--- title: News | Prime Care Technologies | HETS description: HETS | Timely updates from the long-term, post-acute care industry and Prime Care Technologies. --- [![PCT PCD Email Signature (524 x 102 px) (300 x 100 px) (1)](https://www.primecareholdings.com/hs-fs/hubfs/PCT%20%20PCD%20Email%20Signature%20(524%20x%20102%20px)%20(300%20x%20100%20px)%20(1).png?width=300&height=100&name=PCT%20%20PCD%20Email%20Signature%20(524%20x%20102%20px)%20(300%20x%20100%20px)%20(1).png) ](https://www.primecareholdings.com/prv) [![Request A Demo](https://no-cache.hubspot.com/cta/default/79917/f5e6168c-e0a4-45aa-912f-32a380cc04e5.png)](https://cta-redirect.hubspot.com/cta/redirect/79917/f5e6168c-e0a4-45aa-912f-32a380cc04e5) ###### 2 min read ## [Clearinghouse 101 – a re-introduction to automated claims processing](https://www.primecareholdings.com/news/clearinghouse-101-a-re-introduction-to-automated-claims-processing) By [Prime Care Tech Marketing](https://www.primecareholdings.com/news/author/prime-care-tech-marketing) on Fri, Mar 25, 2016 @ 07:00 PM ![pCL-Blog-Clearinghouse-Basics.jpg](http://info.primecaretech.com/hubfs/pCL-Blog-Clearinghouse-Basics.jpg "pCL-Blog-Clearinghouse-Basics.jpg")Now would be a good time to get back to the basics, the essentials, of what a clearinghouse is and offers. “Clearinghouse 101” – an introduction to the some of the critical features and benefits of a claims clearinghouse. Whether you are using one today or not, take a peak. You may find some of the following tips and points useful. **One portal does it all** A clearinghouse becomes the one-stop shop, the aggregator, for all claims processing actions - all in one portal with a single sign-on to submit, respond to, monitor, and manage all claims submitted to Medicare, Medicaid, Managed Care, private insurances, and other 3rd party payers. Within the portal, billers can make changes or corrections to the claims and have access to DDE, HETS, and claims-in-process. **A claims translator** The clearinghouse takes the claims created within billing software and should run them through a scrubber to make sure that they are compliant with each payer’s requirements. If the clearinghouse find errors, it notifies the billers which claims need what information. Once the clearinghouse verifies that the claims are complete and comply with the payer billing requirements, it converts them into a format readable by the payer and forwards the claims. As a link between the provider and its payers, in essence, a clearinghouse is a claims translator. **Not a billing service** Periodically, someone will ask us if we, a clearinghouse, are a billing service. The straightforward answer is, “No.” A clearinghouse works with a provider's billing service/billers to complete the revenue cycle and to get cash back in your hand. **A convenient tool to monitor, manage, and follow-through** Submitting the claims is one thing, monitoring and follow-through are another. The clearinghouse portal enables you to see into what is happening with the claims once the payer has accepted them. Through the portal, billers can view the entire lifecycle of the claim and take action as needed to keep the claims flow steady. **Create secondary claims automatically** Please refer to [this blog](http://www.primecaretech.com/business-it-services-blog/using-a-clearinghouse-for-secondary-claims) to learn more about how a clearinghouse should help to process secondary claims automatically and timely. **Claims data storage** Our clearinghouse, for example, securely stores the data up to 10 years, retrievable for the provider at any time. **Support ** Experience and expertise are the foundation of a responsive and reliable support system. A clearinghouse can identify what is acceptable and answer claims submissions and processing questions. **Reports ** A clearinghouse should have a core set of useful reports to help billers, their managers, and the executive team to track and trend the claims cycle. The reports offerings should help providers to track their billers and claims.   **The bottom line** From a benefits point of view, what does a clearinghouse offer? - **Simplicity** - An effective clearinghouse makes the submission and management of claims simple, easy to learn, and monitor – a single location for claims management. - **Efficiency** - From clearinghouse.org, we find that “the average error rate for paper claims is 28%. But using the right clearinghouse can reduce that to 2-3%.” - **Control** – A clearinghouse delivers a provider-specific portal which serves as an all-in-one centralized location to monitor, manage, and extract necessary information. - **Speed** – A clearinghouse facilitates quicker claims turnaround with higher claims success. - **Peace of mind** – With a clearinghouse, billers have the confidence that they can track all claims easily throughout the entire claims-based revenue cycle. It all makes cents. ###### Topics: [clearinghouse](https://www.primecareholdings.com/news/topic/clearinghouse) [HETS](https://www.primecareholdings.com/news/topic/hets) [Medicare claims](https://www.primecareholdings.com/news/topic/medicare-claims) [DDE](https://www.primecareholdings.com/news/topic/dde) [CLIP](https://www.primecareholdings.com/news/topic/clip) [claims clearinghouse](https://www.primecareholdings.com/news/topic/claims-clearinghouse) [revenue cycle](https://www.primecareholdings.com/news/topic/revenue-cycle) [paper claims](https://www.primecareholdings.com/news/topic/paper-claims) [Managed Medicare](https://www.primecareholdings.com/news/topic/managed-medicare) [Medicaid claims](https://www.primecareholdings.com/news/topic/medicaid-claims) [claims scrubber](https://www.primecareholdings.com/news/topic/claims-scrubber) [software portal](https://www.primecareholdings.com/news/topic/software-portal) [intermediary](https://www.primecareholdings.com/news/topic/intermediary) [claims cycle](https://www.primecareholdings.com/news/topic/claims-cycle) ###### 2 min read ## [Update and Improve Medicare Claims Management](https://www.primecareholdings.com/news/update-and-improve-medicare-claims-management) By [Proclaim Partners](https://www.primecareholdings.com/news/author/proclaim-partners) on Thu, May 29, 2014 @ 08:00 AM ![pcl_horn_player](http://info.primecaretech.com/hubfs/pcl_horn_player.jpg)I acknowledge that blogs are for the purpose of educating and earning your trust, but at times I think it’s alright to blow one’s own horn once in a while. After all no less a business guru than Kenneth H. Blanchard said, “If you don't blow your own horn, someone else will use it as a spittoon.” In the highly competitive world of claims clearinghouses, blowing our own horn is a must and doing it early is essential. Otherwise, the ensuing copycat cacophony will drown it out. So, here it is. ProClaim Partners announces the release of its new integrated [HETS/CLIP/DDE module](http://www.proclaimpartners.com/company/press-release---hets-clip-dde/) as part of its automated claim processing clearinghouse software. For providers who bill Medicare this is a boon. It gives them access to Medicare eligibility and claims management tools through one portal. What is particularly noteworthy is that billers will be able to: - Browse claims data through the ProClaim Partners proprietary web user interface - Have a secure, high speed connection between the portal and the Centers for Medicare and Medicaid Services (CMS) - Enjoy an integrated implementation of the new HIPAA Eligibility Transaction System (HETS) for real-time eligibility determinations - Access Claims-in-Process (CLIP) which securely sweeps the CMS data during off hours for the latest claims activities. The data seamlessly integrates into the ProClaim database and workflows. Together these functions will present the CMS data in a much more user-friendly, browser-based format than what billers have had through other tools. While CMS has recently delayed the sunset date for access to the older technology used for eligibility determination, the transition to HETS is still imminent. Why wait? With this new module providers don’t have to worry about a future sunset date. #### Eligibility For real-time Medicare eligibility determinations, ProClaim implements the new digital certificates (X.509), Simple Object Access Protocol (SOAP), and Multipurpose Internet Male Extension (MIME) standards within the ProClaim software service to provide web-based workflow and access to HETS. ProClaim makes instant programmatic determinations of eligibility against the CMS backend data store with minimum time and effort. #### Claims in Process The ProClaim Claims-in-Process (CLIP) function displays the current Medicare claims status, avoiding the need to navigate through the many legacy screens of the soon-to-be-phased-out eligibility inquiries into CWF using DDE for each individual claim. ProClaim’s CLIP accesses DDE during off hours to deliver programmed operator services. These services sweep the claims data off the DDE Mainframe and into the ProClaim database. #### DDE Access By design ProClaim minimizes DDE usage. However, under certain circumstances, claims administrators and billers may still need to access DDE. ProClaim provides a new and powerful DDE access solution as an integrated part of the software service. Now, providers have the choice of continuing to use 3rd party terminal emulation software for DDE access to the CMS Host or using the new ProClaim DDE access. In summary, ProClaim Partners helps Long Term Care providers face a challenging environment converting claims to cash, especially when dealing with CMS/Medicare systems. In short, we’ve modernized and simplified the daily Medicare claims processing workload. The key benefits of using the system include: - Real time eligibility determination - Faster access to CWF data - Faster access to Claims in Process - Faster resolution of ADRs - Reduced training time for new claims administrators - Quicker collection of cash from claims Tada! I have finished my horn solo. It’s nice to know that technology has caught up with the complex world of revenue cycle management. Where are you in adopting new technologies to accelerate payments and improve cash flow? ###### Topics: [automated claims management](https://www.primecareholdings.com/news/topic/automated-claims-management) [revenue cycle management](https://www.primecareholdings.com/news/topic/revenue-cycle-management) [web portal to manage claims](https://www.primecareholdings.com/news/topic/web-portal-to-manage-claims) [HETS](https://www.primecareholdings.com/news/topic/hets) [DDE](https://www.primecareholdings.com/news/topic/dde) [CLIP](https://www.primecareholdings.com/news/topic/clip) ###### 2 min read ## [Accurate Medicare claims submission & eligibility determination](https://www.primecareholdings.com/news/accurate-medicare-claims-submission-eligibility-determination) By [Proclaim Partners](https://www.primecareholdings.com/news/author/proclaim-partners) on Mon, Mar 10, 2014 @ 09:00 AM **Is it HETS or miss?** **![Man_Woman_Desk_Laptop_Clock_trimmed](http://info.primecaretech.com/hubfs/Man_Woman_Desk_Laptop_Clock_trimmed.jpg)In a recent issue of CMS’s Medicare Learning Network Matters News Flash, SE 1249, CMS reaffirmed its intention to replace the Common Working File (CWF) Medicare beneficiary health insurance eligibility queries with HIPAA Eligibility Transaction System (HETS).** (You can refer to last year’s [blog posting](http://www.proclaimpartners.com/blog/bid/275459/HETS-to-replace-CWF-eligibility-inquiries-in-April-no-foolin?Preview=true) for more details.) However, CMS has opted to postpone (again) the CWF access termination – this time indefinitely, but with a caveat. While this announcement will not affect the use of DDE to submit claims or to correct claims and will not impact access to beneficiary eligibility information, providers “should immediately begin transitioning to the Medicare Health Insurance Portability and Accountability Act (HIPAA) Eligibility Transaction System (HETS).” Succinctly put, **“While termination was originally scheduled for April 2014, CMS is delaying the date. CMS will provide at least 90 days advanced notice of the new termination date.”** **So, in other words, transition to HETS sooner than later or you are at risk of missing out.** Borrowing from our earlier blog, at some point in time you will no longer be able to check on a resident’s Medicare eligibility through the Common Working File (CWF).  HETS is replacing CWF inquiries. In a way, CMS has made life much easier for billers, because with HETS you can check a beneficiary’s eligibility in real time. CMS has simplified the eligibility checking process so that through HETS you can submit your inquiry with a real-time 270 request and receive your 271 response, a Functional Acknowledgement (999), an Interchange Acknowledgement (TA1), or a proprietary error response over a secure connection. According to the guide, “The information included in the 271 response is not intended to provide a complete representation of all benefits, but rather to address the status of eligibility (active or inactive) and patient financial responsibility for Medicare Part A and Part B.” This change will likely require you to change your billing processes. Some of the information HETS will reveal to you will be in a format somewhat different from what you may be used to. Also, HETS will eventually be able to send Hospice information in the same format as the CWF. The HETS 270/271 Companion Guide gives you more insight into the eligibility information you will receive in the HETS 271 response. ProClaim Partners offers direct access to HETS through its enterprise-class automated claims clearinghouse portal. Not only can you submit, monitor, and correct claims, if necessary, you can also determine a Medicare beneficiary’s eligibility. You can select exactly what information you want to see. There is no need to bounce between applications; your information regarding all things Medicare and other insurance payers is conveniently accessible in your own branded portal. **Question**: If you are using HETS, how has this changed how you check a resident’s eligibility? ###### Topics: [270 Request](https://www.primecareholdings.com/news/topic/270-request) [HETS](https://www.primecareholdings.com/news/topic/hets) [Medicare claims](https://www.primecareholdings.com/news/topic/medicare-claims) [271 Response](https://www.primecareholdings.com/news/topic/271-response) [Medicare Eligibility](https://www.primecareholdings.com/news/topic/medicare-eligibility) ###### 5 min read ## [Medicare Secondary Payer – 5 Steps to win the race to timely payments](https://www.primecareholdings.com/news/medicare-secondary-payer-5-steps-to-win-the-race-to-timely-payments) By [Proclaim Partners](https://www.primecareholdings.com/news/author/proclaim-partners) on Fri, Apr 12, 2013 @ 01:20 PM **![Winning the race](http://info.primecaretech.com/hubfs/istock_000021300870xsmall-resized-600.jpg "Winning the race")Winning the race to collect your money on time is everything. **However,* Medicare Secondary Payer*[1] (MSP) may cause nursing home billers to trip up in their efforts to get payments as quickly as possible. Tripped too often, and providers may find themselves not quite reaching the monthly collection goal finish line. Worse yet, they may find themselves going backwards due to fines imposed for “knowingly, willfully, and repeatedly providing inaccurate information related to the existence of other health insurance or coverage.” Perhaps it’s time to get in shape regarding MSPs. **But first, what is MSP and why is it so important?** **Conditioning exercise** **– know the terms of the game.** Let’s start with primary payers. Primary payers are those which have the primary responsibility for paying a claim. Sounds simple, right?  How does this apply to MSP? Medicare does not pay for services and items that other health insurance or coverage is primarily responsible for paying. In other words, Medicare is the secondary payer when it is not responsible for paying first; when it is not the beneficiary’s primary health insurance coverage. So, remember, only in the *absence* of other primary insurance or coverage does Medicare remain the primary payer.  Examples include accidents where the auto insurance would eclipse Medicare, workers compensation, a fall whether at home or on public property, etc. **Are there any exceptions to the MSP requirements? No and Yes.** First, no.  Federal law takes precedence over state laws and private contracts. It doesn’t matter what an insurance contract or state law may claim federal law always take precedence. Second, yes. In the following situations, Medicare may make payment, assuming Medicare covers the services and you file a proper claim. - A Group Health Plan (GHP) denies payment for services because the beneficiary is not covered by the GHP; - A no-fault or liability insurer does not pay or denies the medical bill; - A Workers Compensation (WC)  program denies payment, as in situations where WC is not required to pay for a given medical condition; or - A WC Medicare Set-aside Arrangement (WCMSA) is exhausted. **Conditioning note: **When submitting a claim to Medicare, include documentation from the other payer stating the claim was denied and/or benefits were exhausted. OK. With this understanding, you should be in shape and in racing trim. Let’s discuss **5 tactics** to completing the collection race in good time. **1. ****Contact the COBC (Coordination of Benefits Contractor).** You may contact the COBC to: - Verify Medicare’s primary/secondary status, - Report changes to a beneficiary’s health coverage, - Report a beneficiary’s accident/injury, - Report potential MSP situations, or - Ask questions regarding Medicare development letters and questionnaires **2. ****Know your responsibilities. ** As a Medicare provider you should obtain billing information *prior* to providing services.  You will need to: - Gather accurate MSP data to determine whether or not Medicare is the primary payer by asking Medicare beneficiaries (or their representatives) questions concerning the beneficiary’s MSP status. - Bill the primary payer before billing Medicare. - For Part A, submit any MSP information on your Medicare claim using proper condition and occurrence codes on the claim. - For Part B, submit an Explanation of Benefits (EOB) form from the primary payer on your claim with all appropriate MSP information. If submitting an electronic claim, provide the necessary fields, loops, and segments needed to process the MSP claim. **3. ****Gather accurate data from the MSP beneficiary.** You must determine whether Medicare is the primary or secondary payer for each inpatient admission prior to submitting a bill by asking Medicare beneficiaries about other coverage. You should also inquire through [HETS (HIPAA Eligibility Transaction System)](http://www.proclaimpartners.com/blog/bid/275459/HETS-to-replace-CWF-eligibility-inquiries-in-April-no-foolin). **The MSP Questionnaire** CMS developed an MSP questionnaire[2] for providers to use as a guide to help identify other payers that may be primary to Medicare. The questionnaire follows a logical step-by-step sequence of Yes/No questions involving whether or not: - The beneficiary is receiving Black Lung (BL) Benefits - The services are to be paid by a government research program - Department of Veterans Affairs (DVA) has authorized and agreed to pay for your care at this facility - The illness/injury was due to a work-related accident/condition - The illness/injury was due to a non-work-related accident - No-fault insurance is available - Liability insurance is available - The beneficiary is employed - The spouse is currently employed - The beneficiary has group health plan (GHP) coverage based on his or her own or a spouse's current employment - The beneficiary has GHP coverage based on own current employment: does the employer that sponsors or contributes to the GHP employ 20 or more employees or 100 or more employees? - The beneficiary has GHP coverage based on his or her spouse’s current employment: does the spouse’s employer that sponsors or contributes to the GHP employ 20 or more employees or 100 or more employees - The beneficiary is covered under the GHP of a family member other than his or her spouse whose employer that sponsors or contributes to the GHP employs 100 or more employees - The beneficiary has End Stage Renal Disease (ESRD) and has group health plan (GHP) coverage - The beneficiary has received a kidney transplant - The beneficiary has received maintenance dialysis treatments - The beneficiary is within the 30-month coordination period that starts MM/DD/CCYY - The beneficiary is entitled to Medicare on the basis of either ESRD and age or ESRD and disability - The initial entitlement to Medicare (including simultaneous or dual entitlement) was based on ESRD - The GHP is already primary based on age or disability entitlement **Race tactic: **You should retain a copy of completed MSP questionnaires in your files or online for 10 years. **4. ****Avoid submitting a claim to Medicare without providing the other insurer’s information.** Medicare may erroneously pay the claim as primary if it meets all Medicare requirements, including coverage and medical necessity guidelines. However, if the beneficiary’s Medicare record in HETS indicates that another insurer should have paid primary to Medicare, Medicare will deny the claim, unless it may rightly pay conditionally. **5. ****Avoid the penalties to failure to filing correct and accurate claims with Medicare.** Medicare can fine providers, physicians, and other suppliers up to $2,000 for knowingly, willfully, and repeatedly providing inaccurate information related to the existence of other health insurance or coverage. **MSP is a serious matter you should carefully address BEFORE you file a claim.** By following these five steps you will be in good shape to cross the collection finish line successfully and in good time. --- [1] The term "Medicare Secondary Payer" is sometimes confused with Medicare supplement. A Medicare supplement (Medigap) policy is a private health insurance policy designed specifically to fill in some of the "gaps" in Medicare's coverage when Medicare is the primary payer. Medicare supplement policies typically pay for expenses that Medicare does not pay because of deductible or coinsurance amounts or other limits under the Medicare program. [2] Medicare Secondary Payer (MSP) Manual, Chapter 3 - MSP Provider, Physician, and Other, Supplier Billing Requirements, 20.2.1 - Admission Questions to Ask Medicare Beneficiaries. ###### Topics: [MSP](https://www.primecareholdings.com/news/topic/msp) [HETS](https://www.primecareholdings.com/news/topic/hets) [collections](https://www.primecareholdings.com/news/topic/collections) [Medicare Secondary Payer](https://www.primecareholdings.com/news/topic/medicare-secondary-payer) ###### 2 min read ## [HETS to replace CWF eligibility inquiries in April – no foolin’!](https://www.primecareholdings.com/news/hets-to-replace-cwf-eligibility-inquiries-in-april-no-foolin) By [Proclaim Partners](https://www.primecareholdings.com/news/author/proclaim-partners) on Tue, Mar 12, 2013 @ 09:00 AM **![Working at desk](http://info.primecaretech.com/hubfs/iStock_000020547970XSmall-resized-600.jpg "Working at desk")Likely, this is not new to you, but I think it’s worthwhile repeating** – URGENTLY - and doing something about it, if you haven’t. Time is running out for those of you who are procrastinators. By April 2013, you will no longer be able to check on a resident’s Medicare eligibility through the Common Working File (CWF).  What does this mean? It means that if you haven’t already, you should start checking Medicare eligibility through the (bear with me here) Medicare Health Insurance Portability and Accountability Act (HIPAA) Eligibility Transaction System (HETS). (Ah, what’s in an acronym?) HETS replaces CWF inquiries. In a way, CMS has made life much easier for billers, because with HETS you can check a beneficiary’s eligibility in real time. (**For more information about HETS and how to get into the system,contact us at 877-644-2312 or info@proclaimpartners.com**.) **A little background, please.** CMS has simplified the eligibility checking process so that through HETS you can submit your inquiry with a real-time 270 request and receive your 271 response, a Functional Acknowledgement (999), an Interchange Acknowledgement (TA1), or a proprietary error response over a secure connection. According to the guide, “The information included in the 271 response is not intended to provide a complete representation of all benefits, but rather to address the status of eligibility (active or inactive) and patient financial responsibility for Medicare Part A and Part B.” This change will likely require you to change your billing processes. **When you submit the 270 inquiry**, essentially, you need only to include the following information: - Health Insurance Claim Number (HICN) - The Medicare beneficiary’s birth date - The beneficiary’s complete first name - The beneficiary’s complete last name While the first name and birth date are optional, you will need to include at least one of them. **What information should you receive? **The information includes the same you received from CWF which you need to file a claim, excepting psychiatric information.  Also it will give you additional information, such as the Part D plan number, address, and enrollment dates as well as the Medicare Advantage Organization name, address, website, and phone number. (Pretty nifty.) **Who can you talk to for help?** If you have questions regarding eligibility/benefit data for Medicare Part A and Part B, you should contact your regional Medicare Administrative Contractor (MAC). For questions about Medicare Advantage (MA), Part D, eligibility/benefit and Medicare Secondary Payer (MSP) you should contact the appropriate plan(s) listed in the 271 response. **You can also contact us at 877-644-2312 or info@proclaimpartners.com.** **Some of the information HETS will send you will be in a format somewhat different** from what you may be used to. Also, HETS will eventually be able to send Hospice information in the same format as the CWF. The HETS 270/271 Companion Guide gives you more insight into the eligibility information you will receive in the HETS 271 response. Click [here](http://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/HETSHelp/Downloads/HETS270271CompanionGuide5010.pdf) for to view or download the guide. **If you are using a clearinghouse, such as ProClaim Partners**, to access Medicare beneficiary eligibility information, they can also answer the questions you may have. **Question**: If you are using HETS, how has this changed how you check a resident’s eligibility? Has this change helped you? If so, in what ways? ###### Topics: [270 Request](https://www.primecareholdings.com/news/topic/270-request) [Common Working File](https://www.primecareholdings.com/news/topic/common-working-file) [HETS](https://www.primecareholdings.com/news/topic/hets) [271 Response](https://www.primecareholdings.com/news/topic/271-response) [CWF](https://www.primecareholdings.com/news/topic/cwf) [All posts](https://www.primecareholdings.com/news/all) ### Sign up for updates ### Featured ### Posts by Tag - [primeCLOUD (34)](https://www.primecareholdings.com/news/topic/primecloud) - [Prime Care Technologies (33)](https://www.primecareholdings.com/news/topic/prime-care-technologies) - [business intelligence (33)](https://www.primecareholdings.com/news/topic/business-intelligence) - [#solutions (27)](https://www.primecareholdings.com/news/topic/solutions) - [cyber security (25)](https://www.primecareholdings.com/news/topic/cyber-security) - [primeVIEW (18)](https://www.primecareholdings.com/news/topic/primeview) - 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