Privacy Act of 1974; Report of a Modified System of Records, 10537-10540 [E7-4177]

Agencies

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

[Federal Register Volume 72, Number 45 (Thursday, March 8, 2007)]
[Notices]
[Pages 10537-10540]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: E7-4177]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services


Privacy Act of 1974; Report of a Modified System of Records

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

ACTION: Notice of a Modified 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 an existing system titled, ``Medicare 
Learning Network (MLN) Registration and Product Ordering System 
(REPOS),'' No. 09-70-0542, most recently modified at 68 FR 35897 (June 
17, 2003). 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 delete routine use number 2 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.
    Finally, we will delete the section titled ``Additional 
Circumstances Affecting Routine Use Disclosures,'' that addresses 
``Protected Health Information (PHI)'' and ``small cell size.'' The 
requirement for compliance with HHS regulation ``Standards for Privacy 
of Individually Identifiable Health Information'' does not apply 
because this system does not collect or maintain PHI. In addition, our 
policy to prohibit release if there is a possibility that an individual 
can be identified through ``small cell size'' is not applicable to the 
data maintained in this system.
    We are modifying the language in the 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) (Pub. L. 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 system of records is to collect and 
maintain information on health care providers, and other individuals 
ordering provider educational materials who voluntarily register for 
computer/web-based training courses, satellite broadcasts and train-
the-trainer sessions. Information in this system will also be used to: 
(1) support regulatory and policy functions performed within the Agency 
or by a contractor, consultant, or grantee; and (2) to support 
litigation involving the Agency related to this system. 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.

DATES: Effective Date: CMS filed a modified SOR 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 February 7, 2007. To ensure that all 
parties have adequate time in which to comment, the modified system 
will become effective 30 days from the publication of the notice, or 40 
days from the date it was submitted to OMB and the Congress, whichever 
is later. We may defer implementation of this system or one or more of 
the routine use statements listed below if we receive comments that 
persuade us to defer implementation.

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: Mary Case, Technical Advisor, Division

[[Page 10538]]

of Provider Information Planning and Development (DPIPD), Providers 
Communications Group, Center for Medicare Management, CMS, Mail Stop 
C4-13-07, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. She 
can be reached by telephone at 410-786-0021 or e-mail 
mary.case@cms.hhs.gov.

SUPPLEMENTARY INFORMATION:

I. Description of the Modified System of Records

A. Statutory and Regulatory Basis for SOR

    Authority for this collection is given under the provisions of 
Title IV of the Benefits Improvement Protection Act of 2000 (Public Law 
(Pub. L.) 106-554, Appendix F), Title IV of the Balanced Budget Act of 
1997 (Pub. L. 105-33), and Sec. Sec.  1816(a) and 1842(a)(3) of the 
Social Security Act.

B. Collection and Maintenance of Data in the System

    This system will collect and maintain individually identifiable 
information and other data collected on health care providers, and 
other individuals ordering provider educational materials who 
voluntarily register for computer/Web-based training courses, satellite 
broadcasts and train-the-trainer sessions. Information collected will 
include, but is not limited to, the health care provider's first and 
last name, mailing address, provider type, facility type, telephone 
number, fax number and e-mail address. If CMS becomes an accredited 
provider of continuing education credits, this system may also contain 
social security number, provider identification number (UPIN/NPI), or 
tax identification number.

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

    A. 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 REPOS information that can be 
associated with an individual as provided for under ``Section III. 
Proposed Routine Use Disclosures of Data in the System.'' Both 
identifiable and non-identifiable data may be disclosed under a routine 
use. We will only collect the minimum personal data necessary to 
achieve the purpose of REPOS.
    CMS has the following policies and procedures concerning 
disclosures of information that will be maintained in the system. 
Disclosure of information from the system will be approved only to the 
extent necessary to accomplish the purpose of the disclosure and only 
after CMS:
    1. Determines that the use or disclosure is consistent with the 
reason that the data is being collected; e.g., to collect and maintain 
information on health care providers, and other individuals ordering 
provider educational materials who voluntarily register for computer/
Web-based training courses, satellite broadcasts and train-the-trainer 
sessions.
    2. Determines that:
    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 patient-
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. Modified Routine Use Disclosures of Data in the System

    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 Agency contractors, consultants, or CMS grantees who have 
been contracted by the Agency to assist in 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. 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 functions relating to purposes for this 
system.
    CMS occasionally contracts out certain of its functions when this 
would contribute to effective and efficient operations. CMS must be 
able to give a contractor, consultants, or grantees whatever 
information is necessary for the contractor to fulfill its duties. In 
these situations, safeguards are provided in the contract prohibiting 
the contractor, consultants, or grantees from using or disclosing the 
information for any purpose other than that described in the contract 
and to return or destroy all information at the completion of the 
contract.
    2. To 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.
    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. A determination would be made in each instance that, 
under the circumstances involved, the purposes served by the use of the 
information in the particular litigation is compatible with a purpose 
for which CMS collects the information.

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

[[Page 10539]]

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; 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 establish 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 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 the disclosure of information relating to individuals.

    Dated: February 7, 2007.
Charlene Frizzera,
Acting Chief Operating Officer, Centers for Medicare & Medicaid 
Services.
SYSTEM NO. 09-70-0542

SYSTEM NAME:
    ``Medicare Learning Network (MLN) Registration and Product Ordering 
System (REPOS),'' HHS/CMS/CMM.

SECURITY CLASSIFICATION:
    Level Three Privacy Act Sensitive Data.

SYSTEM LOCATION:
    The Centers for Medicare & Medicaid Services (CMS) Data Center, 
7500 Security Boulevard, North Building, First Floor, Baltimore, 
Maryland 21244-1850 and at various contractor locations.

CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:
    This system will collect and maintain individually identifiable 
information and other data collected on health care providers, and 
other individuals ordering provider educational materials who 
voluntarily register for computer/Web-based training courses, satellite 
broadcasts and train-the-trainer sessions.

CATEGORIES OF RECORDS IN THE SYSTEM:
    Information collected will include, but is not limited to, the 
health care provider's first and last name, mailing address, provider 
type, facility type, telephone number, fax number and e-mail address. 
If CMS becomes an accredited provider of continuing education credits, 
this system may also contain social security number, provider 
identification number (UPIN/NPI), or tax identification number.

AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
    Authority for this collection is given under the provisions of 
Title IV of the Benefits Improvement Protection Act of 2000 (Public Law 
(Pub. L.) 106-554, Appendix F), Title IV of the Balanced Budget Act of 
1997 (Pub. L. 105-33), and Sec. Sec.  1816(a) and 1842(a)(3) of the 
Social Security Act.

PURPOSE(S) OF THE SYSTEM:
    The primary purpose of the system of records is to collect and 
maintain information on health care providers, and other individuals 
ordering provider educational materials who voluntarily register for 
computer/web-based training courses, satellite broadcasts and train-
the-trainer sessions. Information in this system will also be used to: 
(1) support regulatory and policy functions performed within the Agency 
or by a contractor, consultant, or grantee; and (2) to support 
litigation involving the Agency related to this system.

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 Agency contractors, or consultants, or grantees who have been 
contracted by the Agency to assist in 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 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.

POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING, 
AND DISPOSING OF RECORDS IN THE SYSTEM:
STORAGE:
    All records are stored on electronic media.

RETRIEVABILITY:
    The collected data are retrieved by an individual identifier; e.g., 
provider name or unique provider 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

[[Page 10540]]

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 may apply 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:
    CMS will retain information for a total period not to exceed 8 
years.

SYSTEM MANAGER AND ADDRESS:
    Director, Division of Provider Information Planning and 
Development, Providers Communications Group, Center for Medicare 
Management, CMS, Mail Stop C4-10-07, 7500 Security Boulevard, 
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, employee 
identification number, tax identification number, national provider 
number, and for verification purposes, the subject individual's name 
(woman's maiden name, if applicable), HICN, and/or 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.)

RECORDS SOURCE CATEGORIES:
    The data collected and maintained in this is voluntary submitted 
and/or is self reported by the health care provider.

SYSTEMS EXEMPTED FROM CERTAIN PROVISIONS OF THE ACT:
    None.

[FR Doc. E7-4177 Filed 3-7-07; 8:45 am]
BILLING CODE 4120-03-P