Providers must use the HETS Provider Attestation to exchange ANSI X12 270/271 eligibility transactions
with a third-party entity.
NOTE: For Virginia and West Virginia Providers -
Palmetto GBA has subcontracted with
Wellpoint Federal
(formerly National Government Services) to continue to support
electronic claim submission for your state. Please contact the Wellpoint Federal Helpdesk at 855-696-0705.
This form must be completed by the provider or authorized or delegated official for the provider. All
providers and authorized or delegated officials participating in functions or activities regulated to
any part of a HETS transaction are subject to all applicable rules and regulations. Clearinghouse and
Billing Service representatives are not permitted to complete this form or attest on behalf of the
provider.
Please complete all fields to create a provider attestation.
Fields marked with a red asterisk (*) are
required.
Please enter a valid PTAN, NPI, and HETS Trading Partner Unique ID.
Enter the Trading Partner Unique ID assigned by HETS to identify the Trading Partner. The trading
partner will communicate their unique ID to the provider for the purpose of allowing the provider to
attest their relationship with the trading partner.
