Privacy Act of 1974; System of Records., 6587-6591 [2018-02933]
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REPORTING REQUIREMENTS—Continued
Number of
respondents
Regulatory/section requirements
Responses
per
respondent
Total annual
responses
Hours per
response
Total hour
burden
57.310(b)(1)(vi), Notification of Delinquent Accounts ..........
57.310(b)(1)(x), Credit Bureau Notification ..........................
57.310(b)(4)(i), Write-off of Uncollectible Loans ..................
57.311(a), Disability Cancellation ........................................
57.315(a)(1)(ii), Administrative Hearings .............................
57.316a, Administrative Hearings ........................................
348
348
23
16
0
0
42.5
709.0
1.0
1.0
0.0
0.0
14,790
246,732
23
16
0
0
0.04
0.006
3.00
1.00
0.00
0.00
592
1,480
69
16
0
0
NSL Subtotal .................................................................
* 348
........................
277,382
........................
7,567
* Includes active and closing schools.
Amy McNulty.
Acting Director, Division of the Executive
Secretariat.
[FR Doc. 2018–02958 Filed 2–13–18; 8:45 am]
BILLING CODE 4165–15–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Privacy Act of 1974; System of
Records.
Centers for Medicare &
Medicaid Services (CMS), Department
of Health and Human Services (HHS).
ACTION: Notice of a New System of
Records.
AGENCY:
The Department of Health and
Human Services (HHS), Centers for
Medicare & Medicaid Services (CMS)
proposes to establish a new system of
records subject to the Privacy Act,
System No. 09–70–0539, titled ‘‘Quality
Payment Program (QPP).’’ The new
system of records will cover quality and
performance data collected and used by
CMS in determining merit-based
payment adjustments for health care
services provided by clinicians to
Medicare beneficiaries, and in providing
expert feedback to clinicians and third
party data submitters for the purpose of
helping clinicians provide high-value
care to patients.
DATES: In accordance with 5 U.S.C.
552a(e)(4) and (11), this notice is
effective upon publication, subject to a
30-day period in which to comment on
the routine uses, described below.
Please submit any comments by March
16, 2018.
ADDRESSES: Written comments should
be submitted by mail or email to: CMS
Privacy Act Officer, Division of
Security, Privacy Policy & Governance,
Information Security & Privacy Group,
Office of Information Technology, CMS,
7500 Security Boulevard, Baltimore, MD
21244–1870, Location N1-14–56, or
walter.stone@cms.hhs.gov. Comments
received will be available for review
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SUMMARY:
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without redaction unless otherwise
advised by the commenter at this
location, by appointment, during regular
business hours, Monday through Friday
from 9:00 a.m.–3:00 p.m., Eastern Time
zone.
FOR FURTHER INFORMATION CONTACT:
General questions about the new system
of records should be submitted by mail
or email to: Michelle Peterman, Health
Insurance Specialist, Division of
Electronic Clinician and Quality,
Quality Measurement and Value-Based
Incentives Group, Center for Clinical
Standards and Quality, CMS, 7500
Security Boulevard, Baltimore, MD
21244–1870, Mailstop: S3–02–01, or
michelle.peterman@cms.hhs.gov.
SUPPLEMENTARY INFORMATION:
I. Background on the New Quality
Payment Program Supported by the
New System of Records
The Medicare Access and CHIP
Reauthorization Act of 2015 (MACRA)
amended title XVIII of the Social
Security Act (the Act) to repeal the way
physicians were paid under the
previous Sustainable Growth Rate (SOR)
formula and replaced it with a new
approach known as the Quality Payment
Program. The Quality Payment Program
streamlines and consolidates
components of three existing incentive
programs that reward high-value patient
centered care: (1) Physician Quality
Reporting System (PQRS) (§ 1848(k) and
(m) of the Act (42 U.S.C. 1395w–4)), (2)
Medicare Electronic Health Records
(EHR) Incentive Program for Eligible
Professionals (§ 1848(0) of the Act), and
(3) Physician Value-Based Payment
Modifier (VM) (§ 1848(p) of the Act). For
more information, see rulemakings
implementing the existing programs, at
80 Fed. Reg. 71135 (November 16, 2015)
(PQRS); 80 FR 62761 (October 16, 2015)
(EHR); and 80 FR 71273 (November 16,
2015) (VM).
There are two separate pathways
within the Quality Payment Program,
Advanced Alternative Payment Models
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(Advanced APM) and Merit-based
Incentive Payment System (MIPS), both
of which contribute toward the goal of
seamless integration of the Quality
Payment Program into clinical practice
workflows. MIPS provides clinicians
measures and activities to assist them in
providing high-value, patient-centered
care to Medicare patients, and to
encourage and reward their use of the
same. The participants generate and
submit to CMS data on health care
coordination. The data will be
submitted to CMS by eligible clinicians
and approved third party data
submitters (for example, registries
which collect and submit disease
tracking data; health information
technology (IT) vendors which submit
data from clinicians’ Certified Electronic
Health Record Technology (CEHRT)
systems). The data will include
information about, and will be retrieved
by personal identifiers for: (1) The
clinicians, (2) any third party data
submitters who are individuals (e.g.,
sole proprietor vendors), (3) individuals
who submit data for clinicians or third
party data submitters as their
representatives or contact persons, and
(4) Medicare beneficiaries and any nonMedicare beneficiaries receiving the
health care services referenced in the
Quality Payment Program data. The
records are described below.
The data submission process will
require that clinicians and third party
submitters use their identifying and
contact information, tax identification
number (TIN/EIN), national provider
identifier (NPI), and information about
health care services provided to patients
for the performance categories of the
MIPS including (1) quality-including a
set of evidence-based, specialty-specific
standards; (2) cost of services provided;
(3) improvement activities that
improved or are likely to improve
clinical practice or care delivery; and (4)
advancing care information which
focuses on the use of CEHRT to support
interoperability and avoid
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redundancies. Except for specific
measures or activities identified and
published in the Federal Register by
November 1 of each year, there are no
changes in Calendar Year (CY) 2017
with respect to the collection and use of
Privacy Act records associated with
these activities in the QPP system of
record notice (SORN) other than what is
collected by the overlapping SORNs
described below. There were no changes
to the Call for Quality Measures process
in the CY 2018 rule and so there are no
changes to the use or additional
collection of Privacy Act records related
to the four performance categories.
Payment adjustments for eligible
clinicians do not begin until CY 2019
and at that time any additional Privacy
Act records associated with those
payment adjustments based on their
performance during the applicable
performance period will be described if
needed in an update to this SORN.
MIPS quality and performance data
used in the program will be reported to
CMS by eligible clinicians and approved
third party data submitters of the types
described in 42 CFR 414.1400. The data
will pertain to health care services
provided to Medicare beneficiaries, but
may also include data about nonMedicare patients. As mentioned above,
except for specific measures or activities
identified and published in the Federal
Register by November 1 of each year,
there are no changes in CY 2017 with
respect to the collection and use of
Privacy Act records associated with
these activities in the QPP SORN other
than what is collected by the
overlapping SORNs described below.
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II. Related Systems of Records
Supporting the Existing PQRS, EHR,
and VM Programs
The PQRS, EHR, and VM programs
each maintain records subject to the
Privacy Act which are maintained in
existing systems of records; these
systems of records will necessarily
overlap with this system of records until
the existing programs fully sunset.
Therefore, these SORNs cover the
Quality Payment Program Privacy Act
records until the QPP SORN is finalized:
1. PQRS: ‘‘Performance Measurement
and Reporting System (PMRS),’’ System
No. 09–70–0584, last published at 73 FR
80412 (December 31, 2008);
2. EHR: ‘‘Medicare and Medicaid
Electronic Health Record (EHR)
Incentive Program National Level
Repository’’ System No. 09–70–0587,
last published at 75 FR 73095
(November 29, 2010);
3. VM: ‘‘Medicare Multi-Carrier
Claims System (MCS),’’ System No. 09–
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70–0501, last published at 71 FR 64968
(November 6, 2006); and
4. VM: ‘‘Fiscal Intermediary Shared
System (FISS),’’ System No. 09–70–
0503, last published at 71 FR 64961
(November 6, 2006).
The Performance Measurement and
Reporting System (PMRS) SORN covers
the Better Quality Information (BQI) to
Improve Care for Medicare Beneficiaries
Project, the Electronic Prescribing (EPrescribing) Incentive Program, and the
PQRS. The BQI to Improve Care for
Medicare Beneficiaries Project and the
E-Prescribing Incentive Program have
fully sunsetted. The PQRS program’s
last reporting year was CY 2016.
However, Privacy Act records related to
the PQRS program will continue to be
utilized for several additional years to
assess payment adjustments in CY 2018
and data as needed. The Medicare and
Medicaid Electronic Health Record
(EHR) Incentive Program National Level
Repository SORN covers the Medicare
and Medicaid EHR Incentive Programs.
The Medicare EHR Incentive program’s
last payment year was CY 2016.
However, Privacy Act records related to
the Medicare EHR Incentive program
will continue to be utilized for several
additional years to assess data as
needed. In addition, the Medicare EHR
Incentive for eligible hospitals and
critical access hospitals (CAHs) and the
Medicaid EHR Incentive program are
active programs. Therefore, the EHR
SORN will not be rescinded. The
SORNs that cover the VM program will
not be rescinded as they are applicable
to many CMS programs.
The Quality Payment Program will
continue to evolve over multiple years
to accommodate payment policy
implementations and take advantage of
new system capabilities. This SORN
will be similarly reviewed and updated
to reflect significant changes, including
the sunsetting of the existing programs
and disposition of the records covered
by the existing SORNs, when they
occur.
III. Related Rulemakings and
Information Collections
Requirements for submitting data
about improvement activities did not
exist in the legacy programs replaced by
MIPS, and CMS does not have historical
data which is directly relevant.
However, the Privacy Act records
collected through these legacy programs
are the same data elements that are used
for the Quality Payment Program in CY
2017 and 2018 although the specific
uses for the previous programs may be
more expansive. To date, participants in
the Quality Payment Program have
registered, have selected measures and
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are submitting data beginning in 2018 as
individuals, as part of a group or as part
of a virtual group—a scenario not
provided through the legacy SORNs.
The primary purpose of the PMRS
system of records, entitled
‘‘Performance Measurement and
Reporting System (PMRS),’’ is to
support the collection, maintenance,
and processing of information to
promote the delivery of high quality,
efficient, effective, and economical
health care services, and promote the
quality and efficiency of services of the
type for which payment may be made
under title XVIII by allowing for the
establishment and implementation of
performance measures, the provision of
feedback to physicians, and public
reporting of performance information.
The primary purpose of the EHR
system of records, entitled ‘‘Medicare
and Medicaid Electronic Health Record
(EHR) Incentive Program National Level
Repository,’’ called the National Level
Repository or NLR, is to collect,
maintain, and process information that
is required for the Medicare and
Medicaid EHR Incentive Programs.
The primary purpose of the VM
program covered by the systems of
records entitled, ‘‘Medicare MultiCarrier Claims System (MCS) and the
Fiscal Intermediary Shared System
(FISS),’’ is to identify and associate a
provider (physician or individual
provider) to their registration and their
reports, known as the Quality and
Resource Use Report (QRUR). QRUR is
a report given to providers on quality of
care and cost performance. In most
cases, systems of records maintain Tax
Identification Number (TIN) and the
name of the organization. In very few
cases, providers may be using their
Social Security number (SSN) as Billing
TIN.
As discussed above the programs
covered by the PMRS SORN have
sunsetted; however, the final payment
year for the PQRS program is CY 2018
requiring the PMRS SORN to remain in
effect until all pertinent data has been
utilized. The EHR SORN and VM
SORNs will not be rescinded as there
are programs covered by these SORNs
that are currently active and have no
plans to sunset.
Once the PQRS program sunsets the
records will be dispositioned entirely
into the QPP system of records under
NARA CMS Records Schedule: DAA–
0440–2015–0009–003. The retention
period for these records is 10 years.
Because the PMRS and the QPP
systems of records maintain identical
records for the categories of individuals
covered by the respective system of
records and also overlap for purposes of
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making payment based on quality
measures and improvement activities
(though not with the same percentages
of activity weighting or payment
calculation), the routine uses for
disclosures of records in the system of
records and uses of records in the
system of records are the same.
Categories of individuals covered by the
system of records will expand under the
QPP SORN to include all-payer data.
All of the routine uses either are
necessary and proper or are compatible
with the original collection purpose of
encouraging and rewarding clinicians’
use of measures and activities that help
them provide high-value, patientcentered care to Medicare beneficiaries.
Dated: February 1, 2018.
Emery Csulak,
Director, Information Security Privacy Group,
and Senior Official for Privacy, Centers for
Medicare & Medicaid Services.
SYSTEM NAME AND NUMBER
‘‘Quality Payment Program (QPP)’’,
HHS/CMS/CCSQ System No. 09–70–
0539.
SECURITY CLASSIFICATION:
Unclassified.
SYSTEM LOCATION:
The address of the agency component
responsible for the system of records is:
CMS Data Center, 7500 Security
Boulevard, North Building, First Floor,
Baltimore, Maryland 21244–1850.
SYSTEM MANAGER(S):
The agency official who is responsible
for the system of records is: Director,
Quality Measurement and Value-based
Incentives Group, CCSQ, CMS, Room
C1–23–14, 7500 Security Boulevard,
Baltimore, Maryland 21244–1870.
AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
Provisions of the Social Security Act
codified at 42 U.S.C. §§ 1320c–3, 13951,
1395w–4, 1395w–21, and 1395y.
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PURPOSE(S) OF THE SYSTEM:
The purposes for which HHS/CMS
will use the records are:
• To be utilized for program
management and administration
purposes;
• To determine payment adjustments
for health care services provided by
clinicians to Medicare beneficiaries;
• To provide expert feedback to
clinicians and third party data
submitters, in order to help clinicians
provide high-value, patient-centered
care to Medicare beneficiaries;
• To make clinician-level
performance measure results available
to Medicare patients and caregivers
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through Physician Compare, as defined
via regulation, either on public profile
pages or via the Downloadable Database
housed on data.medicare.gov for the
purpose of promoting more informed
health care choices for people with
Medicare; and
• To provide relevant records to other
Federal and state agencies which
administer federally-funded health
benefit programs; Quality Improvement
Networks that review claims and
conduct outreach and reviews; and
individuals and organizations that assist
consumers, to use for program
administrative purposes and in health,
disease, and payment-related research,
evaluation, outreach, and transparency
projects.
CATEGORIES OF INDIVIDUALS COVERED BY THE
SYSTEM:
The records will be about these
categories of individuals involved in the
Quality Payment Program:
• Eligible clinicians (such as,
physicians, physician assistants, nurse
practitioners) who submit quality and
performance data to CMS under the
Program;
• Any third party data submitters of
the types described in 42 CFR 414.1400
who are individuals (e.g., sole
proprietor health IT or survey vendors)
and submit data to the Program;
• Individuals who submit data for
clinicians and third party data
submitters (i.e., as their representatives
or contact persons); and
• Medicare beneficiaries (and any
non-Medicare beneficiaries) receiving
the health care services referenced in
the data submitted to CMS under the
Program.
CATEGORIES OF RECORDS IN THE SYSTEM:
The system will include these
categories of records:
• Records about clinicians. These
will include identifying information and
contact information (such as the
clinician’s name, address, phone
number, email address, date of birth,
business address, tax identification
number (TIN/EIN), national provider
identifier (NPI), Social Security number
(SSN), prescriber identification number,
and other assigned clinician numbers)
and information about health care
services the clinician provided to
Medicare beneficiaries (and any nonMedicare beneficiaries) and the
measures and activities the clinician
used in providing the services.
• Records about any third party data
submitters who are individuals (for
example, sole proprietor health IT or
survey vendors). These records will
include the third party’s name, email
address, business address, and TIN/EIN.
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• Records about individuals who
submit data for clinicians and third
party data submitters. These will
include the representative’s name and
contact information such as address,
TIN/EIN, email address, and business
address.
• Records about Medicare
beneficiaries (and any non-Medicare
beneficiaries). These will include the
beneficiary’s identifying and health
information, i.e. name, address, date of
birth, gender, ethnicity, health care
utilization and claims data, health
insurance claim number (HICN),
Medicare beneficiary identifier (MBI),
and SSN.
• Records about other payer payment
arrangements. These will include other
payer payment arrangement information
submitted by non-Medicare payers to
determine whether a payment
arrangement meets the Other Payer
Advanced Alternative Payment Model
(APM) criteria. These records will
include payer identifying information,
payment arrangement information,
supporting documentation, and a
certification statement.
RECORD SOURCE CATEGORIES:
The sources of the records covered by
this system of records are (1) clinicians,
(2) third party data submitters, and (3)
individuals who submit data for
clinicians or third party data submitters.
ROUTINE USES OF RECORDS MAINTAINED IN THE
SYSTEM, INCLUDING CATEGORIES OF USERS AND
PURPOSES OF SUCH USES:
A. These routine uses specify
circumstances, in addition to those
provided by statute in the Privacy Act
of 1974, under which CMS may disclose
records from the Quality Payment
Program to a party outside HHS without
the prior, written consent of the
individual to whom such information
pertains.
1. Records may be disclosed to agency
contractors (including, but not limited
to, Medicare Administrative Contractors
(MACs), fiscal intermediaries, and
carriers) that assist in the health
operations of a CMS-administered
health benefits program, to CMS
consultants, or to a grantee of a CMSadministered grant program, who have
been engaged by the agency to assist in
accomplishment of a CMS function
relating to the purposes for this system
of records and who need to have access
to the records in order to assist CMS.
Such disclosures include (but are not
limited to) disclosures deemed
reasonably necessary by CMS to
prevent, deter, discover, detect,
investigate, examine, prosecute, sue
with respect to, defend against, correct,
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remedy, or otherwise combat fraud,
waste, or abuse in such program.
2. Records may be disclosed to
another Federal or state agency to the
extent deemed necessary to: (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 health
benefit programs funded in whole or in
part with Federal funds; and/or (c) assist
state Medicaid programs which may
require Quality Payment Program
information.
3. Clinician-level performance
measurement results may be made
available to the public, through
Physician Compare, as defined via
regulation, either on public profile
pages or via the Downloadable Database
housed on data.medicare.gov for the
purpose of promoting more informed
health care choices for people with
Medicare.
4. Records may be disclosed to MIPSeligible clinicians and eligible entities
in order to provide them with expert
feedback, and records may be disclosed
to CMS authorized entities participating
in health care transparency projects.
5. Records may be disclosed to
organizations that assist consumers in
comparing the quality and price of
health care services, and/or that use
such information for purposes related to
prevention of disease or disability, or
restoration or maintenance of health.
6. Records may be disclosed to
organizations for research, evaluation,
and projects involving payment issues.
7. Records may be disclosed to
Beneficiary and Family Centered Care
(BFCC)-QIOs, Quality Innovation
Network-QIOs (QIN–QIOs), the Small,
Underserved, and Rural Support (SURS)
technical assistance contractors, and the
Practice Transformation Networks
(PTNs) under the Transforming Clinical
Practice Initiative (TCPI) for purposes
of: (a) Identifying clinicians who are
included in the Quality Payment
Program, specifically the MIPS track,
based on the low-volume threshold; (b)
determining the appropriate form of
Technical Assistance based on practice
size and clinician need; (c) providing
eligibility information to clinicians
interested in forming a virtual group; (d)
transitioning clinician referrals from the
Quality Payment Program Service
Center to the appropriate Technical
Assistance channel; (e) performing
proactive outreach and engagement
activities for the purpose of helping
MIPS eligible clinicians participate in
the program; (f) developing educational
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tools and resources; (g) monitoring
annual MIPS eligible clinician
performance; (h) assessing future need
based on a MIPS eligible clinician’s
Final Score; (i) tracking non-MIPS
eligible clinicians who voluntarily
report measures and activities to MIPS;
and (j) assisting MIPS eligible clinicians
transition into an Advanced APM.
8. Records may be disclosed to the
Department of Justice (DOJ), a court, or
an adjudicatory body when: (a) The
Agency or any component thereof, (b)
any employee of the Agency in his or
her official capacity, (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.
9. Records may be disclosed to
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.
10. Records may be disclosed to
appropriate agencies, entities, and
persons when (a) HHS suspects or has
confirmed that there has been a breach
of the system of records; (b) HHS has
determined that as a result of the
suspected or confirmed breach there is
a risk of harm to individuals, HHS
(including its information systems,
programs, and operations), the Federal
government, or national security; and (c)
the disclosure made to such agencies,
entities, and persons is reasonably
necessary to assist in connection with
HHS’ efforts to respond to the suspected
or confirmed breach or to prevent,
minimize, or remedy such harm.
11. Records may be disclosed to
another Federal agency or Federal
entity, when HHS determines that
information from this system of records
is reasonably necessary to as.sist the
recipient agency or entity in (a)
responding to a suspected or confirmed
breach or (b) preventing, minimizing, or
remedying the risk of harm to
individuals, the recipient agency or
entity (including its information
systems, programs, and operations), the
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Federal government, or national
security, resulting from a suspected or
confirmed breach.
12. Records may be disclosed to the
U.S. Department of Homeland Security
(OHS) if captured in an intrusion
detection system used by HHS and OHS
pursuant to a OHS cybersecurity
program that monitors internet traffic to
and from Federal government computer
networks to prevent a variety of types of
cybersecurity incidents.
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 oflndividually Identifiable
Health Information’’ (45 CFR parts 160
and 164, Subparts A and E), 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)(l)).
POLICIES AND PRACTICES FOR STORAGE OF
RECORDS:
The records will be stored
electronically or on magnetic media or
paper.
POLICIES AND PRACTICES FOR RETRIEVAL OF
RECORDS:
The data collected on clinicians will
be retrieved by the clinician’s name,
address, NPI, TIN/EIN and other
identifying provider numbers.
Information about third party data
submitters who are individuals will be
retrieved by name, address, and TIN/
EIN. Records about contact persons will
be retrieved by name, email address and
business address. The data collected on
Medicare beneficiaries (and any nonMedicare beneficiaries) will be retrieved
by the beneficiary’s name, Medicare
beneficiary identifier (MBI), health
insurance claim number (HICN), SSN,
address, and date of birth.
POLICIES AND PRACTICES FOR RETENTION AND
DISPOSAL OF RECORDS:
A records disposition schedule for the
Quality Payment Program is pending
submission to and approval by the
National Archives and Records
Administration (NARA); until NARA
approval is obtained, CMS will retain
the records indefinitely. CMS is
proposing a retention period of
approximately 10 years for these records
under the NARA CMS Records
Schedule: DAA–0440–2015–0009–0003.
Any claims-related records that become
encompassed by a document
preservation order may be retained
longer (i.e., until notification is received
from the Department of Justice).
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ADMINISTRATIVE, TECHNICAL, AND PHYSICAL
SAFEGUARDS:
Safeguards will conform to the HHS
Information Security and Privacy
Program, https://www.hhs.gov/ocio/
securityprivacy/. Information
will be safeguarded in accordance with
applicable Federal laws and regulations
and Federal, HHS, and CMS policies
and standards, including, all pertinent
National Institutes of Standards and
Technology (NIST) publications, and
0MB Circular A–130. Records will be
protected from unauthorized access
through appropriate administrative,
physical, and technical safeguards.
These safeguards include protecting the
facilities where records are stored or
accessed with security guards, badges,
and cameras; securing hard-copy
records in locked file cabinets, file
rooms, or offices during off-duty hours;
controlling access to physical locations
where records are maintained and used
by means of combination locks and
identification badges issued only to
authorized users; limiting access to
electronic databases to authorized users
based on roles and two-factor
authentication (user ID and password);
using a secured operating system
protected by encryption, firewalls, and
intrusion detection systems; requiring
encryption for records stored on
removable media; and training
personnel in Privacy Act and
information security requirements.
Records that are eligible for destruction
will be disposed of using secure
destruction methods prescribed by NIST
SP 800–88.
RECORD ACCESS PROCEDURES:
An individual seeking access to a
record about him or her in this system
should write to tbe System Manager
indicated above, who will require the
individual’s name and particulars
necessary to distinguish between
records on subject individuals with the
same name, such as NPI or TIN. The
requestor should also reasonably specify
the record(s) to which access is sought.
(These procedures are in accordance
with Department regulation 45 CFR
5b.5(a)(2)).
daltland on DSKBBV9HB2PROD with NOTICES
CONTESTING RECORD PROCEDURES:
Any subject individual may request
that his record be corrected or amended
if he believes that the record is not
accurate, timely, complete, or relevant
or necessary to accomplish a
Department function. A subject
individual making a request to amend or
correct his record shall address his
request to the responsible System
Manager as stated above, in writing. The
subject individual shall specify in each
VerDate Sep<11>2014
22:07 Feb 13, 2018
Jkt 244001
request: (I) The system of records from
which the record is retrieved; (2) The
particular record which he is seeking to
correct or amend; (3) Whether he is
seeking an addition to or a deletion or
substitution of the record; and, (4) His
reasons for requesting correction or
amendment of the record. (These
procedures are in accordance with
Department regulation 45 CFR Sb.7).
NOTIFICATION PROCEDURES:
Individuals wishing to know if this
system contains records about them
should write to the System Manager
indicated above and follow the same
instructions under Record Access
Procedures.
EXEMPTIONS PROMULGATED FOR THE SYSTEM:
None.
HISTORY:
None.
[FR Doc. 2018–02933 Filed 2–13–18; 8:45 am]
BILLING CODE 4120–03–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Privacy Act of 1974; System of
Records
Office of the Assistant
Secretary for Administration (ASA),
Department of Health and Human
Services (HHS).
ACTION: Notice of modified systems of
records.
AGENCY:
The Department of Health and
Human Services (HHS) proposes to
modify all of its systems of records to
add two security-related routine uses
which are needed to improve federal
agencies’ ability to detect and address
actual and suspected breaches of
personally identifiable information (PII)
in Privacy Act systems of records. The
routine uses are explained in the
Supplementary Information section of
this notice.
DATES: This notice will become effective
30 days after publication, unless the
Department makes changes based on
comments received. Written comments
should be submitted on or before the
effective date.
ADDRESSES: The public should address
written comments to Beth Kramer, HHS
Privacy Act Officer, by mail or email, at
HHS.ACFO@hhs.gov, or FOIA/PA
Division, Suite 729H, 200 Independence
Avenue SW, Washington, DC 20201.
FOR FURTHER INFORMATION CONTACT:
General questions may be submitted to
Beth Kramer, HHS Privacy Act Officer,
by mail or email, at HHS.ACFO@
SUMMARY:
PO 00000
Frm 00085
Fmt 4703
Sfmt 4703
6591
hhs.gov, or FOIA/PA Division, Suite
729H, 200 Independence Avenue SW,
Washington, DC 20201.
SUPPLEMENTARY INFORMATION: The
Privacy Act (5 U.S.C. 552a), at
subsection (b)(3), requires each agency
to publish, for public notice and
comment, routine uses describing any
disclosures of information about an
individual that the agency intends to
make from a Privacy Act system of
records without the individual’s prior
written consent, other than those which
are authorized directly in the Privacy
Act at subsections (b)(1)–(2) and (b)(4)–
(12). The Privacy Act defines ‘‘routine
use’’ at subsection (a)(7) to mean a
disclosure for a purpose compatible
with the purpose for which the record
was collected.
In accordance with Office of
Management and Budget (OMB)
Memorandum M–17–12, issued January
3, 2017, titled ‘‘Preparing for and
Responding to a Breach of Personally
Identifiable Information,’’ HHS is
adding the following two routine uses to
all of its system of records notices
(SORNs) to authorize HHS to disclose
information from each system of records
when necessary to obtain assistance
with a suspected or confirmed breach of
PII or to assist another agency in its
response to a breach. The first routine
use is a revised version of a routine use
prescribed in 2007, in former OMB
Memorandum M–07–16. The second
routine use is new:
‘‘To appropriate agencies, entities, and
persons when (1) HHS suspects or has
confirmed that there has been a breach of the
system of records; (2) HHS has determined
that as a result of the suspected or confirmed
breach there is a risk of harm to individuals,
HHS (including its information systems,
programs, and operations), the federal
government, or national security; and (3) the
disclosure made to such agencies, entities,
and persons is reasonably necessary to assist
in connection with HHS’s efforts to respond
to the suspected or confirmed breach or to
prevent, minimize, or remedy such harm.’’
‘‘To another federal agency or federal
entity, when HHS determines that
information from this system of records is
reasonably necessary to assist the recipient
agency or entity in (1) responding to a
suspected or confirmed breach or (2)
preventing, minimizing, or remedying the
risk of harm to individuals, the recipient
agency or entity (including its information
systems, programs, and operations), the
federal government, or national security,
resulting from a suspected or confirmed
breach.’’
Both routine uses are compatible with
the purposes for which PII is collected
in the affected systems of records,
because individuals whose PII is
included in any federal record system
E:\FR\FM\14FEN1.SGM
14FEN1
Agencies
[Federal Register Volume 83, Number 31 (Wednesday, February 14, 2018)]
[Notices]
[Pages 6587-6591]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2018-02933]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Privacy Act of 1974; System of Records.
AGENCY: Centers for Medicare & Medicaid Services (CMS), Department of
Health and Human Services (HHS).
ACTION: Notice of a New System of Records.
-----------------------------------------------------------------------
SUMMARY: The Department of Health and Human Services (HHS), Centers for
Medicare & Medicaid Services (CMS) proposes to establish a new system
of records subject to the Privacy Act, System No. 09-70-0539, titled
``Quality Payment Program (QPP).'' The new system of records will cover
quality and performance data collected and used by CMS in determining
merit-based payment adjustments for health care services provided by
clinicians to Medicare beneficiaries, and in providing expert feedback
to clinicians and third party data submitters for the purpose of
helping clinicians provide high-value care to patients.
DATES: In accordance with 5 U.S.C. 552a(e)(4) and (11), this notice is
effective upon publication, subject to a 30-day period in which to
comment on the routine uses, described below. Please submit any
comments by March 16, 2018.
ADDRESSES: Written comments should be submitted by mail or email to:
CMS Privacy Act Officer, Division of Security, Privacy Policy &
Governance, Information Security & Privacy Group, Office of Information
Technology, CMS, 7500 Security Boulevard, Baltimore, MD 21244-1870,
Location N1-14-56, or [email protected]. Comments received will
be available for review without redaction unless otherwise advised by
the commenter at this location, by appointment, during regular business
hours, Monday through Friday from 9:00 a.m.-3:00 p.m., Eastern Time
zone.
FOR FURTHER INFORMATION CONTACT: General questions about the new system
of records should be submitted by mail or email to: Michelle Peterman,
Health Insurance Specialist, Division of Electronic Clinician and
Quality, Quality Measurement and Value-Based Incentives Group, Center
for Clinical Standards and Quality, CMS, 7500 Security Boulevard,
Baltimore, MD 21244-1870, Mailstop: S3-02-01, or
[email protected].
SUPPLEMENTARY INFORMATION:
I. Background on the New Quality Payment Program Supported by the New
System of Records
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
amended title XVIII of the Social Security Act (the Act) to repeal the
way physicians were paid under the previous Sustainable Growth Rate
(SOR) formula and replaced it with a new approach known as the Quality
Payment Program. The Quality Payment Program streamlines and
consolidates components of three existing incentive programs that
reward high-value patient centered care: (1) Physician Quality
Reporting System (PQRS) (Sec. 1848(k) and (m) of the Act (42 U.S.C.
1395w-4)), (2) Medicare Electronic Health Records (EHR) Incentive
Program for Eligible Professionals (Sec. 1848(0) of the Act), and (3)
Physician Value-Based Payment Modifier (VM) (Sec. 1848(p) of the Act).
For more information, see rulemakings implementing the existing
programs, at 80 Fed. Reg. 71135 (November 16, 2015) (PQRS); 80 FR 62761
(October 16, 2015) (EHR); and 80 FR 71273 (November 16, 2015) (VM).
There are two separate pathways within the Quality Payment Program,
Advanced Alternative Payment Models (Advanced APM) and Merit-based
Incentive Payment System (MIPS), both of which contribute toward the
goal of seamless integration of the Quality Payment Program into
clinical practice workflows. MIPS provides clinicians measures and
activities to assist them in providing high-value, patient-centered
care to Medicare patients, and to encourage and reward their use of the
same. The participants generate and submit to CMS data on health care
coordination. The data will be submitted to CMS by eligible clinicians
and approved third party data submitters (for example, registries which
collect and submit disease tracking data; health information technology
(IT) vendors which submit data from clinicians' Certified Electronic
Health Record Technology (CEHRT) systems). The data will include
information about, and will be retrieved by personal identifiers for:
(1) The clinicians, (2) any third party data submitters who are
individuals (e.g., sole proprietor vendors), (3) individuals who submit
data for clinicians or third party data submitters as their
representatives or contact persons, and (4) Medicare beneficiaries and
any non-Medicare beneficiaries receiving the health care services
referenced in the Quality Payment Program data. The records are
described below.
The data submission process will require that clinicians and third
party submitters use their identifying and contact information, tax
identification number (TIN/EIN), national provider identifier (NPI),
and information about health care services provided to patients for the
performance categories of the MIPS including (1) quality-including a
set of evidence-based, specialty-specific standards; (2) cost of
services provided; (3) improvement activities that improved or are
likely to improve clinical practice or care delivery; and (4) advancing
care information which focuses on the use of CEHRT to support
interoperability and avoid
[[Page 6588]]
redundancies. Except for specific measures or activities identified and
published in the Federal Register by November 1 of each year, there are
no changes in Calendar Year (CY) 2017 with respect to the collection
and use of Privacy Act records associated with these activities in the
QPP system of record notice (SORN) other than what is collected by the
overlapping SORNs described below. There were no changes to the Call
for Quality Measures process in the CY 2018 rule and so there are no
changes to the use or additional collection of Privacy Act records
related to the four performance categories. Payment adjustments for
eligible clinicians do not begin until CY 2019 and at that time any
additional Privacy Act records associated with those payment
adjustments based on their performance during the applicable
performance period will be described if needed in an update to this
SORN. MIPS quality and performance data used in the program will be
reported to CMS by eligible clinicians and approved third party data
submitters of the types described in 42 CFR 414.1400. The data will
pertain to health care services provided to Medicare beneficiaries, but
may also include data about non-Medicare patients. As mentioned above,
except for specific measures or activities identified and published in
the Federal Register by November 1 of each year, there are no changes
in CY 2017 with respect to the collection and use of Privacy Act
records associated with these activities in the QPP SORN other than
what is collected by the overlapping SORNs described below.
II. Related Systems of Records Supporting the Existing PQRS, EHR, and
VM Programs
The PQRS, EHR, and VM programs each maintain records subject to the
Privacy Act which are maintained in existing systems of records; these
systems of records will necessarily overlap with this system of records
until the existing programs fully sunset. Therefore, these SORNs cover
the Quality Payment Program Privacy Act records until the QPP SORN is
finalized:
1. PQRS: ``Performance Measurement and Reporting System (PMRS),''
System No. 09-70-0584, last published at 73 FR 80412 (December 31,
2008);
2. EHR: ``Medicare and Medicaid Electronic Health Record (EHR)
Incentive Program National Level Repository'' System No. 09-70-0587,
last published at 75 FR 73095 (November 29, 2010);
3. VM: ``Medicare Multi-Carrier Claims System (MCS),'' System No.
09-70-0501, last published at 71 FR 64968 (November 6, 2006); and
4. VM: ``Fiscal Intermediary Shared System (FISS),'' System No. 09-
70-0503, last published at 71 FR 64961 (November 6, 2006).
The Performance Measurement and Reporting System (PMRS) SORN covers
the Better Quality Information (BQI) to Improve Care for Medicare
Beneficiaries Project, the Electronic Prescribing (E-Prescribing)
Incentive Program, and the PQRS. The BQI to Improve Care for Medicare
Beneficiaries Project and the E-Prescribing Incentive Program have
fully sunsetted. The PQRS program's last reporting year was CY 2016.
However, Privacy Act records related to the PQRS program will continue
to be utilized for several additional years to assess payment
adjustments in CY 2018 and data as needed. The Medicare and Medicaid
Electronic Health Record (EHR) Incentive Program National Level
Repository SORN covers the Medicare and Medicaid EHR Incentive
Programs. The Medicare EHR Incentive program's last payment year was CY
2016. However, Privacy Act records related to the Medicare EHR
Incentive program will continue to be utilized for several additional
years to assess data as needed. In addition, the Medicare EHR Incentive
for eligible hospitals and critical access hospitals (CAHs) and the
Medicaid EHR Incentive program are active programs. Therefore, the EHR
SORN will not be rescinded. The SORNs that cover the VM program will
not be rescinded as they are applicable to many CMS programs.
The Quality Payment Program will continue to evolve over multiple
years to accommodate payment policy implementations and take advantage
of new system capabilities. This SORN will be similarly reviewed and
updated to reflect significant changes, including the sunsetting of the
existing programs and disposition of the records covered by the
existing SORNs, when they occur.
III. Related Rulemakings and Information Collections
Requirements for submitting data about improvement activities did
not exist in the legacy programs replaced by MIPS, and CMS does not
have historical data which is directly relevant. However, the Privacy
Act records collected through these legacy programs are the same data
elements that are used for the Quality Payment Program in CY 2017 and
2018 although the specific uses for the previous programs may be more
expansive. To date, participants in the Quality Payment Program have
registered, have selected measures and are submitting data beginning in
2018 as individuals, as part of a group or as part of a virtual group--
a scenario not provided through the legacy SORNs.
The primary purpose of the PMRS system of records, entitled
``Performance Measurement and Reporting System (PMRS),'' is to support
the collection, maintenance, and processing of information to promote
the delivery of high quality, efficient, effective, and economical
health care services, and promote the quality and efficiency of
services of the type for which payment may be made under title XVIII by
allowing for the establishment and implementation of performance
measures, the provision of feedback to physicians, and public reporting
of performance information.
The primary purpose of the EHR system of records, entitled
``Medicare and Medicaid Electronic Health Record (EHR) Incentive
Program National Level Repository,'' called the National Level
Repository or NLR, is to collect, maintain, and process information
that is required for the Medicare and Medicaid EHR Incentive Programs.
The primary purpose of the VM program covered by the systems of
records entitled, ``Medicare Multi-Carrier Claims System (MCS) and the
Fiscal Intermediary Shared System (FISS),'' is to identify and
associate a provider (physician or individual provider) to their
registration and their reports, known as the Quality and Resource Use
Report (QRUR). QRUR is a report given to providers on quality of care
and cost performance. In most cases, systems of records maintain Tax
Identification Number (TIN) and the name of the organization. In very
few cases, providers may be using their Social Security number (SSN) as
Billing TIN.
As discussed above the programs covered by the PMRS SORN have
sunsetted; however, the final payment year for the PQRS program is CY
2018 requiring the PMRS SORN to remain in effect until all pertinent
data has been utilized. The EHR SORN and VM SORNs will not be rescinded
as there are programs covered by these SORNs that are currently active
and have no plans to sunset.
Once the PQRS program sunsets the records will be dispositioned
entirely into the QPP system of records under NARA CMS Records
Schedule: DAA-0440-2015-0009-003. The retention period for these
records is 10 years.
Because the PMRS and the QPP systems of records maintain identical
records for the categories of individuals covered by the respective
system of records and also overlap for purposes of
[[Page 6589]]
making payment based on quality measures and improvement activities
(though not with the same percentages of activity weighting or payment
calculation), the routine uses for disclosures of records in the system
of records and uses of records in the system of records are the same.
Categories of individuals covered by the system of records will expand
under the QPP SORN to include all-payer data.
All of the routine uses either are necessary and proper or are
compatible with the original collection purpose of encouraging and
rewarding clinicians' use of measures and activities that help them
provide high-value, patient-centered care to Medicare beneficiaries.
Dated: February 1, 2018.
Emery Csulak,
Director, Information Security Privacy Group, and Senior Official for
Privacy, Centers for Medicare & Medicaid Services.
SYSTEM NAME AND NUMBER
``Quality Payment Program (QPP)'', HHS/CMS/CCSQ System No. 09-70-
0539.
SECURITY CLASSIFICATION:
Unclassified.
SYSTEM LOCATION:
The address of the agency component responsible for the system of
records is: CMS Data Center, 7500 Security Boulevard, North Building,
First Floor, Baltimore, Maryland 21244-1850.
SYSTEM MANAGER(S):
The agency official who is responsible for the system of records
is: Director, Quality Measurement and Value-based Incentives Group,
CCSQ, CMS, Room C1-23-14, 7500 Security Boulevard, Baltimore, Maryland
21244-1870.
AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
Provisions of the Social Security Act codified at 42 U.S.C.
Sec. Sec. 1320c-3, 13951, 1395w-4, 1395w-21, and 1395y.
PURPOSE(S) OF THE SYSTEM:
The purposes for which HHS/CMS will use the records are:
To be utilized for program management and administration
purposes;
To determine payment adjustments for health care services
provided by clinicians to Medicare beneficiaries;
To provide expert feedback to clinicians and third party
data submitters, in order to help clinicians provide high-value,
patient-centered care to Medicare beneficiaries;
To make clinician-level performance measure results
available to Medicare patients and caregivers through Physician
Compare, as defined via regulation, either on public profile pages or
via the Downloadable Database housed on data.medicare.gov for the
purpose of promoting more informed health care choices for people with
Medicare; and
To provide relevant records to other Federal and state
agencies which administer federally-funded health benefit programs;
Quality Improvement Networks that review claims and conduct outreach
and reviews; and individuals and organizations that assist consumers,
to use for program administrative purposes and in health, disease, and
payment-related research, evaluation, outreach, and transparency
projects.
CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:
The records will be about these categories of individuals involved
in the Quality Payment Program:
Eligible clinicians (such as, physicians, physician
assistants, nurse practitioners) who submit quality and performance
data to CMS under the Program;
Any third party data submitters of the types described in
42 CFR 414.1400 who are individuals (e.g., sole proprietor health IT or
survey vendors) and submit data to the Program;
Individuals who submit data for clinicians and third party
data submitters (i.e., as their representatives or contact persons);
and
Medicare beneficiaries (and any non-Medicare
beneficiaries) receiving the health care services referenced in the
data submitted to CMS under the Program.
CATEGORIES OF RECORDS IN THE SYSTEM:
The system will include these categories of records:
Records about clinicians. These will include identifying
information and contact information (such as the clinician's name,
address, phone number, email address, date of birth, business address,
tax identification number (TIN/EIN), national provider identifier
(NPI), Social Security number (SSN), prescriber identification number,
and other assigned clinician numbers) and information about health care
services the clinician provided to Medicare beneficiaries (and any non-
Medicare beneficiaries) and the measures and activities the clinician
used in providing the services.
Records about any third party data submitters who are
individuals (for example, sole proprietor health IT or survey vendors).
These records will include the third party's name, email address,
business address, and TIN/EIN.
Records about individuals who submit data for clinicians
and third party data submitters. These will include the
representative's name and contact information such as address, TIN/EIN,
email address, and business address.
Records about Medicare beneficiaries (and any non-Medicare
beneficiaries). These will include the beneficiary's identifying and
health information, i.e. name, address, date of birth, gender,
ethnicity, health care utilization and claims data, health insurance
claim number (HICN), Medicare beneficiary identifier (MBI), and SSN.
Records about other payer payment arrangements. These will
include other payer payment arrangement information submitted by non-
Medicare payers to determine whether a payment arrangement meets the
Other Payer Advanced Alternative Payment Model (APM) criteria. These
records will include payer identifying information, payment arrangement
information, supporting documentation, and a certification statement.
RECORD SOURCE CATEGORIES:
The sources of the records covered by this system of records are
(1) clinicians, (2) third party data submitters, and (3) individuals
who submit data for clinicians or third party data submitters.
ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES
OF USERS AND PURPOSES OF SUCH USES:
A. These routine uses specify circumstances, in addition to those
provided by statute in the Privacy Act of 1974, under which CMS may
disclose records from the Quality Payment Program to a party outside
HHS without the prior, written consent of the individual to whom such
information pertains.
1. Records may be disclosed to agency contractors (including, but
not limited to, Medicare Administrative Contractors (MACs), fiscal
intermediaries, and carriers) that assist in the health operations of a
CMS-administered health benefits program, to CMS consultants, or to a
grantee of a CMS-administered grant program, who have been engaged by
the agency to assist in accomplishment of a CMS function relating to
the purposes for this system of records and who need to have access to
the records in order to assist CMS. Such disclosures include (but are
not limited to) disclosures deemed reasonably necessary by CMS to
prevent, deter, discover, detect, investigate, examine, prosecute, sue
with respect to, defend against, correct,
[[Page 6590]]
remedy, or otherwise combat fraud, waste, or abuse in such program.
2. Records may be disclosed to another Federal or state agency to
the extent deemed necessary to: (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 health benefit programs funded in whole or in part with
Federal funds; and/or (c) assist state Medicaid programs which may
require Quality Payment Program information.
3. Clinician-level performance measurement results may be made
available to the public, through Physician Compare, as defined via
regulation, either on public profile pages or via the Downloadable
Database housed on data.medicare.gov for the purpose of promoting more
informed health care choices for people with Medicare.
4. Records may be disclosed to MIPS-eligible clinicians and
eligible entities in order to provide them with expert feedback, and
records may be disclosed to CMS authorized entities participating in
health care transparency projects.
5. Records may be disclosed to organizations that assist consumers
in comparing the quality and price of health care services, and/or that
use such information for purposes related to prevention of disease or
disability, or restoration or maintenance of health.
6. Records may be disclosed to organizations for research,
evaluation, and projects involving payment issues.
7. Records may be disclosed to Beneficiary and Family Centered Care
(BFCC)-QIOs, Quality Innovation Network-QIOs (QIN-QIOs), the Small,
Underserved, and Rural Support (SURS) technical assistance contractors,
and the Practice Transformation Networks (PTNs) under the Transforming
Clinical Practice Initiative (TCPI) for purposes of: (a) Identifying
clinicians who are included in the Quality Payment Program,
specifically the MIPS track, based on the low-volume threshold; (b)
determining the appropriate form of Technical Assistance based on
practice size and clinician need; (c) providing eligibility information
to clinicians interested in forming a virtual group; (d) transitioning
clinician referrals from the Quality Payment Program Service Center to
the appropriate Technical Assistance channel; (e) performing proactive
outreach and engagement activities for the purpose of helping MIPS
eligible clinicians participate in the program; (f) developing
educational tools and resources; (g) monitoring annual MIPS eligible
clinician performance; (h) assessing future need based on a MIPS
eligible clinician's Final Score; (i) tracking non-MIPS eligible
clinicians who voluntarily report measures and activities to MIPS; and
(j) assisting MIPS eligible clinicians transition into an Advanced APM.
8. Records may be disclosed to the Department of Justice (DOJ), a
court, or an adjudicatory body when: (a) The Agency or any component
thereof, (b) any employee of the Agency in his or her official
capacity, (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.
9. Records may be disclosed to 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.
10. Records may be disclosed to appropriate agencies, entities, and
persons when (a) HHS suspects or has confirmed that there has been a
breach of the system of records; (b) HHS has determined that as a
result of the suspected or confirmed breach there is a risk of harm to
individuals, HHS (including its information systems, programs, and
operations), the Federal government, or national security; and (c) the
disclosure made to such agencies, entities, and persons is reasonably
necessary to assist in connection with HHS' efforts to respond to the
suspected or confirmed breach or to prevent, minimize, or remedy such
harm.
11. Records may be disclosed to another Federal agency or Federal
entity, when HHS determines that information from this system of
records is reasonably necessary to as.sist the recipient agency or
entity in (a) responding to a suspected or confirmed breach or (b)
preventing, minimizing, or remedying the risk of harm to individuals,
the recipient agency or entity (including its information systems,
programs, and operations), the Federal government, or national
security, resulting from a suspected or confirmed breach.
12. Records may be disclosed to the U.S. Department of Homeland
Security (OHS) if captured in an intrusion detection system used by HHS
and OHS pursuant to a OHS cybersecurity program that monitors internet
traffic to and from Federal government computer networks to prevent a
variety of types of cybersecurity incidents.
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 oflndividually
Identifiable Health Information'' (45 CFR parts 160 and 164, Subparts A
and E), 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)(l)).
POLICIES AND PRACTICES FOR STORAGE OF RECORDS:
The records will be stored electronically or on magnetic media or
paper.
POLICIES AND PRACTICES FOR RETRIEVAL OF RECORDS:
The data collected on clinicians will be retrieved by the
clinician's name, address, NPI, TIN/EIN and other identifying provider
numbers. Information about third party data submitters who are
individuals will be retrieved by name, address, and TIN/EIN. Records
about contact persons will be retrieved by name, email address and
business address. The data collected on Medicare beneficiaries (and any
non-Medicare beneficiaries) will be retrieved by the beneficiary's
name, Medicare beneficiary identifier (MBI), health insurance claim
number (HICN), SSN, address, and date of birth.
POLICIES AND PRACTICES FOR RETENTION AND DISPOSAL OF RECORDS:
A records disposition schedule for the Quality Payment Program is
pending submission to and approval by the National Archives and Records
Administration (NARA); until NARA approval is obtained, CMS will retain
the records indefinitely. CMS is proposing a retention period of
approximately 10 years for these records under the NARA CMS Records
Schedule: DAA-0440-2015-0009-0003. Any claims-related records that
become encompassed by a document preservation order may be retained
longer (i.e., until notification is received from the Department of
Justice).
[[Page 6591]]
ADMINISTRATIVE, TECHNICAL, AND PHYSICAL SAFEGUARDS:
Safeguards will conform to the HHS Information Security and Privacy
Program, https://www.hhs.gov/ocio/securityprivacy/.
Information will be safeguarded in accordance with applicable Federal
laws and regulations and Federal, HHS, and CMS policies and standards,
including, all pertinent National Institutes of Standards and
Technology (NIST) publications, and 0MB Circular A-130. Records will be
protected from unauthorized access through appropriate administrative,
physical, and technical safeguards. These safeguards include protecting
the facilities where records are stored or accessed with security
guards, badges, and cameras; securing hard-copy records in locked file
cabinets, file rooms, or offices during off-duty hours; controlling
access to physical locations where records are maintained and used by
means of combination locks and identification badges issued only to
authorized users; limiting access to electronic databases to authorized
users based on roles and two-factor authentication (user ID and
password); using a secured operating system protected by encryption,
firewalls, and intrusion detection systems; requiring encryption for
records stored on removable media; and training personnel in Privacy
Act and information security requirements. Records that are eligible
for destruction will be disposed of using secure destruction methods
prescribed by NIST SP 800-88.
RECORD ACCESS PROCEDURES:
An individual seeking access to a record about him or her in this
system should write to tbe System Manager indicated above, who will
require the individual's name and particulars necessary to distinguish
between records on subject individuals with the same name, such as NPI
or TIN. The requestor should also reasonably specify the record(s) to
which access is sought. (These procedures are in accordance with
Department regulation 45 CFR 5b.5(a)(2)).
CONTESTING RECORD PROCEDURES:
Any subject individual may request that his record be corrected or
amended if he believes that the record is not accurate, timely,
complete, or relevant or necessary to accomplish a Department function.
A subject individual making a request to amend or correct his record
shall address his request to the responsible System Manager as stated
above, in writing. The subject individual shall specify in each
request: (I) The system of records from which the record is retrieved;
(2) The particular record which he is seeking to correct or amend; (3)
Whether he is seeking an addition to or a deletion or substitution of
the record; and, (4) His reasons for requesting correction or amendment
of the record. (These procedures are in accordance with Department
regulation 45 CFR Sb.7).
NOTIFICATION PROCEDURES:
Individuals wishing to know if this system contains records about
them should write to the System Manager indicated above and follow the
same instructions under Record Access Procedures.
EXEMPTIONS PROMULGATED FOR THE SYSTEM:
None.
HISTORY:
None.
[FR Doc. 2018-02933 Filed 2-13-18; 8:45 am]
BILLING CODE 4120-03-P