HETS

A HETS inquiry uses the standard 270/271 eligibility transaction. The response includes the beneficiary's Part A and Part B entitlement dates, Medicare Advantage (MA) plan enrollment, Medicare Secondary Payer indicators, hospice election periods, and home health episode information. For a home health agency, three items matter most: whether the patient is in traditional Medicare or an MA plan (which changes who you bill and whether authorization is needed), whether a hospice election is active (home health and hospice generally cannot bill Medicare for the same condition concurrently), and whether another agency has an open home health period, which affects transfer handling and Notice of Admission (NOA) sequencing.

Providers do not usually query HETS directly. Common access paths include:

• The agency's EHR or revenue cycle system with a built-in eligibility connection
• A clearinghouse or eligibility vendor submitting 270/271 transactions
• Medicare Administrative Contractor (MAC) provider portals

Whichever path an agency uses, the underlying data source is the same CMS system. Agencies must be enrolled and authorized to submit eligibility transactions, and responses are limited to providers with a treatment relationship or a pending one. HETS replaced older eligibility lookups that ran against the Common Working File, so it is the authoritative real-time source for Medicare eligibility today.

Best practice is to check eligibility at more than one point, not just at referral. A patient can enroll in an MA plan effective the first of a month mid-episode, elect hospice, or have Medicare Secondary Payer changes. A practical cadence: verify at referral before accepting the patient, re-verify at the start of care before submitting the NOA, and re-check monthly for active patients, especially around January 1 and other enrollment effective dates. Agencies that skip the monthly re-check are the ones that discover an MA enrollment only when the final claim rejects, weeks after visits were delivered without authorization.

The most expensive HETS mistake is treating a single admission-time check as permanent. Others include missing an active hospice election buried in the response, overlooking an open home health period with another agency (which signals a transfer and affects payment), ignoring Medicare Secondary Payer flags and billing Medicare as primary, and failing to act on MA enrollment effective dates that fall mid-episode. Each of these surfaces later as a rejected NOA, a denied claim, or an overpayment. Build the review of the full HETS response, not just the entitlement line, into intake and billing workflows.