Medicare eligibility verification is a critical step in the revenue cycle. Before submitting claims, providers rely on eligibility checks (270/271 transactions) to confirm active coverage, identify plan details, and reduce denials.
A key update from CMS may impact this process.
What’s Changing
CMS is enforcing HETS EDI enrollment requirements for Medicare eligibility transactions (270/271).
Effective May 11, 2026, NPIs without active HETS enrollment may experience rejected eligibility requests.
This means eligibility inquiries for Medicare patients may not return coverage information unless proper enrollment is in place.
What Is HETS and Why It Matters
The HIPAA Eligibility Transaction System (HETS) is the CMS-managed system that processes Medicare eligibility requests.
When your system sends a 270 eligibility inquiry:
- It routes through HETS
- HETS validates and processes the request
- A 271 response is returned with coverage details
Without proper enrollment, the request may be rejected before a response is generated.
What Happens If You’re Not Enrolled
If HETS enrollment is not completed for your NPI:
- Medicare eligibility requests may be rejected
- Coverage details may not be returned
- Claims may be submitted without verified eligibility
- Denial rates may increase due to missing or incorrect coverage
For organizations with Medicare volume, this introduces direct revenue risk.
What You Need to Do
All providers should complete HETS EDI enrollment for each active NPI prior to May 11, 2026.
Enrollment is completed through the CMS Enterprise Portal and typically takes a short amount of time, though processing and activation may vary.
For ClaimRev Clients
If you are a current ClaimRev client, your eligibility transactions are routed through an authorized HETS intermediary.
When completing enrollment, use the following:
| Field | Value |
|---|---|
| HETS ID | VQAS |
| Submitter Name | Inovalon |
These values ensure your NPI is correctly associated with the ClaimRev transaction pathway.
Best Practices Before the Deadline
To avoid disruptions:
- Confirm all active NPIs are enrolled
- Prioritize high Medicare-volume providers
- Complete enrollment as soon as possible
- Test a Medicare eligibility check after enrollment
Final Thoughts
This is not a new system, but an enforcement of existing CMS requirements. Providers who complete enrollment ahead of the deadline should not experience disruption.
However, waiting until the last minute may result in rejected eligibility requests and downstream billing issues.
If you have questions about your enrollment status or need assistance, contact the ClaimRev team.