Privacy Act of 1974; Computer Match No. 2005-02, 42558-42560 [05-14562]
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<![CDATA[
42558
Federal Register / Vol. 70, No. 141 / Monday, July 25, 2005 / Notices
and on the Web site of the HHS Office
of Global Health Affairs, Internet
address: https://www.globalhealth.gov.
William P. Nichols,
MPA, Director, Procurement and Grants
Office, Centers for Disease Control and
Prevention, U.S. Department of Health and
Human Services.
[FR Doc. 05–14573 Filed 7–22–05; 8:45 am]
BILLING CODE 4163–18–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Review Administrator, 24 Executive Park,
NE., Mailstop E74, Atlanta, GA 30333,
Telephone (404) 498–2530.
The Director, Management Analysis and
Services Office, has been delegated the
authority to sign Federal Register notices
pertaining to announcements of meetings and
other committee management activities, for
both CDC and the Agency for Toxic
Substances and Disease Registry.
Dated: July 19, 2005.
Alvin Hall,
Director, Management Analysis and Services
Office, Centers for Disease Control and
Prevention.
[FR Doc. 05–14578 Filed 7–22–05; 8:45 am]
Services, CMS, Mail-stop N2–04–27,
7500 Security Boulevard, Baltimore,
Maryland 21244–1850. Comments
received will be available for review at
this location, by appointment, during
regular business hours, Monday through
Friday from 9 a.m.–3 p.m., eastern
daylight time.
FOR FURTHER INFORMATION CONTACT:
Linda Guenin, Government Task Leader,
Centers for Medicare & Medicaid
Services, Division of Medicare Financial
Management, Program Integrity Branch,
233 N. Michigan Avenue, 6th Floor,
Chicago, Illinois 60601. The telephone
number is (312) 353–1279 and e-mail is
Linda.Guenin@cms.hhs.gov.
Centers for Disease Control and
Prevention
BILLING CODE 4163–18–P
Disease, Disability, and Injury
Prevention and Control
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
SUPPLEMENTARY INFORMATION:
Centers for Medicare & Medicaid
Services
A. General
Special Emphasis Panels (SEP):
Reducing Racial and Ethnic Disparities
in Childhood Immunization, RFA IP 05–
087; Influenza Vaccination of
Healthcare Workers in Hospitals, RFA
IP 05–089; Expanding Utilization of ProActive Pharmacist Pneumococcal
Vaccination Programs, RFA IP 05–092;
and CDC Disparities in Elderly
Pneumococcal Vaccination, RFA IP 05–
093.
In accordance with Section 10(a)(2) of
the Federal Advisory Committee Act
(Pub. L. 92–463), the Centers for Disease
Control and Prevention (CDC)
announces the following meeting:
Name: Disease, Disability, and Injury
Prevention and Control Special Emphasis
Panel (SEP): Reducing Racial and Ethnic
Disparities in Childhood Immunization, RFA
IP 05–087; Influenza Vaccination of
Healthcare Workers in Hospitals, RFA IP 05–
089; Expanding Utilization of Pro-Active
Pharmacist Pneumococcal Vaccination
Programs, RFA IP 05–092; and CDC
Disparities in Elderly Pneumococcal
Vaccination, RFA IP 05–093.
Times and Dates: 8 a.m.–5 p.m., August 9,
2005 (Closed).
Place: Renaissance Concourse Hotel, One
Hartsfield Centre Parkway, Atlanta, GA
30354, Telephone Number (404) 209–9999.
Status: The meeting will be closed to the
public in accordance with provisions set
forth in Section 552b(c) (4) and (6), Title 5
U.S.C., and the Determination of the Director,
Management Analysis and Services Office,
CDC, pursuant to Public Law 92–463.
Matters to be Discussed: The meeting will
include the review, discussion, and
evaluation of applications received in
response to: Reducing Racial and Ethnic
Disparities in Childhood Immunization, RFA
IP 05–087; Influenza Vaccination of
Healthcare Workers in Hospitals, RFA IP 05–
089; Expanding Utilization of Pro-Active
Pharmacist Pneumococcal Vaccination
Programs, RFA IP 05–092; and CDC
Disparities in Elderly Pneumococcal
Vaccination, RFA IP 05–093.
Contact Person for More Information: H.
Mac Stiles, PhD, D.D.S, M.P.H., Scientific
VerDate jul<14>2003
14:21 Jul 22, 2005
Jkt 205001
Privacy Act of 1974; Computer Match
No. 2005–02
Department of Health and
Human Services (HHS), Centers for
Medicare & Medicaid Services (CMS).
ACTION: Notice of Computer Matching
Program (CMP).
AGENCY:
SUMMARY: In accordance with the
requirements of the Privacy Act of 1974,
as amended, this notice establishes a
CMP that CMS plans to conduct with
the Ohio Department of Jobs & Family
Services (ODJFS). We have provided
background information about the
proposed matching program in the
SUPPLEMENTARY INFORMATION section
below. The Privacy Act requires that
CMS provide an opportunity for
interested persons to comment on the
proposed matching program. We may
defer implementation of this matching
program if we receive comments that
persuade us to defer implementation.
See DATES section below for comment
period.
DATES: CMS filed a report of the CMP
with the Chair of the House Committee
on Government Reform and Oversight,
the Chair of the Senate Committee on
Governmental Affairs, and the
Administrator, Office of Information
and Regulatory Affairs, Office of
Management and Budget (OMB) on July
14, 2005. We will not disclose any
information under a matching
agreement until 40 days after filing a
report to OMB and Congress or 30 days
after publication.
ADDRESSES: The public should address
comments to: CMS Privacy Officer,
Division of Privacy Compliance Data
Development (DPCDD), Enterprise
Databases Group, Office of Information
PO 00000
Frm 00028
Fmt 4703
Sfmt 4703
Description of the Matching Program
The Computer Matching and Privacy
Protection Act of 1988 (Public Law
(Pub. L.) 100–503), amended the Privacy
Act (5 U.S.C. 552a) by describing the
manner in which computer matching
involving Federal agencies could be
performed and adding certain
protections for individuals applying for
and receiving Federal benefits. Section
7201 of the Omnibus Budget
Reconciliation Act of 1990 (Pub. L. 101–
508) further amended the Privacy Act
regarding protections for such
individuals. The Privacy Act, as
amended, regulates the use of computer
matching by Federal agencies when
records in a system of records are
matched with other Federal, state, or
local government records. It requires
Federal agencies involved in computer
matching programs to:
1. Negotiate written agreements with
the other agencies participating in the
matching programs;
2. Obtain the Data Integrity Board
approval of the match agreements;
3. Furnish detailed reports about
matching programs to Congress and
OMB;
4. Notify applicants and beneficiaries
that the records are subject to matching;
and,
5. Verify match findings before
reducing, suspending, terminating, or
denying an individual’s benefits or
payments.
B. CMS Computer Matches Subject to
the Privacy Act
CMS has taken action to ensure that
all CMPs that this Agency participates
in comply with the requirements of the
Privacy Act of 1974, as amended.
E:\FR\FM\25JYN1.SGM
25JYN1
Federal Register / Vol. 70, No. 141 / Monday, July 25, 2005 / Notices
Dated: July 12, 2005.
John R. Dyer,
Chief Operating Officer, Centers for Medicare
& Medicaid Services.
Computer Match No. 2005–02
Name
‘‘Computer Matching Agreement
(CMA) Between the Centers for
Medicare & Medicaid Services (CMS)
and the State of Ohio Department of Job
& Family Services (ODJFS) for
Disclosure of Medicare and Medicaid
Information’’.
Security Classification
Level Three Privacy Act Sensitive.
Participating Agencies
The Centers for Medicare & Medicaid
Services, and State of Ohio Department
of Job & Family Services.
Authority for Conducting Matching
Program
This CMA is executed to comply with
the Privacy Act of 1974 (Title 5 United
States Code (U.S.C.) 552a), as amended,
(as amended by Public Law (Pub. L.)
100–503, the Computer Matching and
Privacy Protection Act (CMPPA) of
1988), the Office of Management and
Budget (OMB) Circular A–130, titled
‘‘Management of Federal Information
Resources’’ at 65 Federal Register (FR)
77677 (December 12, 2000), 61 FR 6435
(February 20, 1996), and OMB
guidelines pertaining to computer
matching at 54 FR 25818 (June 19,
1989).
This Agreement provides for
information matching fully consistent
with the authority of the Secretary of the
Department of Health and Human
Services (Secretary). Section 1816 of the
Social Security Act (the Act) permits the
Secretary to contract with Fiscal
Intermediaries (FI) to ‘‘make such audits
of the records of providers as may be
necessary to insure that proper
payments are made under this part,’’
and to ‘‘perform such other functions as
are necessary to carry out this
subsection’’ (42 U.S.C. 1395h (a)).
Section 1842 of the Act provides that
the Secretary may contract with entities
known as carriers to ‘‘make such audits
of the records of providers of services as
may be necessary to assure that proper
payments are made’’ (42 U.S.C.
1395u(a)(1)(C)); ‘‘assist in the
application of safeguards against
unnecessary utilization of services
furnished by providers of services and
other persons to individuals entitled to
benefits’’ (42 U.S.C. 1395u(a)(2)(B)); and
‘‘to otherwise assist * * * in
discharging administrative duties
VerDate jul<14>2003
14:21 Jul 22, 2005
Jkt 205001
necessary to carry out the purposes of
this part’’ (42 U.S.C. 1395u(a)(4)).
Furthermore, § 1874(b) of the Act
authorizes the Secretary to contract with
any person, agency, or institution to
secure on a reimbursable basis such
special data, actuarial information, and
other information as may be necessary
in the carrying out of his functions
under this title (42 U.S.C. 1395kk(b)).
Section 1893 of the Act establishes
the Medicare Integrity Program, under
which the Secretary may contract with
eligible entities to conduct a variety of
program safeguard activities, including
fraud review employing equipment and
software technologies that surpass the
existing capabilities of FIs and Carriers
(42 U.S.C. § 1395ddd)). The contracting
entities are called Program Safeguards
Contractors.
Authority for ODJFS to participate in
this computer-matching program is
given under the provisions of
§§ 5101.27–30 of the Ohio Revised
Code, and 42 CFR 431.300 through
431.307. ODJFS is charged with
administration of the Medicaid program
in Ohio and is the single state agency for
such purpose. ODJFS may act as an
agent or representative of the Federal
Government for any purpose in
furtherance of ODJFS’s functions or
administration of the Federal funds
granted to the state. In Ohio, the
Medicaid program provides qualifying
individuals with health care and related
remedial or preventive services,
including both Medicaid services and
services authorized under state law that
are not provided under Federal law.
Purpose(s) of the Matching Program
The purpose of this agreement is to
establish the conditions, safeguards, and
procedures under which CMS will
conduct a computer matching program
with ODJFS to study claims, billing, and
eligibility information to detect
suspected instances of fraud and abuse
(F&A) in the State of Ohio. CMS and
ODJFS will provide a CMS contractor
(hereinafter referred to as the
‘‘Custodian’’) with Medicare and
Medicaid records pertaining to
eligibility, claims, and billing which the
Custodian will match in order to merge
the information into a single database.
Utilizing fraud detection software, the
information will then be used to
identify patterns of aberrant practices
requiring further investigation. The
following are examples of the type of
aberrant practices that may constitute
F&A by practitioners, providers, and
suppliers in the State of Ohio expected
to be identified in this matching
program: (1) Billing for provisions of
more than 24 hours of services in one
PO 00000
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Fmt 4703
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42559
day, (2) providing treatment and
services in ways more statistically
significant than similar practitioner
groups, and (3) up-coding and billing for
services more expensive than those
actually performed.
Categories of Records and Individuals
Covered by the Match
This CMP will enhance the ability of
CMS and ODJFS to detect F&A by
matching claims data, eligibility, and
practitioner, provider, and supplier
enrollment records of Medicare
beneficiaries, practitioners, providers,
and suppliers in the State of Ohio
against records of Medicaid
beneficiaries, practitioners, providers,
and suppliers in the State of Ohio.
Description of Records To Be Used in
the Matching Program
The data for CMS are maintained in
the following Systems of Records (SOR):
National Claims History (NCH), System
No. 09–70–0005 was most recently
published in the Federal Register, at 67
FR 57015 (September 6, 2002). NCH
contains records needed to facilitate
obtaining Medicare utilization review
data that can be used to study the
operation and effectiveness of the
Medicare program. Matched data will be
released to ODJFS pursuant to the
routine use as set forth in the system
notice.
Carrier Medicare Claims Record,
System No. 09–70–0501 was published
in the Federal Register at 67 FR 54428
(August 22, 2002). Matched data will be
released to ODJFS pursuant to the
routine use as set forth in the system
notice.
Enrollment Database, System No. 09–
70–0502 was published in the Federal
Register at 67 FR 3203 (January 23,
2002). Matched data will be released to
ODJFS pursuant to the routine use set
forth in the system notice.
Intermediary Medicare Claims
Record, System No. 09–70–0503 was
published in the Federal Register at 67
FR 65982 (October 29, 2002). Matched
data will be released to ODJFS pursuant
to the routine use as set forth in the
system notice.
Unique Physician/Provider
Identification Number, System No. 09–
70–0525, was most recently published
in the Federal Register at 69 FR 75316
(December 16, 2004). Matched data will
be released to ODJFS pursuant to the
routine use as set forth in the system
notice.
Medicare Supplier Identification File,
System No. 09–70–0530 was most
recently published in the Federal
Register, at 67 FR 48184 (July 23, 2002).
Matched data will be released to ODJFS
E:\FR\FM\25JYN1.SGM
25JYN1
42560
Federal Register / Vol. 70, No. 141 / Monday, July 25, 2005 / Notices
pursuant to the routine use as set forth
in the system notice.
Medicare Beneficiary Database,
System No. 09–70–0536 was published
in the Federal Register at 66 FR 63392
(December 6, 2001). Matched data will
be released to ODJFS pursuant to the
routine use as set forth in the system
notice.
The data for ODJFS are/is maintained
in the following Medical Data
Warehouse Files:
DRUGOUT.txt DRUG pre-convert layout
EDRUGOUT.txt Encounter Drug extract
layout (no pre-convert)
EFACOUT.txt Encounter Facility extract
layouts (no pre-convert and there are 4
extract files)
ELIGOUT.txt Eligibility pre-convert layout
EPROFOUT.txt Encounter Prof. extract
layout (no pre-convert)
FACOUT.txt Facility pre-convert layout
GROSSOUT.txt Gross financial extract (no
pre-convert)
PROFOUT.txt Professional pre-convert
layout
PROVOUT.txt Provider pre-convert layout.
ODJFS may change files maintained
in the Medical Data Warehouse after
giving reasonable notice to CMS and the
Custodian.
Inclusive Dates of the Match
The CMP shall become effective no
sooner than 40 days after the report of
the Matching Program is sent to OMB
and Congress, or 30 days after
publication in the Federal Register,
which ever is later. The matching
program will continue for 18 months
from the effective date and may be
extended for an additional 12 months
thereafter, if certain conditions are met.
[FR Doc. 05–14562 Filed 7–22–05; 8:45 am]
BILLING CODE 4120–03–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Privacy Act of 1974; Computer Match
No. 2005–03
Department of Health and
Human Services (HHS), Centers for
Medicare & Medicaid Services (CMS).
ACTION: Notice of Computer Matching
Program (CMP).
AGENCY:
SUMMARY: In accordance with the
requirements of the Privacy Act of 1974,
as amended, this Notice announces the
establishment of a CMP that CMS plans
to conduct with the Washington
Department of Social and Health
Services (DSHS). We have provided
background information about the
14:21 Jul 22, 2005
Jkt 205001
matched with other Federal, State, or
local government records. It requires
Federal agencies involved in computer
matching programs to:
1. Negotiate written agreements with
the other agencies participating in the
matching programs;
2. Obtain the Data Integrity Board
approval of the match agreements;
3. Furnish detailed reports about
matching programs to Congress and
OMB;
4. Notify applicants and beneficiaries
that the records are subject to matching;
and,
5. Verify match findings before
reducing, suspending, terminating, or
denying an individual’s benefits or
payments.
B. CMS Computer Matches Subject to
the Privacy Act
CMS has taken action to ensure that
all CMPs that this Agency participates
in comply with the requirements of the
Privacy Act of 1974, as amended.
Dated: July 12, 2005.
John R. Dyer,
Chief Operating Officer, Centers for Medicare
& Medicaid Services.
Computer Match No. 2005–03
Name
‘‘Computer Matching Agreement
Between the Centers for Medicare &
Medicaid Services (CMS) and the State
of Washington Department of Social and
Health Services for Disclosure of
Medicare and Medicaid Information.’’
Security Classification
Level Three Privacy Act Sensitive.
Participating Agencies
The Centers for Medicare & Medicaid
Services, and State of Washington
Department of Social and Health
Services.
Description of the Matching Program
Centers for Medicare & Medicaid
Services
VerDate jul<14>2003
proposed Matching Program in the
section
below. The Privacy Act requires that
CMS provide an opportunity for
interested persons to comment on the
proposed matching program. We may
defer implementation of this Matching
Program if we receive comments that
persuade us to defer implementation.
See DATES section below for comment
period.
DATES: CMS filed a report of the CMP
with the Chair of the House Committee
on Government Reform and Oversight,
the Chair of the Senate Committee on
Governmental Affairs, and the
Administrator, Office of Information
and Regulatory Affairs, Office of
Management and Budget (OMB) on July
14, 2005. We will not disclose any
information under a Matching
Agreement until 40 days after filing a
report to OMB and Congress or 30 days
after publication.
ADDRESSES: The public should address
comments to: CMS Privacy Officer,
Division of Privacy Compliance Data
Development (DPCDD), Enterprise
Databases Group, Office of Information
Services, CMS, Mailstop N2–04–27,
7500 Security Boulevard, Baltimore,
Maryland 21244–1850. Comments
received will be available for review at
this location, by appointment, during
regular business hours, Monday through
Friday from 9 a.m.–3 p.m., eastern
daylight time.
FOR FURTHER INFORMATION CONTACT:
Phillip Kauzlarich, Health Insurance
Specialist, Centers for Medicare &
Medicaid Services, Office of Financial
Management, Program Integrity Group,
Mail-stop C3–02–16, 7500 Security
Boulevard, Baltimore Maryland 21244–
1850. The telephone number is (410)–
786–7170 and e-mail is
pkauzlarich@cms.hhs.gov.
SUPPLEMENTARY INFORMATION:
SUPPLEMENTARY INFORMATION
Authority for Conducting Matching
Program
A. General
The Computer Matching and Privacy
Protection Act of 1988 (Pub. L. 100–
503), amended the Privacy Act (5 U.S.C.
552a) by describing the manner in
which computer matching involving
Federal agencies could be performed
and adding certain protections for
individuals applying for and receiving
Federal benefits. Section 7201 of the
Omnibus Budget Reconciliation Act of
1990 (Pub. L. 101–508) further amended
the Privacy Act regarding protections for
such individuals. The Privacy Act, as
amended, regulates the use of computer
matching by Federal agencies when
records in a system of records are
This CMA is executed to comply with
the Privacy Act of 1974 (Title 5 United
States Code (U.S.C.) 552a), as amended,
(as amended by Pub. L. 100–503, the
Computer Matching and Privacy
Protection Act (CMPPA) of 1988), the
Office of Management and Budget
(OMB) Circular A–130, titled
‘‘Management of Federal Information
Resources’’ at 65 Federal Register (FR)
77677 (December 12, 2000), 61 FR 6435
(February 20, 1996), and OMB
guidelines pertaining to computer
matching at 54 FR 25818 (June 19,
1989).
This Agreement provides for
information matching fully consistent
PO 00000
Frm 00030
Fmt 4703
Sfmt 4703
E:\FR\FM\25JYN1.SGM
25JYN1
]]>Agencies
[Federal Register Volume 70, Number 141 (Monday, July 25, 2005)]
[Notices]
[Pages 42558-42560]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 05-14562]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
Privacy Act of 1974; Computer Match No. 2005-02
AGENCY: Department of Health and Human Services (HHS), Centers for
Medicare & Medicaid Services (CMS).
ACTION: Notice of Computer Matching Program (CMP).
-----------------------------------------------------------------------
SUMMARY: In accordance with the requirements of the Privacy Act of
1974, as amended, this notice establishes a CMP that CMS plans to
conduct with the Ohio Department of Jobs & Family Services (ODJFS). We
have provided background information about the proposed matching
program in the SUPPLEMENTARY INFORMATION section below. The Privacy Act
requires that CMS provide an opportunity for interested persons to
comment on the proposed matching program. We may defer implementation
of this matching program if we receive comments that persuade us to
defer implementation. See DATES section below for comment period.
DATES: CMS filed a report of the CMP with the Chair of the House
Committee on Government Reform and Oversight, the Chair of the Senate
Committee on Governmental Affairs, and the Administrator, Office of
Information and Regulatory Affairs, Office of Management and Budget
(OMB) on July 14, 2005. We will not disclose any information under a
matching agreement until 40 days after filing a report to OMB and
Congress or 30 days after publication.
ADDRESSES: The public should address comments to: CMS Privacy Officer,
Division of Privacy Compliance Data Development (DPCDD), Enterprise
Databases Group, Office of Information Services, CMS, Mail-stop N2-04-
27, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. Comments
received will be available for review at this location, by appointment,
during regular business hours, Monday through Friday from 9 a.m.-3
p.m., eastern daylight time.
FOR FURTHER INFORMATION CONTACT: Linda Guenin, Government Task Leader,
Centers for Medicare & Medicaid Services, Division of Medicare
Financial Management, Program Integrity Branch, 233 N. Michigan Avenue,
6th Floor, Chicago, Illinois 60601. The telephone number is (312) 353-
1279 and e-mail is Linda.Guenin@cms.hhs.gov.
SUPPLEMENTARY INFORMATION: Description of the Matching Program
A. General
The Computer Matching and Privacy Protection Act of 1988 (Public
Law (Pub. L.) 100-503), amended the Privacy Act (5 U.S.C. 552a) by
describing the manner in which computer matching involving Federal
agencies could be performed and adding certain protections for
individuals applying for and receiving Federal benefits. Section 7201
of the Omnibus Budget Reconciliation Act of 1990 (Pub. L. 101-508)
further amended the Privacy Act regarding protections for such
individuals. The Privacy Act, as amended, regulates the use of computer
matching by Federal agencies when records in a system of records are
matched with other Federal, state, or local government records. It
requires Federal agencies involved in computer matching programs to:
1. Negotiate written agreements with the other agencies
participating in the matching programs;
2. Obtain the Data Integrity Board approval of the match
agreements;
3. Furnish detailed reports about matching programs to Congress and
OMB;
4. Notify applicants and beneficiaries that the records are subject
to matching; and,
5. Verify match findings before reducing, suspending, terminating,
or denying an individual's benefits or payments.
B. CMS Computer Matches Subject to the Privacy Act
CMS has taken action to ensure that all CMPs that this Agency
participates in comply with the requirements of the Privacy Act of
1974, as amended.
[[Page 42559]]
Dated: July 12, 2005.
John R. Dyer,
Chief Operating Officer, Centers for Medicare & Medicaid Services.
Computer Match No. 2005-02
Name
``Computer Matching Agreement (CMA) Between the Centers for
Medicare & Medicaid Services (CMS) and the State of Ohio Department of
Job & Family Services (ODJFS) for Disclosure of Medicare and Medicaid
Information''.
Security Classification
Level Three Privacy Act Sensitive.
Participating Agencies
The Centers for Medicare & Medicaid Services, and State of Ohio
Department of Job & Family Services.
Authority for Conducting Matching Program
This CMA is executed to comply with the Privacy Act of 1974 (Title
5 United States Code (U.S.C.) 552a), as amended, (as amended by Public
Law (Pub. L.) 100-503, the Computer Matching and Privacy Protection Act
(CMPPA) of 1988), the Office of Management and Budget (OMB) Circular A-
130, titled ``Management of Federal Information Resources'' at 65
Federal Register (FR) 77677 (December 12, 2000), 61 FR 6435 (February
20, 1996), and OMB guidelines pertaining to computer matching at 54 FR
25818 (June 19, 1989).
This Agreement provides for information matching fully consistent
with the authority of the Secretary of the Department of Health and
Human Services (Secretary). Section 1816 of the Social Security Act
(the Act) permits the Secretary to contract with Fiscal Intermediaries
(FI) to ``make such audits of the records of providers as may be
necessary to insure that proper payments are made under this part,''
and to ``perform such other functions as are necessary to carry out
this subsection'' (42 U.S.C. 1395h (a)).
Section 1842 of the Act provides that the Secretary may contract
with entities known as carriers to ``make such audits of the records of
providers of services as may be necessary to assure that proper
payments are made'' (42 U.S.C. 1395u(a)(1)(C)); ``assist in the
application of safeguards against unnecessary utilization of services
furnished by providers of services and other persons to individuals
entitled to benefits'' (42 U.S.C. 1395u(a)(2)(B)); and ``to otherwise
assist * * * in discharging administrative duties necessary to carry
out the purposes of this part'' (42 U.S.C. 1395u(a)(4)).
Furthermore, Sec. 1874(b) of the Act authorizes the Secretary to
contract with any person, agency, or institution to secure on a
reimbursable basis such special data, actuarial information, and other
information as may be necessary in the carrying out of his functions
under this title (42 U.S.C. 1395kk(b)).
Section 1893 of the Act establishes the Medicare Integrity Program,
under which the Secretary may contract with eligible entities to
conduct a variety of program safeguard activities, including fraud
review employing equipment and software technologies that surpass the
existing capabilities of FIs and Carriers (42 U.S.C. Sec. 1395ddd)).
The contracting entities are called Program Safeguards Contractors.
Authority for ODJFS to participate in this computer-matching
program is given under the provisions of Sec. Sec. 5101.27-30 of the
Ohio Revised Code, and 42 CFR 431.300 through 431.307. ODJFS is charged
with administration of the Medicaid program in Ohio and is the single
state agency for such purpose. ODJFS may act as an agent or
representative of the Federal Government for any purpose in furtherance
of ODJFS's functions or administration of the Federal funds granted to
the state. In Ohio, the Medicaid program provides qualifying
individuals with health care and related remedial or preventive
services, including both Medicaid services and services authorized
under state law that are not provided under Federal law.
Purpose(s) of the Matching Program
The purpose of this agreement is to establish the conditions,
safeguards, and procedures under which CMS will conduct a computer
matching program with ODJFS to study claims, billing, and eligibility
information to detect suspected instances of fraud and abuse (F&A) in
the State of Ohio. CMS and ODJFS will provide a CMS contractor
(hereinafter referred to as the ``Custodian'') with Medicare and
Medicaid records pertaining to eligibility, claims, and billing which
the Custodian will match in order to merge the information into a
single database. Utilizing fraud detection software, the information
will then be used to identify patterns of aberrant practices requiring
further investigation. The following are examples of the type of
aberrant practices that may constitute F&A by practitioners, providers,
and suppliers in the State of Ohio expected to be identified in this
matching program: (1) Billing for provisions of more than 24 hours of
services in one day, (2) providing treatment and services in ways more
statistically significant than similar practitioner groups, and (3) up-
coding and billing for services more expensive than those actually
performed.
Categories of Records and Individuals Covered by the Match
This CMP will enhance the ability of CMS and ODJFS to detect F&A by
matching claims data, eligibility, and practitioner, provider, and
supplier enrollment records of Medicare beneficiaries, practitioners,
providers, and suppliers in the State of Ohio against records of
Medicaid beneficiaries, practitioners, providers, and suppliers in the
State of Ohio.
Description of Records To Be Used in the Matching Program
The data for CMS are maintained in the following Systems of Records
(SOR): National Claims History (NCH), System No. 09-70-0005 was most
recently published in the Federal Register, at 67 FR 57015 (September
6, 2002). NCH contains records needed to facilitate obtaining Medicare
utilization review data that can be used to study the operation and
effectiveness of the Medicare program. Matched data will be released to
ODJFS pursuant to the routine use as set forth in the system notice.
Carrier Medicare Claims Record, System No. 09-70-0501 was published
in the Federal Register at 67 FR 54428 (August 22, 2002). Matched data
will be released to ODJFS pursuant to the routine use as set forth in
the system notice.
Enrollment Database, System No. 09-70-0502 was published in the
Federal Register at 67 FR 3203 (January 23, 2002). Matched data will be
released to ODJFS pursuant to the routine use set forth in the system
notice.
Intermediary Medicare Claims Record, System No. 09-70-0503 was
published in the Federal Register at 67 FR 65982 (October 29, 2002).
Matched data will be released to ODJFS pursuant to the routine use as
set forth in the system notice.
Unique Physician/Provider Identification Number, System No. 09-70-
0525, was most recently published in the Federal Register at 69 FR
75316 (December 16, 2004). Matched data will be released to ODJFS
pursuant to the routine use as set forth in the system notice.
Medicare Supplier Identification File, System No. 09-70-0530 was
most recently published in the Federal Register, at 67 FR 48184 (July
23, 2002). Matched data will be released to ODJFS
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pursuant to the routine use as set forth in the system notice.
Medicare Beneficiary Database, System No. 09-70-0536 was published
in the Federal Register at 66 FR 63392 (December 6, 2001). Matched data
will be released to ODJFS pursuant to the routine use as set forth in
the system notice.
The data for ODJFS are/is maintained in the following Medical Data
Warehouse Files:
DRUGOUT.txt DRUG pre-convert layout
EDRUGOUT.txt Encounter Drug extract layout (no pre-convert)
EFACOUT.txt Encounter Facility extract layouts (no pre-convert and
there are 4 extract files)
ELIGOUT.txt Eligibility pre-convert layout
EPROFOUT.txt Encounter Prof. extract layout (no pre-convert)
FACOUT.txt Facility pre-convert layout
GROSSOUT.txt Gross financial extract (no pre-convert)
PROFOUT.txt Professional pre-convert layout
PROVOUT.txt Provider pre-convert layout.
ODJFS may change files maintained in the Medical Data Warehouse
after giving reasonable notice to CMS and the Custodian.
Inclusive Dates of the Match
The CMP shall become effective no sooner than 40 days after the
report of the Matching Program is sent to OMB and Congress, or 30 days
after publication in the Federal Register, which ever is later. The
matching program will continue for 18 months from the effective date
and may be extended for an additional 12 months thereafter, if certain
conditions are met.
[FR Doc. 05-14562 Filed 7-22-05; 8:45 am]
BILLING CODE 4120-03-P
