Common use of Assurance Agreement Clause in Contracts

Assurance Agreement. 1. Submitter agrees to abide by all applicable federal laws, regulations, and guidance governing access to, and use and disclosure of, CMS data, Protected Health Information (PHI) as defined in 45 CFR §160.103, and Personally Identifiable Information (PII) as defined in OMB Memorandum M-07-16 (May 22, 2007) and understands that individuals or entities may be subject to civil and/or criminal penalties for failing to abide by such provisions. Agree Disagree 2. Before initiating any transmission in HIPAA standard 270/271 transaction format, and thereafter through the term of this Agreement, the Trading Partner will cooperate with CMS and any contractors representing CMS in testing of the transmission and processing systems used in connection with CMS as deemed appropriate to ensure the accuracy, timeliness, completeness, and security of each data transmission. Agree Disagree 3. Submitter will take reasonable care to ensure that the information submitted in each electronic transaction is timely, complete, accurate, and secure, and will take reasonable precautions to prevent unauthorized access of the party’s transmission and processing systems. The Submitter will ensure that each electronic transaction submitted to CMS conforms with the requirements applicable to the transaction. Agree Disagree 4. Every Submitter must be an active enrolled Medicare provider or a Business Associate working on behalf of active enrolled Medicare provider(s) before any submission of electronic transactions is allowed. The Submitter agrees to notify CMS when its relationship with a Medicare provider both begins and terminates. Business Associate Submitters are responsible for providing current information about the provider(s) for whom they are submitting transactions in accordance with the HETS Rules of Behavior. CMS reserves the right to confirm the status of a Business Associate relationship with a provider directly. Agree Disagree 5. Submitters shall notify CMS of a change in Business Associate representation consistent with the HETS Rules of Behavior. Agree Disagree 6. All Submitters must comply with and follow the HETS Rules of Behavior, referenced in Appendix A, in all areas not specifically listed in this Agreement, including how to address making changes to the information supplied in Appendix B. Agree Disagree 7. This Agreement shall take effect and be binding on the Trading Partner and CMS when signed by the Trading Partner and reviewed and signed by an authorized CMS representative. Agree Disagree 8. Termination or expiration of this Agreement or any other contract between the parties does not relieve either party of its obligations under this Agreement and under federal and state laws and regulations pertaining to the privacy and security of PHI and PII, nor its obligations regarding the confidentiality of CMS proprietary information. Agree Disagree 9. Submitters who perform Medicare work offshore (any location outside of the United States where U.S. law is non-binding) must attest that safeguards to protect Medicare Beneficiary Information are actively enforced. Any Submitters who perform work or either directly or indirectly employ offshore labor must attest to the terms specified in Appendix E. Submitters who do not perform any Medicare work offshore (or directly or indirectly employ any offshore labor should mark this assurance as ‘Not Applicable.’ Agree Disagree Not Applicable The Authorized Representative whose name is supplied below is authorized to bind the Trading Partner as a HETS Submitter to the undertakings of this Agreement. By completing the section below, you are agreeing that your organization will be in compliance with the provisions of this Agreement. Trading Partner Authorized Representative Signature Title Printed Name of Trading Partner Authorized Signer Date Signed Telephone Number E-Mail Address This document details the Submitter’s responsibilities in obtaining, disseminating, and using beneficiary’s Medicare eligibility data. It further explains the expectations for using HETS. Compliance with these HETS Rules of Behavior is necessary in order to gain and maintain continued access to the system. This document details the Authorized Representatives HETS roles and responsibilities. It is written confirmation that the Submitter’s Authorized Representative understands his/her responsibility for the organization’s use of HETS and compliance with the HETS Rules of Behavior. (fields marked with * are optional, all others are required) *Name: (Optional) *Title: (Optional) *Telephone number: (Optional) *E-mail address: (Optional) Submitter Organization Name: Submitter Organization Legal Business Name: Submitter Organization Billing Address: City State Zip Code Submitter Organization Physical Address: City State Zip Code Submitter Organization Technical Representative Name: Submitter Organization Technical Representative Telephone Number: Submitter Organization Technical Representative E-mail Address: CMS requires only one NPI from an active/valid enrolled Medicare provider(s) on this form. In accordance with item 4 in the Assurances section of the Agreement, submitter organization must later share any/all additional NPIs with CMS. Medicare Provider’s Name: Medicare Provider’s NPI: Please indicate the type of connectivity used by the Trading Partner. Extranet: Yes No If yes, Name of Network Service Vendor (NSV) used Internet: Yes No If yes, Message Envelope Used SOAP + WSDL HTTP MIME Multipart Trading Partner IP Address (es) for SOAP/MIME transaction (Note: If sending multiple IP addresses, please use a Classless Inter-Domain Routing [CIDR] notation, i.e., 192.0.1.0/24)