Privacy Act of 1974; Report of Modified or Altered System, 64968-64975 [E6-18613]

Agencies

• DEPARTMENT OF HEALTH AND HUMAN SERVICES
• Centers for Medicare & Medicaid Services

[Federal Register Volume 71, Number 214 (Monday, November 6, 2006)]
[Notices]
[Pages 64968-64975]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: E6-18613]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers For Medicare & Medicaid Services


Privacy Act of 1974; Report of Modified or Altered System

AGENCY: Department of Health and Human Services (HHS) Centers for 
Medicare & Medicaid Services (CMS).

ACTION: Notice of modified or altered system of records (SOR).

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SUMMARY: In accordance with the requirements of the Privacy Act of 
1974, we are proposing to modify or alter a SOR, ``Carrier Medicare 
Claims Record (CMCR) System,'' System No. 09-70-0501, most recently 
modified at 67 Federal Register 54428 (August 22, 2002). We propose to 
change the name of this system to more closely reflect the name of the 
program used for the processing of Part B claims. We will modify the 
name to read: ``Medicare Multi-Carrier Claims System (MCS).'' We 
propose to modify existing routine use number 1 that permits disclosure 
to agency contractors and consultants to include disclosure to CMS 
grantees who perform a task for the agency. CMS grantees, charged with 
completing projects or activities that require CMS data to carry out 
that activity, are classified separate from CMS contractors and/or 
consultants. The modified routine use will remain as routine use number 
1. We will modify

[[Page 64969]]

existing routine use number 5 that permits disclosure to Peer Review 
Organizations (PRO). Organizations previously referred to as PROs will 
be renamed to read: Quality Improvement Organizations (QIO). 
Information will be disclosed to QIOs relating to assessing and 
improving quality of care as well as proper payment of claims. The 
modified routine use will remain as routine use number 5. We will 
delete routine use number 8 authorizing disclosure to support 
constituent requests made to a congressional representative. If an 
authorization for the disclosure has been obtained from the data 
subject, then no routine use is needed. The Privacy Act allows for 
disclosures with the ``prior written consent'' of the data subject. We 
will broaden the scope of routine uses number 10 and 11, authorizing 
disclosures to combat fraud and abuse in the Medicare and Medicaid 
programs to include combating ``waste'' which refers to specific 
beneficiary/recipient practices that result in unnecessary cost to all 
Federally-funded health benefit programs.
    We are modifying the language in the remaining routine uses to 
provide a proper explanation as to the need for the routine use and to 
provide clarity to CMS's intention to disclose individual-specific 
information contained in this system. The routine uses will then be 
prioritized and reordered according to their usage. We will also take 
the opportunity to update any sections of the system that were affected 
by the recent reorganization or because of the impact of the Medicare 
Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) 
(Public Law 108-173) provisions and to update language in the 
administrative sections to correspond with language used in other CMS 
SORs.
    The primary purpose of the SOR is to properly pay medical insurance 
benefits to or on behalf of entitled beneficiaries. Information in this 
system will also be released to: (1) Support regulatory and policy 
functions performed within the Agency or by a contractor, consultant, 
or grantee; (2) assist another Federal or state agency, agency of a 
state government, an agency established by state law, or its fiscal 
agent; (3) assist third party contacts; (4) support providers and 
suppliers of services dealing through fiscal intermediaries or 
carriers; (5) support Quality Improvement Organizations (QIO); (6) 
assist insurance companies and other groups providing protection for 
their enrollees, insurers and other groups providing protection against 
medical expenses who are primary payers to Medicare in accordance with 
42 U.S.C. Sec.  1395y (b); (7) support an individual or organization 
for a research, evaluation, or epidemiological project; (8) support 
litigation involving the Agency related to this SOR; and (9) combat 
fraud, waste, and abuse in certain Federally-funded health care 
programs. We have provided background information about the modified 
system in the ``Supplementary Information'' section below. Although the 
Privacy Act requires only that CMS provide an opportunity for 
interested persons to comment on the proposed routine uses, CMS invites 
comments on all portions of this notice. See ``Effective Dates'' 
section for comment period.

EFFECTIVE DATES: CMS filed a modified or altered system report with the 
Chair of the House Committee on Government Reform and Oversight, the 
Chair of the Senate Committee on Homeland Security & Governmental 
Affairs, and the Administrator, Office of Information and Regulatory 
Affairs, Office of Management and Budget (OMB) on 10/30/2006. To ensure 
that all parties have adequate time in which to comment, the modified 
system, including routine uses, will become effective 30 days from the 
publication of the notice, or 40 days from the date it was submitted to 
OMB and Congress, whichever is later, unless CMS receives comments that 
require alterations to this notice.

ADDRESSES: The public should address comments to: CMS Privacy Officer, 
Division of Privacy Compliance, Enterprise Architecture and Strategy 
Group, Office of Information Services, CMS, Room 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 time zone.

FOR FURTHER INFORMATION CONTACT: Monique Outerbridge, Director, 
Division of System Operations, Business Applications Management Group, 
Office of Information Services, CMS, Room N2-07-27, 7500 Security 
Boulevard, Baltimore, Maryland 21244-1850. The telephone number is 410-
786-2535 or via e-mail at Monique.outerbridge@cms.hhs.gov.

SUPPLEMENTARY INFORMATION:

I. Description of the Modified System

A. Statutory and Regulatory Basis For SOR

    Authority for the collection and maintenance of this system is 
given under the provisions of sections 1842, 1862(b) and 1874 of Title 
XVIII of the Social Security Act (The Act) (42 United States Code 
(U.S.C.) 1395u, 1395y(b), and 1395kk).

B. Scope of the Data Collected

    The system contains information on Medicare beneficiaries who have 
submitted claims for Supplemental Medical Insurance (SMI) benefit 
(Medicare Part B), or individuals whose enrollment in an employer group 
health benefits plan covers the beneficiary. Information contained in 
this system consist of request(s) for payment, provider billing for 
patient services, prepayment plan for group Medicare practice dealing 
through a carrier, health insurance claim form, request(s) for medical 
payment, explanation of benefits, request for claim number 
verification, payment record transmittal, statement of person regarding 
Medicare payment for medical services furnished deceased patient, 
report of prior period of entitlement, itemized bills and other similar 
documents required to support payments to beneficiaries and to 
physicians and other suppliers of Part B services, and Medicare 
secondary payer records containing other party liability insurance 
information necessary for appropriate Medicare claims payment.

II. Collection and Maintenance of Data in the System

A. Agency Policies, Procedures, and Restrictions on the Routine Use

    The Privacy Act permits us to disclose information without an 
individual's consent if the information is to be used for a purpose 
that is compatible with the purpose(s) for which the information was 
collected. Any such disclosure of data is known as a ``routine use.'' 
The government will only release MCS information that can be associated 
with an individual as provided for under ``Section III. Entities Who 
May Receive Disclosures Under Routine Use''. Both identifiable and non-
identifiable data may be disclosed under a routine use.
    We will only disclose the minimum personal data necessary to 
achieve the purpose of MCS. CMS has the following policies and 
procedures concerning disclosures of information that will be 
maintained in the system. In general, disclosure of information from 
the SOR will be approved only for the minimum information necessary to 
accomplish the purpose of the disclosure only after CMS:
    1. Determines that the use or disclosure is consistent with the 
reason that the data is being collected, e.g., to properly pay medical 
insurance benefits to or on behalf of entitled beneficiaries.
    2. Determines that:

[[Page 64970]]

    a. The purpose for which the disclosure is to be made can only be 
accomplished if the record is provided in individually identifiable 
form;
    b. The purpose for which the disclosure is to be made is of 
sufficient importance to warrant the effect and/or risk on the privacy 
of the individual that additional exposure of the record might bring; 
and
    c. There is a strong probability that the proposed use of the data 
would in fact accomplish the stated purpose(s).
    3. Requires the information recipient to:
    a. Establish administrative, technical, and physical safeguards to 
prevent unauthorized use of disclosure of the record;
    b. Remove or destroy at the earliest time all individually-
identifiable information; and
    c. Agree to not use or disclose the information for any purpose 
other than the stated purpose under which the information was 
disclosed.
    4. Determines that the data are valid and reliable.

III. Proposed Routine Use Disclosures of Data in the System

A. Entities Who May Receive Disclosures Under Routine Use

    These routine uses specify circumstances, in addition to those 
provided by statute in the Privacy Act of 1974, under which CMS may 
release information from the MCS without the consent of the individual 
to whom such information pertains. Each proposed disclosure of 
information under these routine uses will be evaluated to ensure that 
the disclosure is legally permissible, including but not limited to 
ensuring that the purpose of the disclosure is compatible with the 
purpose for which the information was collected. We are proposing to 
establish or modify the following routine use disclosures of 
information maintained in the system:
    1. To support agency contractors, consultants, or grantees, who 
have been engaged by the agency to assist in the performance of a 
service related to this collection and who need to have access to the 
records in order to perform the activity. We contemplate disclosing 
information under this routine use only in situations in which CMS may 
enter into a contractual or similar agreement with a third party to 
assist in accomplishing CMS function relating to purposes for this 
system.
    CMS occasionally contracts out certain of its functions when doing 
so would contribute to effective and efficient operations. CMS must be 
able to give a contractor, consultant or grantee whatever information 
is necessary for the contractor or consultant to fulfill its duties. In 
these situations, safeguards are provided in the contract prohibiting 
the contractor, consultant or grantee from using or disclosing the 
information for any purpose other than that described in the contract 
and requires the contractor, consultant or grantee to return or destroy 
all information at the completion of the contract.
    2. To assist another Federal or state agency, agency of a state 
government, an agency established by state law, or its fiscal agent 
pursuant to agreements with CMS to:
    a. Contribute to the accuracy of CMS's proper payment of Medicare 
benefits,
    b. Enable such agency to administer a Federal health benefits 
program, or as necessary to enable such agency to fulfill a requirement 
of a Federal statute or regulation that implements a health benefits 
program funded in whole or in part with Federal funds, and/or
    c. Assist Federal/state Medicaid programs within the state.
    Other Federal or state agencies in their administration of a 
Federal health program may require MCS information for the purposes of 
determining, evaluating, and/or assessing cost, effectiveness, and/or 
the quality of health care services provided in the state, to support 
evaluations and monitoring of Medicare claims information of 
beneficiaries, including proper reimbursement for services provided.
    The Treasury Department may require MCS data for investigating 
alleged theft, forgery, or unlawful negotiation of Medicare 
reimbursement checks.
    The USPS may require MCS data for investigating alleged forgery or 
theft of reimbursement checks.
    The RRB requires MCS information to enable them to assist in the 
implementation and maintenance of the Medicare program.
    The SSA requires MCS data to enable them to assist in the 
implementation and maintenance of the Medicare program.
    The IRS may require MCS data for the application of tax penalties 
against employers and employee organizations that contribute to 
Employer Group Health Plan or Large Group Health Plans that are not in 
compliance with 42 U.S.C. 1395y (b). Disclosure under this routine use 
shall be used by state Medicaid agencies pursuant to agreements with 
the HHS for administration of state supplementation payments for 
determinations of eligibility for Medicaid, for enrollment of welfare 
recipients for medical insurance under section 1843 of the Act, for 
quality control studies, for determining eligibility of recipients of 
assistance under Titles IV, and XIX of the Act, and for the complete 
administration of the Medicaid program. MCS data will be released to 
the state only on those individuals who are patients under the services 
of a Medicaid program within the state or who are residents of that 
state.
    Occasionally state licensing boards require access to the MCS data 
for review of unethical practices or non-professional conduct.
    We also contemplate disclosing information under this routine use 
in situations in which state auditing agencies require MCS information 
for auditing of Medicare eligibility considerations. Disclosure of 
physicians' customary charge data is made to state audit agencies in 
order to ascertain the corrections of Title XIX charges and payments. 
CMS may enter into an agreement with state auditing agencies to assist 
in accomplishing functions relating to purposes for this SOR.
    State and other governmental worker's compensation agencies working 
with CMS to assure that workers' compensation payments are made where 
Medicare has erroneously paid and workers compensation programs are 
liable.
    3. To assist third party contacts (without the consent of the 
individuals to whom the information pertains) in situations where the 
party to be contacted has, or is expected to have information relating 
to the individual's capacity to manage his or her affairs or to his or 
her eligibility for, or an entitlement to, benefits under the Medicare 
program and,
    a. The individual is unable to provide the information being sought 
(an individual is considered to be unable to provide certain types of 
information when any of the following conditions exists: the individual 
is confined to a mental institution, a court of competent jurisdiction 
has appointed a guardian to manage the affairs of that individual, a 
court of competent jurisdiction has declared the individual to be 
mentally incompetent, or the individual's attending physician has 
certified that the individual is not sufficiently mentally competent to 
manage his or her own affairs or to provide the information being 
sought, the individual cannot read or write, cannot afford the cost of 
obtaining the information, a language barrier exists, or the custodian 
of the information will not, as a matter

[[Page 64971]]

of policy, provide it to the individual), or
    b. the data are needed to establish the validity of evidence or to 
verify the accuracy of information presented by the individual, and it 
concerns one or more of the following: the individual's entitlement to 
benefits under the Medicare program; and the amount of reimbursement; 
any case in which the evidence is being reviewed as a result of 
suspected fraud, waste, and abuse, program integrity, quality 
appraisal, or evaluation and measurement of program activities.
    Third parties contacts require MCS information in order to provide 
support for the individual's entitlement to benefits under the Medicare 
program; to establish the validity of evidence or to verify the 
accuracy of information presented by the individual or the 
representative of the applicant, and assist in the monitoring of 
Medicare claims information of beneficiaries, including proper 
reimbursement of services provided.
    Senior citizen volunteers working in the carriers and 
intermediaries' offices to assist Medicare beneficiaries' request for 
assistance may require access to MCS information.
    Occasionally fiscal intermediary/carrier banks, automated clearing 
houses, value added networks (VAN), and provider banks, to the extent 
necessary transfer to provider's electronic remittance advice of 
Medicare payments, and with respect to provider banks, to the extent 
necessary to provide account management services to providers using 
this information.
    4. To assist providers and suppliers of services dealing through 
fiscal intermediaries or carriers for the administration of Title XVIII 
of the Social Security Act.
    Providers and suppliers of services require MCS information in 
order to establish the validity of evidence, or to verify the accuracy 
of information presented by the individual as it concerns the 
individual's entitlement to benefits under the Medicare program, 
including proper reimbursement for services provided.
    Providers and suppliers of services who are attempting to validate 
items on which the amounts included in the annual Physician/Supplier 
Payment List, or other similar publications are based.
    5. To Quality Improvement Organizations (QIO) in connection with 
review of claims, or in connection with studies or other review 
activities, conducted pursuant to Part B of Title XI of the Act and in 
performing affirmative outreach activities to individuals for the 
purpose of establishing and maintaining their entitlement to Medicare 
benefits or health insurance plans.
    QIOs will work to implement quality improvement programs, provide 
consultation to CMS, its contractors, and to state agencies. QIOs will 
assist the state agencies in related monitoring and enforcement 
efforts, assist CMS and Carriers in program integrity assessment, and 
prepare summary information for release to CMS.
    6. To assist insurance companies, third party administrators (TPA), 
employers, self-insurers, managed care organizations, other 
supplemental insurers, non-coordinating insurers, multiple employer 
trusts, group health plans (i.e., health maintenance organizations 
(HMOs) or a competitive medical plan (CMP) with a Medicare contract, or 
a Medicare-approved health care prepayment plan (HCPP)), directly or 
through a contractor, and other groups providing protection for their 
enrollees. Information to be disclosed shall be limited to Medicare 
entitlement data. In order to receive the information, they must agree 
to:
    a. Certify that the individual about whom the information is being 
provided is one of its insured or employees, or is insured and/or 
employed by another entity for whom they serve as a TPA;
    b. Utilize the information solely for the purpose of processing the 
identified individual's insurance claims; and
    c. Safeguard the confidentiality of the data and prevent 
unauthorized access.
    Other insurers, TPAs, HMOs, and HCPPs may require MCS information 
in order to support evaluations and monitoring of Medicare claims 
information of beneficiaries, including proper reimbursement for 
services provided.
    7. To support an individual or organization for a research, 
evaluation, or epidemiological project related to the prevention of 
disease or disability, the restoration or maintenance of health, or 
payment-related projects.
    MCS data will provide for research, evaluation, and epidemiological 
projects, a broader, longitudinal, national perspective of the status 
of Medicare beneficiaries. CMS anticipates that many researchers will 
have legitimate requests to use these data in projects that could 
ultimately improve the care provided to Medicare beneficiaries and the 
policy that governs the care.
    8. To assist the Department of Justice (DOJ), court or adjudicatory 
body when:
    a. The Agency or any component thereof, or
    b. Any employee of the Agency in his or her official capacity, or
    c. Any employee of the Agency in his or her individual capacity 
where the DOJ has agreed to represent the employee, or
    d. The United States Government, is a party to litigation or has an 
interest in such litigation, and by careful review, CMS determines that 
the records are both relevant and necessary to the litigation.
    Whenever CMS is involved in litigation, or occasionally when 
another party is involved in litigation and CMS's policies or 
operations could be affected by the outcome of the litigation, CMS 
would be able to disclose information to the DOJ, court, or 
adjudicatory body involved.
    9. To assist a CMS contractor (including, but not limited to FIs 
and carriers) that assists in the administration of a CMS-administered 
health benefits program, or to a grantee of a CMS-administered grant 
program, when disclosure is deemed reasonably necessary by CMS to 
prevent, deter, discover, detect, investigate, examine, prosecute, sue 
with respect to, defend against, correct, remedy, or otherwise combat 
fraud, waste, or abuse in such programs.
    We contemplate disclosing information under this routine use only 
in situations in which CMS may enter into a contract or grant with a 
third party to assist in accomplishing CMS functions relating to the 
purpose of combating fraud, waste, and abuse.
    CMS occasionally contracts out certain of its functions when doing 
so would contribute to effective and efficient operations. CMS must be 
able to give a contractor or grantee whatever information is necessary 
for the contractor or grantee to fulfill its duties. In these 
situations, safeguards are provided in the contract prohibiting the 
contractor or grantee from using or disclosing the information for any 
purpose other than that described in the contract and requiring the 
contractor or grantee to return or destroy all information.
    10. To assist another Federal agency or to an instrumentality of 
any governmental jurisdiction within or under the control of the United 
States (including any state or local governmental agency), that 
administers, or that has the authority to investigate potential fraud, 
waste, or abuse in, a health benefits program funded in whole or in 
part by Federal funds, when disclosure is deemed reasonably necessary 
by CMS to prevent, deter, discover, detect, investigate, examine, 
prosecute, sue with respect to, defend against, correct, remedy, or 
otherwise

[[Page 64972]]

combat fraud, waste, or abuse in such programs.
    Other agencies may require MCS information for the purpose of 
combating fraud, waste, and abuse in such Federally-funded programs.

B. Additional Circumstances Affecting Routine Use Disclosures

    To the extent this system contains Protected Health Information 
(PHI) as defined by HHS regulation ``Standards for Privacy of 
Individually Identifiable Health Information'' (45 CFR Parts 160 and 
164, Subparts A and E) 65 FR 82462 (12-28-00). Disclosures of such PHI 
that are otherwise authorized by these routine uses may only be made 
if, and as, permitted or required by the ``Standards for Privacy of 
Individually Identifiable Health Information.'' (See 45 CFR 164-512 (a) 
(1)).
    In addition, our policy will be to prohibit release even of data 
not directly identifiable, except pursuant to one of the routine uses 
or if required by law, if we determine there is a possibility that an 
individual can be identified through implicit deduction based on small 
cell sizes (instances where the patient population is so small that 
individuals could, because of the small size, use this information to 
deduce the identity of the beneficiary).

IV. Safeguards

    CMS has safeguards in place for authorized users and monitors such 
users to ensure against unauthorized use. Personnel having access to 
the system have been trained in the Privacy Act and information 
security requirements. Employees who maintain records in this system 
are instructed not to release data until the intended recipient agrees 
to implement appropriate management, operational and technical 
safeguards sufficient to protect the confidentiality, integrity and 
availability of the information and information systems and to prevent 
unauthorized access.
    This system will conform to all applicable Federal laws and 
regulations and Federal, HHS, and CMS policies and standards as they 
relate to information security and data privacy. These laws and 
regulations include but are not limited to: the Privacy Act of 1974; 
the Federal Information Security Management Act of 2002; the Computer 
Fraud and Abuse Act of 1986; the Health Insurance Portability and 
Accountability Act of 1996; the E-Government Act of 2002, the Clinger-
Cohen Act of 1996; the Medicare Modernization Act of 2003, and the 
corresponding implementing regulations. OMB Circular A-130, Management 
of Federal Resources, Appendix III, Security of Federal Automated 
Information Resources also applies. Federal, HHS, and CMS policies and 
standards include but are not limited to: all pertinent National 
Institute of Standards and Technology publications; the HHS Information 
Systems Program Handbook and the CMS Information Security Handbook.

V. Effects of the Modified System of Records on Individual Rights

    CMS proposes to modify this system in accordance with the 
principles and requirements of the Privacy Act and will collect, use, 
and disseminate information only as prescribed therein. Data in this 
system will be subject to the authorized releases in accordance with 
the routine uses identified in this system of records.
    CMS will take precautionary measures (see item IV above) to 
minimize the risks of unauthorized access to the records and the 
potential harm to individual privacy or other personal or property 
rights of patients whose data are maintained in the system. CMS will 
collect only that information necessary to perform the system's 
functions. In addition, CMS will make disclosure from the proposed 
system only with consent of the subject individual, or his/her legal 
representative, or in accordance with an applicable exception provision 
of the Privacy Act. CMS, therefore, does not anticipate an unfavorable 
effect on individual privacy as a result of information relating to 
individuals.

    Dated: October 24, 2006.
John R. Dyer,
Chief Operating Officer, Centers for Medicare & Medicaid Services.
System No. 09-70-0501

SYSTEM NAME:
    ``Medicare Multi-Carrier Claims System (MCS),'' HHS/CMS/OIS

SECURITY CLASSIFICATION:
    Level Three Privacy Act Sensitive Data.

SYSTEM LOCATION:
    Centers for Medicare & Medicaid Services (CMS) Data Center, 7500 
Security Boulevard, North Building, First Floor, Baltimore, Maryland 
21244-1850. See Appendix A for various remote sites where this system 
is also maintained.

CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:
    The system contains information on Medicare beneficiaries who have 
submitted claims for Supplemental Medical Insurance (SMI) benefit 
(Medicare Part B), or individuals whose enrollment in an employer group 
health benefits plan covers the beneficiary.

CATEGORIES OF RECORDS IN THE SYSTEM:
    Information contained in this system consist of request(s) for 
payment, provider billing for patient services, prepayment plan for 
group Medicare practice dealing through a carrier, health insurance 
claim form, request(s) for medical payment, explanation of benefits, 
request for claim number verification, payment record transmittal, 
statement of person regarding Medicare payment for medical services 
furnished deceased patient, report of prior period of entitlement, 
itemized bills and other similar documents required to support payments 
to beneficiaries and to physicians and other suppliers of Part B 
services, and Medicare secondary payer records containing other party 
liability insurance information necessary for appropriate Medicare 
claims payment.

AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
    Authority for the collection and maintenance of this system is 
given under the provisions of sections 1842, 1862 (b) and 1874 of Title 
XVIII of the Social Security Act (The Act) (42 United States Code 
(U.S.C.) 1395u, 1395y (b), and 1395kk).

PURPOSE(S) OF THE SYSTEM:
    The primary purpose of the SOR is to properly pay medical insurance 
benefits to or on behalf of entitled beneficiaries. Information in this 
system will also be released to: (1) support regulatory and policy 
functions performed within the Agency or by a contractor, consultant, 
or grantee; (2) assist another Federal or state agency, agency of a 
state government, an agency established by state law, or its fiscal 
agent; (3) assist third party contacts; (4) support providers and 
suppliers of services dealing through fiscal intermediaries or 
carriers; (5) support Quality Improvement Organizations (QIO); (6) 
assist insurance companies and other groups providing protection for 
their enrollees, insurers and other groups providing protection against 
medical expenses who are primary payers to Medicare in accordance with 
42 U.S.C. Sec.  1395y (b); (7) support an individual or organization 
for a research, evaluation, or epidemiological project; (8) support 
litigation involving the Agency related to this SOR; and (9) combat 
fraud, waste, and abuse in certain Federally-funded health care 
programs.

[[Page 64973]]

ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES 
OR USERS AND THE PURPOSES OF SUCH USES:
    A. The Privacy Act allows us to disclose information without an 
individual's consent if the information is to be used for a purpose 
that is compatible with the purpose(s) for which the information was 
collected. Any such compatible use of data is known as a ``routine 
use.'' The proposed routine uses in this system meet the compatibility 
requirement of the Privacy Act. We are proposing to establish the 
following routine use disclosures of information maintained in the 
system:
    1. To support agency contractor, consultant or grantee who have 
been engaged by the agency to assist in the accomplishment of a CMS 
function relating to the purposes for this system and who need to have 
access to the records in order to assist CMS.
    2. To assist another Federal and/or state agency, agency of a state 
government, an agency established by state law, or its fiscal agent:
    a. Contribute to the accuracy of CMS' proper payment of Medicare 
benefits,
    b. Enable such agency to administer a Federal health benefits 
program, or as necessary to enable such agency to fulfill a requirement 
of a Federal statute or regulation that implements a health benefits 
program funded in whole or in part with Federal funds, and/or
    c. Assist Federal/state Medicaid programs within the state.
    3. To assist third party contacts (without the consent of the 
individuals to whom the information pertains) in situations where the 
party to be contacted has, or is expected to have information relating 
to the individual's capacity to manage his or her affairs or to his or 
her eligibility under the Medicare program and,
    a. The individual is unable to provide the information being sought 
(an individual is considered to be unable to provide certain types of 
information when any of the following conditions exists: the individual 
is confined to a mental institution, a court of competent jurisdiction 
has appointed a guardian to manage the affairs of that individual, a 
court of competent jurisdiction has declared the individual to be 
mentally incompetent, or the individual's attending physician has 
certified that the individual is not sufficiently mentally competent to 
manage his or her own affairs or to provide the information being 
sought, the individual cannot read or write, cannot afford the cost of 
obtaining the information, a language barrier exists, or the custodian 
of the information will not, as a matter of policy, provide it to the 
individual), or
    b. The data are needed to establish the validity of evidence or to 
verify the accuracy of information presented by the individual, and it 
concerns one or more of the following: The individual's entitlement to 
benefits under the Medicare program; and the amount of reimbursement; 
any case in which the evidence is being reviewed as a result of 
suspected fraud, waste, and abuse, program integrity, quality 
appraisal, or evaluation and measurement of program activities.
    4. To assist providers and suppliers of services dealing through 
fiscal intermediaries or carriers for the administration of Title XVIII 
of the Act.
    5. To Quality Improvement Organizations (QIO) in connection with 
review of claims, or in connection with studies or other review 
activities, conducted pursuant to Part B of Title XI of the Act and in 
performing affirmative outreach activities to individuals for the 
purpose of establishing and maintaining their entitlement to Medicare 
benefits or health insurance plans.
    6. To assist insurance companies, third party administrators (TPA), 
employers, self-insurers, managed care organizations, other 
supplemental insurers, non-coordinating insurers, multiple employer 
trusts, group health plans (i.e., health maintenance organizations 
(HMO) or a competitive medical plan (CMP) with a Medicare contract, or 
a Medicare-approved health care prepayment plan (HCPP)), directly or 
through a contractor, and other groups providing protection for their 
enrollees. Information to be disclosed shall be limited to Medicare 
entitlement data. In order to receive the information, they must agree 
to:
    a. Certify that the individual about whom the information is being 
provided is one of its insured or employees, or is insured and/or 
employed by another entity for whom the serve as a TPA;
    b. Utilize the information solely for the purpose of processing the 
identified individual's insurance claims; and
    c. Safeguard the confidentiality of the data a prevent unauthorized 
access.
    7. To support an individual or organization for a research, 
evaluation, or epidemiological project related to the prevention of 
disease or disability, the restoration or maintenance of health, or 
payment-related projects.
    8. To support the Department of Justice (DOJ), court or 
adjudicatory body when:
    a. The agency or any component thereof, or
    b. Any employee of the agency in his or her official capacity, or
    c. Any employee of the agency in his or her individual capacity 
where the DOJ has agreed to represent the employee, or
    d. The United States Government is a party to litigation or has an 
interest in such litigation, and by careful review, CMS determines that 
the records are both relevant and necessary to the litigation and that 
the use of such records by the DOJ, court or adjudicatory body is 
compatible with the purpose for which the agency collected the records.
    9. To support a CMS contractor (including, but not limited to 
fiscal intermediaries and carriers) that assists in the administration 
of a CMS-administered health benefits program, or to a grantee of the 
CMS-administered grant program, when disclosure is deemed reasonably 
necessary by CMS to prevent, deter, discover, detect, investigate, 
examine, prosecute, sue with respect to, defend against, correct, 
remedy, or otherwise combat fraud, waste, or abuse in such programs.
    10. To support another Federal agency or to an instrumentality of 
any governmental jurisdiction within or under the control of the United 
States (including any state or local governmental agency), that 
administers, or that has the authority to investigate potential fraud, 
waste, or abuse in, a health benefits program funded in whole or in 
part by Federal funds, when disclosure is deemed reasonably necessary 
by CMS to prevent, deter, discover, detect, investigate, examine, 
prosecute, sue with respect to, defend against, correct, remedy, or 
otherwise combat fraud, waste, or abuse in such programs.
    B. Additional Provisions Affecting Routine Use Disclosures
    To the extent this system contains Protected Health Information 
(PHI) as defined by HHS regulation ``Standards for Privacy of 
Individually Identifiable Health Information'' (45 CFR Parts 160 and 
164, Subparts A and E) 65 FR 82462 (12-28-00). Disclosures of such PHI 
that are otherwise authorized by these routine uses may only be made 
if, and as, permitted or required by the ``Standards for Privacy of 
Individually Identifiable Health Information.'' (See 45 CFR 164-
512(a)(1)).
    In addition, our policy will be to prohibit release even of data 
not directly identifiable, except pursuant to one of the routine uses 
or if required by law, if we determine there is a possibility that an 
individual can be identified through implicit deduction based on small 
cell sizes (instances where the patient population is so small that 
individuals who are familiar with the

[[Page 64974]]

enrollees could, because of the small size, use this information to 
deduce the identity of the beneficiary).

POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING, 
AND DISPOSING OF RECORDS IN THE SYSTEM:
STORAGE:
    Records are maintained on paper, computer diskette and on magnetic 
storage media.

RETRIEVABILITY:
    Information can be retrieved by the beneficiary's name, HIC, and 
assigned unique physician identification number.

SAFEGUARDS:
    CMS has safeguards in place for authorized users and monitors such 
users to ensure against unauthorized use. Personnel having access to 
the system have been trained in the Privacy Act and information 
security requirements. Employees who maintain records in this system 
are instructed not to release data until the intended recipient agrees 
to implement appropriate management, operational and technical 
safeguards sufficient to protect the confidentiality, integrity and 
availability of the information and information systems and to prevent 
unauthorized access.
    This system will conform to all applicable Federal laws and 
regulations and Federal, HHS, and CMS policies and standards as they 
relate to information security and data privacy. These laws and 
regulations include but are not limited to: The Privacy Act of 1974; 
the Federal Information Security Management Act of 2002; the Computer 
Fraud and Abuse Act of 1986; the Health Insurance Portability and 
Accountability Act of 1996; the E-Government Act of 2002, the Clinger-
Cohen Act of 1996; the Medicare Modernization Act of 2003, and the 
corresponding implementing regulations. OMB Circular A-130, Management 
of Federal Resources, Appendix III, Security of Federal Automated 
Information Resources also applies. Federal, HHS, and CMS policies and 
standards include but are not limited to: All pertinent National 
Institute of Standards and Technology publications; the HHS Information 
Systems Program Handbook and the CMS Information Security Handbook.

RETENTION AND DISPOSAL:
    Records are maintained in a secure storage area with identifiers. 
Records are closed at the end of the fiscal year, in which paid, and 
destroyed after 6 years and 3 months. All claims-related records are 
encompassed by the document preservation order and will be retained 
until notification is received from DOJ.

SYSTEM MANAGER(S) AND ADDRESS:
    Director, Division of Systems Operations, Business Applications 
Management Group, Office of Information Services, CMS, 7500 Security 
Boulevard, Room N2-07-27, Baltimore, Maryland 21244-1850.

NOTIFICATION PROCEDURE:
    For purpose of access, the subject individual should write to the 
system manager who will require the system name, HIC, address, date of 
birth, and sex, and for verification purposes, the subject individual's 
name (woman's maiden name, if applicable), social security number 
(SSN). Furnishing the SSN is voluntary, but it may make searching for a 
record easier and prevent delay.

RECORD ACCESS PROCEDURE:
    For purpose of access, use the same procedures outlined in 
Notification Procedures above. Requestors should also reasonably 
specify the record contents being sought. (These procedures are in 
accordance with Department regulation 45 CFR 5b.5(a)(2)).

CONTESTING RECORD PROCEDURES:
    The subject individual should contact the system manager named 
above, and reasonably identify the record and specify the information 
to be contested. State the corrective action sought and the reasons for 
the correction with supporting justification. (These procedures are in 
accordance with Department regulation 45 CFR 5b.7).

RECORD SOURCE CATEGORIES:
    Sources of information contained in this records system is obtained 
from third party agencies, Social Security Administration's Master 
Beneficiary Record, and CMS's Enrollment Database.

SYSTEMS EXEMPTED FROM CERTAIN PROVISIONS OF THE ACT:
    None.

Appendix A.--Health Insurance Claims

    Medicare records are maintained at the CMS Central Office (see 
section 1 below for the address). Health Insurance Records of the 
Medicare program can also be accessed through a representative of 
the CMS Regional Office (see section 2 below for addresses). 
Medicare claims records are also maintained by private insurance 
organizations that share in administering provisions of the health 
insurance programs. These private insurance organizations, referred 
to as carriers and intermediaries, are under contract to the Centers 
for Medicare & Medicaid Services and the Social Security 
Administration to perform specific task in the Medicare program (see 
section three below for addresses for intermediaries, section four 
addresses the carriers, and section five addresses the Payment 
Safeguard Contractors.

I. Central Office Address

    CMS Data Center, 7500 Security Boulevard, North Building, First 
Floor, Baltimore, Maryland 21244-1850.

II. CMS Regional Offices

    Boston Region--Connecticut, Maine, Massachusetts, New Hampshire, 
Rhode Island, Vermont. John F. Kennedy Federal Building, Room 1211, 
Boston, Massachusetts 02203. Office Hours: 8:30 a.m.-5 p.m.
    New York Region--New Jersey, New York, Puerto Rico, Virgin 
Islands. 26 Federal Plaza, Room 715, New York, New York 10007, 
Office Hours: 8:30 a.m.-5 p.m.
    Philadelphia Region--Delaware, District of Columbia, Maryland, 
Pennsylvania, Virginia, West Virginia. Post Office Box 8460, 
Philadelphia, Pennsylvania 19101. Office Hours: 8:30 a.m.-5 p.m.
    Atlanta Region--Alabama, North Carolina, South Carolina, 
Florida, Georgia, Kentucky, Mississippi, Tennessee. 101 Marietta 
Street, Suite 702, Atlanta, Georgia 30223, Office Hours: 8:30 a.m.-
4:30 p.m.
    Chicago Region--Illinois, Indiana, Michigan, Minnesota, Ohio, 
Wisconsin. Suite A-824, Chicago, Illinois 60604. Office Hours: 8 
a.m.-4:45 p.m.
    Dallas Region--Arkansas, Louisiana, New Mexico, Oklahoma, Texas, 
1200 Main Tower Building, Dallas, Texas. Office Hours: 8 a.m.-4:30 
p.m.
    Kansas City Region--Iowa, Kansas, Missouri, Nebraska. New 
Federal Office Building, 601 East 12th Street-Room 436, Kansas City, 
Missouri 64106. Office Hours: 8 a.m.-4:45 p.m.
    Denver Region--Colorado, Montana, North Dakota, South Dakota, 
Utah, Wyoming. Federal Office Building, 1961 Stout St-Room 1185, 
Denver, Colorado 80294. Office Hours: 8 a.m.-4:30 p.m.
    San Francisco Region--American Samoa, Arizona, California, Guam, 
Hawaii, Nevada. Federal Office Building, 10 Van Ness Avenue, 20th 
Floor, San Francisco, California 94102. Office Hours: 8 a.m.-4:30 
p.m.
    Seattle Region--Alaska, Idaho, Oregon, Washington. 1321 Second 
Avenue, Room 615, Mail Stop 211, Seattle, Washington 98101. Office 
Hours 8 a.m.-4:30 p.m.

III. Intermediary Addresses (Hospital Insurance)

    Medicare Coordinator, Assoc. Hospital Serv. Maine (ME BC), 2 
Gannett Drive, South Portland, ME 04106-6911.
    Medicare Coordinator, Anthem New Hampshire, 300 Goffs Falls 
Road, Manchester, NH 03111-0001.
    Medicare Coordinator, BC/BS Rhode Island (RI BC), 444 
Westminster Street, Providence, RI 02903-3279.
    Medicare Coordinator, Empire Medicare Services, 400 S. Salina 
Street, Syracuse, NY 13202.

[[Page 64975]]

    Medicare Coordinator, Cooperativa, P.O. Box 363428, San Juan, PR 
00936-3428.
    Medicare Coordinator, Maryland B/C, P.O. Box 4368, 1946 
Greenspring Ave., Timonium, MD 21093.
    Medicare Coordinator, Highmark, P5103, 120 Fifth Avenue Place, 
Pittsburgh, PA 15222-3099.
    Medicare Coordinator, United Government Services, 1515 N. 
Rivercenter Dr., Milwaukee, WI 53212.
    Medicare Coordinator, Alabama B/C, 450 Riverchase Parkway East, 
Birmingham, AL 35298.
    Medicare Coordinator, Florida B/C, 532 Riverside Ave., 
Jacksonville, FL 32202-4918.
    Medicare Coordinator, Georgia B/C, P.O. Box 9048, 2357 Warm 
Springs Road, Columbus, GA 31908.
    Medicare Coordinator, Mississippi B/C B MS, P.O. Box 23035, 3545 
Lakeland Drive, Jackson, MI 39225-3035.
    Medicare Coordinator, North Carolina B/C, P.O. Box 2291, Durham, 
NC 27702-2291.
    Medicare Coordinator, Palmetto GBA A/RHHI, 17 Technology Circle, 
Columbia, SC 29203-0001.
    Medicare Coordinator, Tennessee B/C, 801 Pine Street, 
Chattanooga, TN 37402-2555.
    Medicare Coordinator, Anthem Insurance Co. (Anthem In), P.O. Box 
50451, 8115 Knue Road, Indianapolis, IN 46250-1936.
    Medicare Coordinator, Arkansas B/C, 601 Gaines Street, Little 
Rock, AR 72203.
    Medicare Coordinator, Group Health Of Oklahoma, 1215 South 
Boulder, Tulsa, OK 74119-2827.
    Medicare Coordinator, TrailBlazer, P.O. Box 660156, Dallas, TX 
75266-0156.
    Medicare Coordinator, Cahaba GBA, Station 7, 636 Grand Avenue, 
Des Moines, IA 50309-2551.
    Medicare Coordinator, Kansas B/C, P.O. Box 239, 1133 Topeka 
Ave., Topeka, KS 66629-0001.
    Medicare Coordinator, Nebraska B/C, P.O. Box 3248, Main Po 
Station, Omaha, NE 68180-0001.
    Medicare Coordinator, Mutual Of Omaha, P.O. Box 1602, Omaha, NE 
68101.
    Medicare Coordinator, Montana B/C, P.O. Box 5017, Great Falls 
Div., Great Falls, MT 59403-5017.
    Medicare Coordinator, Noridian, 4510 13th Avenue S.W., Fargo, ND 
58121-0001.
    Medicare Coordinator, Utah B/C, P.O. Box 30270, 2455 Parleys 
Way, Salt Lake City, UT 84130-0270.
    Medicare Coordinator, Wyoming B/C, 4000 House Avenue, Cheyenne, 
WY 82003.
    Medicare Coordinator, Arizona B/C, P.O. Box 37700, Phoenix, AZ 
85069.
    Medicare Coordinator, UGS, P.O. Box 70000, Van Nuys, CA 91470-
0000.
    Medicare Coordinator, Regents BC, P.O. Box 8110 M/S D-4A, 
Portland, OR 97207-8110.
    Medicare Coordinator, Premera BC, P.O. Box 2847, Seattle, WA 
98111-2847.

IV. Medicare Carriers

    Medicare Coordinator, NHIC, 75 Sargent William Terry Drive, 
Hingham, MA 02044.
    Medicare Coordinator, B/S Rhode Island (RI BS), 444 Westminster 
Street, Providence, RI 02903-2790.
    Medicare Coordinator, Trailblazer Health Enterprises, Meriden 
Park, 538 Preston Ave., Meriden, CT 06450.
    Medicare Coordinator, Upstate Medicare Division, 11 Lewis Road, 
Binghamton, NY 13902.
    Medicare Coordinator, Empire Medicare Services, 2651 Strang 
Blvd., Yorktown Heights, NY 10598.
    Medicare Coordinator, Empire Medicare Services, NJ, 300 East 
Park Drive, Harrisburg, PA 17106.
    Medicare Coordinator, Triple S, 1441 F.D., Roosvelt 
Ave., Guaynabo, PR 00968.
    Medicare Coordinator, Group Health Inc., 4th Floor, 88 West End 
Avenue, New York, NY 10023.
    Medicare Coordinator, Highmark, P.O. Box 89065, 1800 Center 
Street, Camp Hill, PA 17089-9065.
    Medicare Coordinator, Trailblazers Part B, 11150 McCormick 
Drive, Executive Plaza 3 Suite 200, Hunt Valley, MD 21031.
    Medicare Coordinator, Trailblazer Health Enterprises, Virginia, 
P.O. Box 26463, Richmond, VA 23261-6463. United Medicare 
Coordinator, Tricenturion, 1 Tower Square, Hartford, CT 06183.
    Medicare Coordinator, Alabama B/S, 450 Riverchase Parkway East, 
Birmingham, AL 35298.
    Medicare Coordinator, Cahaba GBA, 12052 Middleground Road, Suite 
A, Savannah, GA 31419.
    Medicare Coordinator, Florida B/S, 532 Riverside Ave, 
Jacksonville, FL 32202-4918.
    Medicare Coordinator, Administar Federal, 9901 Linnstation Road, 
Louisville, KY 40223.
    Medicare Coordinator, Palmetto GBA, 17 Technology Circle, 
Columbia, SC 29203-0001.
    Medicare Coordinator, CIGNA, 2 Vantage Way, Nashville, TN 37228.
    Medicare Coordinator, Railroad Retirement Board, 2743 Perimeter 
Parkway, Building 250, Augusta, GA 30999.
    Medicare Coordinator, Cahaba GBA, Jackson Miss, P.O. Box 22545, 
Jackson, MI 39225-2545.
    Medicare Coordinator, Adminastar Federal (IN), 8115 Knue Road, 
Indianapolis, IN 46250-1936.
    Medicare Coordinator, Wisconsin Physicians Service, P.O. Box 
8190, Madison, WI 53708-8190.
    Medicare Coordinator, Nationwide Mutual Insurance Co., P.O. Box 
16788, 1 Nationwide Plaza, Columbus, OH 43216-6788.
    Medicare Coordinator, Arkansas B/S, 601 Gaines Street, Little 
Rock, AR 72203.
    Medicare Coordinator, Arkansas-New Mexico, 601 Gaines Street, 
Little Rock, AR 72203.
    Medicare Coordinator, Palmetto GBA-DMERC, 17 Technology Circle, 
Columbia, SC 29203-0001.
    Medicare Coordinator, Trailblazer Health Enterprises, 901 South 
Central Expressway, Richardson, TX 75080.
    Medicare Coordinator, Nordian, 636 Grand Avenue, Des Moines, IA 
50309-2551.
    Medicare Coordinator, Kansas B/S, P.O. Box 239, 1133 Topeka 
Ave., Topeka, KS 66629-0001.
    Medicare Coordinator, Kansas B/S-NE, P.O. Box 239, 1133 Topeka 
Ave., Topeka, KS 66629-0239.
    Medicare Coordinator, Montana B/S, P.O. Box 4309, Helena, MT 
59601.
    Medicare Coordinator, Nordian, 4305 13th Avenue South, Fargo, ND 
58103-3373.
    Medicare Coordinator, Noridian Backbend (C0), 730 N. Simms 
100, Golden, CO 80401-4730.
    Medicare Coordinator, Noridian BCBSND (WY), 4305 13th Avenue 
South, Fargo, ND 58103-3373.
    Medicare Coordinator, Utah B/S, P.O. Box 30270, 2455 Parleys 
Way, Salt Lake City, UT 84130-0270.
    Medicare Coordinator, Transamerica Occidental, P.O. Box 54905, 
Los Angeles, CA 90054-4905.
    Medicare Coordinator, NHIC-California, 450 W. East Avenue, 
Chico, CA 95926.
    Medicare Coordinator, Cigna, Suite 254, 3150 Lake Harbor, Boise, 
ID 83703.
    Medicare Coordinator, Cigna, Suite 506, 2 Vantage Way, 
Nashville, TN 37228.

V. Payment Safeguard Contractors

    Medicare Coordinator, Aspen Systems Corporation, 2277 Research 
Blvd., Rockville, MD 20850.
    Medicare Coordinator, DynCorp Electronic Data Systems (EDS), 
11710 Plaza America Drive, 5400 Legacy Drive, Reston, VA 20190-6017.
    Medicare Coordinator, Lifecare Management Partners Mutual of 
Omaha Insurance Co., 6601 Little River Turnpike, Suite 300, Mutual 
of Omaha Plaza, Omaha, NE 68175.
    Medicare Coordinator, Reliance Safeguard Solutions, Inc., P.O. 
Box 30207, 400 South Salina Street, 2890 East Cottonwood Pkwy., 
Syracuse, NY 13202.
    Medicare Coordinator, Science Applications International, Inc., 
6565 Arlington Blvd. P.O. Box 100282, Falls Church, VA.
    Medicare Coordinator, California Medical Review, Inc., 
Integriguard Division Federal Sector Civil Group, One Sansome 
Street, San Francisco, CA 94104-4448.
    Medicare Coordinator, Computer Sciences Corporation, Suite 600, 
3120 Timanus Lane, Baltimore, MD 21244.
    Medicare Coordinator, Electronic Data Systems (EDS), 11710 Plaza 
America Drive, 5400 Legacy Drive, Plano, TX 75204.
    Medicare Coordinator, TriCenturion, L.L.C., P.O. Box 100282, 
Columbia, SC 29202.
[FR Doc. E6-18613 Filed 11-3-06; 8:45 am]
BILLING CODE 4120-03-P