Welcome.do.

Contractor Code

Select the Contractor Code associated with the NPI/PTAN.
Then select ‘Continue.’

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Step 2 – Attestation

3rd Party Entity

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Unique ID

Enter the UID number assigned by HETS to identify the HETS Submitter. The HETS Submitter will communicate their Unique ID to the Provider for purpose of allowing the Provider to attest their relationship with the HETS Submitter.
Select “Confirm” once you have entered the Unique ID.
The system will display the 3rd Party Entity Name. Once the name displays, verify the name and select the ‘Match Found’ box. If the Unique ID is not found or the name does not match, please verify the UID with the 3rd Party Entity.

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Provider Information

The PTAN, NPI and Contractor Code initially entered under Step 1 will automatically populate to the “Provider Information” section of the form. Click ‘Validate.’

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Effective and End Date Updates

Effective Date

If no relationship between the NPI and the Unique ID is currently on file at HETS, the Effective Date will automatically populate with the current date. Select or enter the date you would like the relationship to become effective. This cannot be a past date.
If a relationship between the NPI and the Unique ID is already on file at HETS, the current Effective and End dates will display.

End Date

If no relationship between the NPI and the Unique ID is currently on file at HETS, select or enter the date you would like the relationship to end. This cannot be a past date. If there is no predetermined End Date, check the box “No End Date” to leave this field open.
If a relationship between the NPI and the Unique ID is already on file at HETS, the current Effective and End dates will display.

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Delete Existing Relationship

To delete an existing relationship between the NPI and Unique ID, check the box for “Delete Existing Relationship” below the Date fields. This will unlink the Unique ID and NPI and the Unique ID will no longer be authorized to exchange transactions with HETS on behalf of the NPI.

Select ‘Save or Add More’ once all required information has been entered. This will add the information to the request form. Additional NPI and PTAN combinations can be entered after the first NPI and PTAN have been added to the request as displayed in the “Entries on this Attestation” section of the form. Up to 25 entries can be included on this form using the same or different Unique IDs. Once complete, click on ‘Validate.”

Entries on this Attestation

All entries listed in the “Entries on this Attestation” section will be sent to HETS once the form is submitted.
To remove an entry before submitting the Enrollment Form, select the red “trash can” icon associated with the entry to be removed.
To add additional NPIs to the same Unique ID, return to the Provider Information section and enter the required information. The Unique ID will still be displayed for this
Once all Unique ID to NPI relationship entries have been added to the form, click “Submit Attestation.” All entries listed in the ‘Entries on this Attestation’ section will be automatically submitted to HETS.

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