Privacy Act of 1974; System of Records, 49891-49893 [2022-17392]

Agencies

• Office of Personnel Management

[Federal Register Volume 87, Number 155 (Friday, August 12, 2022)]
[Notices]
[Pages 49891-49893]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2022-17392]



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OFFICE OF PERSONNEL MANAGEMENT


Privacy Act of 1974; System of Records

AGENCY: Office of Personnel Management, Healthcare and Insurance.

ACTION: Notice of new system of records.

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SUMMARY: In accordance with the Privacy Act of 1974, the Office of 
Personnel Management (OPM) proposes to publish a new system of records 
titled ``OPM/Central-27, FEHB Disputed Claims and Complaints Records.'' 
This system of records contains information about enrollees or their 
family members who have submitted a request to OPM for its review of 
healthcare claim denials made by Federal Employees Health Benefits 
(FEHB) plans. This system of records also contains records related to 
complaints received by OPM about the FEHB Program, Carriers, or plans. 
This newly established system of records will be included in OPM's 
inventory of record systems.

DATES: Please submit comments on or before September 12, 2022. This new 
system of records is effective upon publication in today's Federal 
Register, with the exception of the routine uses, which are effective 
September 16, 2022.

ADDRESSES: You may submit written comments through the Federal 
Rulemaking Portal: https://www.regulations.gov. Follow the instructions 
for submitting comments. All submissions received must include the 
agency name and docket number for this Federal Register document. The 
general policy for comments and other submissions from members of the 
public is to make these submissions available for public viewing at 
https://www.regulations.gov as they are received without change, 
including any personal identifiers or contact information.

FOR FURTHER INFORMATION CONTACT: For general questions, please contact 
Dyan Dyttmer, 202-606-1412. For privacy questions, please contact 
Kellie Cosgrove Riley, Chief Privacy Officer, 202-360-6065, or 
[email protected].

SUPPLEMENTARY INFORMATION: In accordance with the Privacy Act of 1974, 
5 U.S.C 552a, the Office of Personnel Management proposes to establish 
a new system of records titled ``OPM/Central-27, FEHB Disputed Claims 
and Complaints Records.'' Established in 1960 through the Federal 
Employees Health Benefits Act of 1959, 5 U.S.C. 8901 et seq., the FEHB 
Program is the largest employer-sponsored group health insurance 
program globally, covering over 8 million individuals. Covered 
individuals, as defined in 5 CFR 890.101, include employees of the 
Federal government, annuitants, members of their families, former 
spouses, and miscellaneous groups, enumerated in 5 U.S.C. 8901; United 
States Postal Service employees and annuitants, pursuant to 39 U.S.C. 
1005; tribal employees, pursuant to 25 U.S.C. 1647b; and separated 
employees and former dependents who are eligible for Temporary 
Continuation of Coverage under 5 U.S.C. 8905a.
    OPM receives, stores, and processes requests from individuals 
covered by FEHB plans (or their authorized representatives) to review 
healthcare claim denials made by FEHB plans. As part of this review, 
OPM gathers records related to the denied claim from the covered 
individual (or authorized representatives) and the FEHB Carrier. OPM 
may also submit records to an Independent Medical Reviewer to obtain an 
advisory opinion from an independent healthcare professional. OPM 
issues a written decision regarding the disputed claim; if OPM reverses 
the denied healthcare claim, in whole or in part, the FEHB Carrier is 
required to comply with OPM's decision. This system of records includes 
the request for review, all records related to the review, 
correspondence, and OPM's decision.
    OPM also receives complaints about the FEHB Program, Carriers, or 
plans. These complaints may come from a variety of sources including 
FEHB-covered individuals,\1\ health care providers, Congressional and 
White House inquiries, tribal entities, the Department of Health and 
Human Services and other Federal, State, or local agencies. This system 
of records includes the complaints, any records received or developed 
by OPM related to investigating the complaints, and OPM's response to 
the complaints.
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    \1\ Under 5 CFR 890.101(a) a ``covered individual'' means an 
enrollee or covered family member. An ``enrollee'' means an 
individual in whose name the enrollment is carried. Under 5 CFR 
890.105(e), a covered individual is authorized to submit a disputed 
claim to OPM.
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    The records in this new system of records to date have been 
included in the OPM/Central-1 Civil Service Retirement and Insurance 
system of records (OPM/Central-1). However, OPM's organizational 
structure and its retirement and insurance programs have evolved over 
time and OPM has determined that OPM/Central-1 no longer provides the 
public with the most informative notice regarding the system of 
records, nor adequately facilitates individuals' ability to exercise 
their rights under the Privacy Act and OPM's ability to respond 
effectively. Accordingly, OPM is in the process of regrouping the 
records currently contained in OPM/Central-1 and publishing 
corresponding systems of records notices. Additional systems of records 
notices related to other record sets currently encompassed in OPM/
Central-1 have been previously published or will be published in the 
future.
    FEHB disputed claims and complaints records will now be maintained 
in the system of records known as OPM/Central-27, FEHB Disputed Claims 
and Complaints Records. This newly established system of records will 
be included in OPM's inventory of records systems. In accordance with 5 
U.S.C. 552a(r), OPM has provided a report of this system of records to 
the Office of Management and Budget and to Congress.

Office of Personnel Management.
Stephen Hickman,
Federal Register Liaison.

SYSTEM NAME AND NUMBER:
    FEHB Disputed Claims and Complaints Records, OPM/Central-27

SECURITY CLASSIFICATION:
    Unclassified.

SYSTEM LOCATION:
    Healthcare and Insurance, Office of Personnel Management, 1900 E 
Street NW, Suite 3400, Washington, DC 20415 is responsible for this 
system of records. The electronic records in this system are maintained 
at OPM's data center in Macon, Georgia.

SYSTEM MANAGER(S):
    Associate Director, Healthcare and Insurance, Office of Personnel 
Management, 1900 E St NW, Washington, DC 20415.

AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
    5 U.S.C. Chapter 89, Health Insurance; 5 CFR part 890 (health 
insurance generally); 5 CFR 890.105 and Sec.  890.107 (regarding OPM's 
review of denied claims and judicial review of OPM's final action); and 
5 CFR 890.114 (regarding complaints related to surprise billing).

PURPOSE(S) OF THE SYSTEM:
    The purpose of this system of records is to collect, process, 
review, maintain, and make decisions concerning disputed healthcare 
claims for individuals covered by FEHB plans; collect, process, review, 
maintain, and respond to complaints regarding the FEHB Program, 
Carriers, and plans;

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track the progress of individual disputed claims and complaints so that 
timely decisions and responses are rendered; and create and maintain 
the administrative record in the event of judicial review of OPM's 
decision related to a disputed healthcare claim. In addition, OPM uses 
the records in this system of records to evaluate FEHB Carrier 
compliance with the plan brochure and the contract, and to evaluate and 
improve FEHB Program benefits and processes.

CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:
    a. Enrollees (defined in 5 CFR 890.101) and their family members 
who have filed an FEHB disputed claim.
    b. Individuals who have submitted a complaint to OPM about the FEHB 
Program, Carriers, or plans.

CATEGORIES OF RECORDS IN THE SYSTEM:
    a. Name;
    b. Date of birth;
    c. Home address;
    d. Email address;
    e. Telephone number;
    f. Health plan name and member ID;
    g. Dates of service under appeal;
    h. All materials submitted by the individual or duly authorized 
representative related to the disputed claim, including written 
correspondence and emails;
    i. Explanation of benefits, including advanced explanation of 
benefits;
    j. Good Faith Estimate of charges;
    k. Notice and Consent Documents related to the No Surprises Act;
    l. Reconsideration determination related to the disputed claim from 
the FEHB Carrier and any related correspondence;
    m. Bills related to the disputed claim;
    n. Medical records related to the disputed claim;
    o. Response from the FEHB Carrier to OPM regarding the disputed 
claim;
    p. Advisory opinion from the Independent Medical Reviewer;
    q. Copy of OPM's final disposition of the claim and any other 
agency correspondence;
    r. System-generated reports or documents;
    s. All materials submitted to OPM related to a complaint submitted 
to OPM about the FEHB Program, Carriers, or plans;
    t. All materials generated by OPM in reviewing a complaint 
submitted to OPM about the FEHB Program, Carriers, or plans; and
    u. Any response generated by OPM to a complaint submitted to OPM 
about the FEHB Program, Carriers, or plans.

RECORD SOURCE CATEGORIES:
    The records in this system related to disputed claims are obtained 
from individuals covered by FEHB plans or their duly authorized 
representatives, FEHB Carriers, and Independent Medical Reviewers. The 
records in this system related to complaints are obtained from a 
variety of sources including FEHB-covered individuals, health care 
providers, Congressional and White House inquiries, tribal entities, 
the Department of Health and Human Services and other Federal, State, 
or local agencies.

ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES 
OF USERS AND THE PURPOSES OF SUCH USES:
    In addition to those disclosures generally permitted under 5 U.S.C. 
552a(b) of the Privacy Act, all or a portion of the records or 
information contained in this system may be disclosed outside OPM as a 
routine use pursuant to 5 U.S.C. 552a(b)(3) as follows:
    a. To the Department of Justice, including Offices of the U.S. 
Attorneys; another Federal agency conducting litigation or in 
proceedings before any court, adjudicative, or administrative body; 
another party in litigation before a court, adjudicative, or 
administrative body; or to a court, adjudicative, or administrative 
body. Such disclosure is permitted only when it is relevant or 
necessary to the litigation or proceeding and one of the following is a 
party to the litigation or has an interest in such litigation:
    (1) OPM, or any component thereof;
    (2) Any employee or former employee of OPM in his or her official 
capacity;
    (3) Any employee or former employee of OPM in his or her individual 
capacity where the Department of Justice or OPM has agreed to represent 
the employee;
    (4) The United States, a Federal agency, or another party in 
litigation before a court, adjudicative, or administrative body, upon 
the OPM General Counsel's approval, pursuant to 5 CFR part 295 or 
otherwise.
    b. To the appropriate Federal, State, or local agency responsible 
for investigating, prosecuting, enforcing, or implementing a statute, 
rule, regulation, or order, when a record, either on its face or in 
conjunction with other information, indicates or is relevant to a 
violation or potential violation of civil or criminal law or 
regulation.
    c. To a member of Congress from the record of an individual in 
response to an inquiry made at the request of the individual to whom 
the record pertains.
    d. To the National Archives and Records Administration (NARA) for 
records management inspections being conducted under the authority of 
44 U.S.C. 2904 and 2906.
    e. To appropriate agencies, entities, and persons when (1) OPM 
suspects or has confirmed that there has been a breach of the system of 
records,[middot] (2) OPM has determined that as a result of the 
suspected or confirmed breach there is a risk of harm to individuals, 
OPM (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 OPM's efforts to respond to the suspected or 
confirmed breach or to prevent, minimize, or remedy such harm.
    f. To another Federal agency or Federal entity, when OPM 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.
    g. To contractors, grantees, experts, consultants, or volunteers 
performing or working on a contract, service, grant, cooperative 
agreement, or other assignment for OPM when necessary to accomplish an 
agency function related to this system of records. Individuals provided 
information under this routine use are subject to the same Privacy Act 
requirements and limitations on disclosure as are applicable to OPM 
employees.
    h. To FEHB Carriers for the purpose of obtaining complete records 
held by the plan regarding the claim or claims in dispute, obtaining 
responsive information relating to a complaint related to the Carrier 
or its FEHB plan, or providing OPM's decision regarding the disputed 
claim review or OPM's response regarding a complaint.
    i. To an Independent Medical Reviewer for the purpose of obtaining 
an advisory opinion from the Reviewer regarding the claim or claims in 
dispute.
    j. To an individual or entity submitting a complaint to OPM about 
the FEHB Program, Carriers, or plans, a response or report of outcome 
related to the complaint.

POLICIES AND PRACTICES FOR STORAGE OF RECORDS:
    The electronic records in this system of records are maintained in 
an

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encrypted database. Paper records are kept in lockable metal file 
cabinets or in a secured facility. Access to records is limited to 
those whose official duties require access.

POLICIES AND PRACTICES FOR RETRIEVAL OF RECORDS:
    These records are retrieved primarily by the name of the 
individual, FEHB health plan name, date of birth and/or claim number of 
the individual to whom they pertain but may be retrieved by any 
personal identifier.

POLICIES AND PRACTICES FOR RETENTION AND DISPOSAL OF RECORDS:
    The disputed claims and complaints records are subject to the NARA-
approved records schedule NC1-146-77-01 INS 4(b) relating to Healthcare 
and Insurance claims correspondence, correspondence with individuals or 
carriers' representatives on the interpretation of contracts, and 
settlement of Federal employee claims under health benefits and life 
insurance plans.

ADMINISTRATIVE, TECHNICAL, AND PHYSICAL SAFEGUARDS:
    Records in this system are protected from unauthorized access and 
misuse through various administrative, technical, and physical security 
measures. OPM security measures are in compliance with the Federal 
Information Security Modernization Act of 2014 (Pub. L. 113-203), 
associated OMB policies, and applicable standards and guidance from the 
National Institute of Standards and Technology (NIST). Transmission of 
the data feed from FEHB Carriers and Independent Medical Reviewers to 
this system is encrypted in compliance with NIST Federal Information 
Processing Standards Publication 197.

RECORD ACCESS PROCEDURES:
    Individuals seeking notification of and access to their records in 
this system of records may do so by submitting a request in writing to 
the Office of Personnel Management, Office of Privacy and Information 
Management--FOIA, 1900 E Street NW, Washington, DC 20415-7900 or by 
emailing [email protected]; ATTN: Healthcare and Insurance. Individuals must 
furnish the following information for their records to be located:
    1. Full name, including any former name.
    2. Date of birth.
    3. FDC Control Number, if known.
    4. Reasonable specification of the requested information.
    5. The address to which the information should be sent.
    6. Signature.
    Individuals requesting access must also comply with OPM's Privacy 
Act regulations regarding verification of identity and access to 
records (5 CFR 297). Medical or psychological records may also be 
subject to 5 CFR 297.205.

Contesting Record Procedures
    Individuals wishing to request amendment of their records in this 
system of records may do so by writing to the to the Office of 
Personnel Management, Office of Privacy and Information Management--
FOIA, 1900 E Street NW, Room 5415, Washington, DC 20415-7900 or by 
emailing [email protected]; ATTN: Healthcare and Insurance. Requests for 
amendment of records should include the words ``PRIVACY ACT AMENDMENT 
REQUEST'' in capital letters at the top of the request letter; if 
emailed, please include those words in the subject line. Individuals 
must furnish the following information for their records to be located:
    1. Full name, including any former name.
    2. Date of birth.
    3. Name and address of employing agency or retirement system.
    4. Precise identification of the information to be amended.
    5. Signature.
    Individuals requesting amendment of their records must also comply 
with OPM's Privacy Act regulations regarding verification of identity 
and access to records (5 CFR 297). OPM may refer amendment requests to 
other entities when those entities are the original source of the 
record.

Notification Procedures
    See ``Record Access Procedures.''

Exemptions Promulgated for the System
    None.

History
    OPM/Central-1, Civil Service Retirement and Insurance Records, 73 
FR 15013 (March 20, 2008), 80 FR 74815 (November 30, 2015).

[FR Doc. 2022-17392 Filed 8-11-22; 8:45 am]
BILLING CODE 6325-63-P