[Federal Register Volume 61, Number 89 (Tuesday, May 7, 1996)]
[Notices]
[Pages 20528-20531]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 96-11260]



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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration


Privacy Act of 1974; System of Records

AGENCY: Department of Health and Human Services (HHS), Health Care 
Financing Administration (HCFA).

ACTION: Notice of proposal to alter an existing system of records by: 
Expanding the purpose of the system, changing the name of the system, 
changing the name of the ``Unique Physician Identification Number 
(UPIN)'' to the ``Unique Physician/Practitioner Identification 
Number,'' changing the structure of the UPIN, adding tax identification 
numbers to the data fields, and adding a new routine use (number 10) to 
the system of records for the release of data to Federal and state 
agencies.

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SUMMARY: HCFA is proposing to revise the systems notice for the 
``Medicare Physician Identification and Eligibility System (MPIES), '' 
System No. 09-70-0525. The following alterations will be made to this 
system of records:
    1. The purpose statement for the system will be revised to better 
reflect the system's expanded function. The new purpose of this system 
of records will read as follows: ``to maintain unique identification of 
each physician, practitioner, and medical group practice requesting 
and/or receiving Medicare reimbursement.''
    2. The name of the system will be changed from the ``Medicare 
Physician Identification and Eligibility System (MPIES),'' to the 
``Unique Physician/Practitioner Identification Number (UPIN) System.''
    3. The name of the ``Unique Physician Identification Number 
(UPIN)'' will be changed to the ``Unique Physician/Practitioner 
Identification Number.'' Despite this amendment, the acronym UPIN will 
not be changed because Federal and state agencies and private and 
public insurance entities are familiar with the use of this acronym.
    4. The structure of the UPIN identifier is being changed from a 6-
digit identifier to a 10-digit identifier so as to uniquely identify 
all physicians, practitioners and medical group practices, and to 
rectify current problems with existing individualized identification 
systems.
    5. Tax identification numbers will be collected and added to the 
data fields

[[Page 20529]]

maintained on all physicians, practitioners, and medical group 
practices in this system.
    6. HCFA is also proposing to add a new routine use (number 10) to 
this system notice for the release of data to other Federal and state 
agencies.

EFFECTIVE DATE: HCFA filed a new system report with the Chairman of the 
Committee on Government Reform and Oversight of the House of 
Representatives, the Chairman of the Committee on Governmental Affairs 
of the Senate, and the Administrator, Office of Information and 
Regulatory Affairs, Office of Management and Budget (OMB) on May 1, 
1996. To ensure that all parties have adequate time in which to 
comment, the revised system of records, including routine uses, will 
become effective 40 days from the publication of this notice or from 
the date it is submitted to OMB and the Congress, whichever is later, 
unless HCFA receives comments which require alterations to this notice.

ADDRESS: Please address comments to: Richard A. DeMeo, HCFA Privacy Act 
Officer, Freedom of Information and Privacy Office, Associate 
Administrator for External Affairs (AAEA), Health Care Financing 
Administration, Room C2-26-21, 7500 Security Boulevard, Baltimore, 
Maryland 21244-1850. Comments received will be available for 
examination at this location.

FOR FURTHER INFORMATION CONTACT: Gerald Wright, Provider Enrollment 
Unit, Office of Program Requirements, Bureau of Program Operations, 
Health Care Financing Administration, Room S1-04-20, 7500 Security 
Boulevard, Baltimore, Maryland 21244-1850. His telephone number is 
(410) 786-5798.

SUPPLEMENTARY INFORMATION: In 1988, HCFA established a new system of 
records, under the authority of section 1842(r) of the Social Security 
Act Pub. L. 101-508, 42 U.S.C. 1395u(r)), to maintain a UPIN for each 
physician who provides services for which payment is made under 
Medicare. Notice of this system, the ``Medicare Physician 
Identification and Eligibility System (MPIES),'' HHS/HCFA/BPO, no. 09-
70-0525, was most recently published on June 10, 1989 in the Federal 
Register. This system contains records of all physicians, as defined by 
Sec. 1861(r) of Title XVIII of the Social Security Act, who provide 
services for which payment is made under Medicare.
    At this time, HCFA is proposing to expand the purpose of this 
system of records: ``to maintain unique identification of each 
physician, practitioner, and medical group practice requesting and/or 
receiving Medicare reimbursement.'' Expanding the purpose to include 
other health care professionals and practitioners will assist HCFA in 
identifying billers and in determining the appropriate amount to pay 
for Medicare services.
    A practitioner includes, but is not limited to, a physical 
therapist, certified registered nurse anesthetist, certified registered 
nurse midwife, physician assistant, occupational therapist, 
audiologist, family nurse practitioner, anesthesia assistant, 
mammography screening center, ambulance service supplier, portable x-
ray supplier, independent physiological laboratory, clinical social 
worker, psychologist, nurse practitioner, certified clinical nurse 
specialist or any other practitioner as may be specified by the 
Secretary as defined in Social Security Act sections 1861(r) and 
1877(h)(4).
    A medical group practice is defined as a group of two or more 
physicians legally organized as a partnership, professional 
corporation, foundation, not-for-profit corporation, faculty practice 
plan, or similar association (A) In which each physician who is a 
member of the group provides substantially the full range of services 
which the physician routinely provides (including medical care, 
consultation, diagnosis, or treatment) through the joint use of shared 
office space, facilities, equipment, and personnel; (B) for which 
substantially all of the services of the physicians who are members of 
the group are provided through the group and are billed in the name of 
the group and amounts so received are treated as receipts of the group; 
(C) in which overhead expenses of, and the income from the practice are 
distributed in accordance with methods previously determined by members 
of the group; and (D) which meets other standards such as the Secretary 
may impose by regulation to implement section 1877(h)(4) of the Social 
Security Act.
    Section 1871(a)(1) of the Act provides that the Secretary shall 
prescribe such regulations as may be necessary to carry out the 
administration of the insurance program under this title (XVIII). 
Section 1833(d) of the Act prohibits making payment under part B for 
services which are payable under Part A. By uniquely identifying Part B 
health professionals, practitioners, and groups we believe we will 
eliminate the possibility of duplicate payments.
    Medicare carriers currently identify physicians, practitioners, and 
groups using their own systems of assigned numbers. These 
individualized systems allow for Physician Identification Numbers 
(PINs) ranging from four to 16 alphabetic and/or numeric characters. 
Some carriers assign separate PINs to the same physician providing 
medical services in more than one locality, office or practice, and 
lack the capability to cross-reference the PINs and related physician 
data (e.g., group affiliation).
    Other carriers maintain a single PIN or cross-referenced PINs for 
each physician practicing within the carrier's geographic area of 
responsibility. Since physicians, groups, and practitioners can furnish 
medical services as well as bill for these services from several 
locations or states which are in different carrier jurisdictions, the 
independent providers who have been found to be ineligible for Medicare 
payments in one area, location or state could move to a different 
location or state in order to receive inappropriate or illegal payment.
    In order to rectify the problems inherent in these individualized 
identification systems, HCFA proposes to expand the national registry 
of physicians under Congressional mandate, (section 1842(r) of the 
Social Security Act, (42 U.S.C. 1395u(r))) so as to identify 
physicians, practitioners and medical group practices deemed eligible 
for Medicare payments and to maintain more comprehensive data on 
provider credentials.
    This initiative will also support the Medicare Transaction System 
(MTS) development effort. MTS is a single, national, government owned, 
standard, integrated claims processing system that will perform 
automated claims processing functions for Part A and Part B Medicare 
claims. HCFA must, therefore, build a national Medicare database of 
provider information, to be known as the MTS Provider File, in order to 
support all MTS functions.
    The MTS Provider File would retain all provider information in a 
standard format so as to facilitate Medicare functions, both internal 
and external to MTS.
    The Medicare Provider Database would uniquely identify and 
enumerate all Medicare providers and would provide summary information 
to support MTS functions. In order to develop that capability, HCFA is 
proposing to expand the UPIN system to provide identifying numbers for 
physicians, practitioners and medical group practices.
    At this time, HCFA is also proposing to change the name of this 
system to better reflect the system's expanded purpose. We are 
proposing to change the name of this system from the ``Medicare 
Physician Identification and Eligibility System (MPIES),'' System No. 
09-70-0525, to the ``Unique Physician/

[[Page 20530]]

Practitioner Identification Number (UPIN) System.'' This system will 
now be referred to as the UPIN system.
    HCFA is proposing to change the name and structure of the unique 
identifier from ``Unique Physician Identification Numbers (UPIN)'' to 
``Unique Physician/Practitioner Identification Numbers.'' HCFA will 
continue to use the acronym UPIN because Federal and state agencies, as 
well as private and public insurance entities are familiar with its 
use.
    The structure of the UPIN will be changed from a 6-digit 
alphanumeric identifier to a 10-digit alphanumeric identifier. It will 
have a 6-digit base (who) identifier along with a 4-digit location 
(where) identifier.
    These changes will enable HCFA to determine the location where the 
service was rendered and to decide whether a physician, practitioner 
and group practice whose services are billed to the program, is 
entitled to Medicare reimbursement. The 4-digit location identifier for 
physicians and the 10-digit UPINs assigned to practitioners and medical 
groups will be used by Medicare only for internal use--to link locally 
assigned providers to a national provider identifier.
    Carriers will continue to use their locally assigned provider 
numbers in claims processing. Practitioners and group practices will 
not need to use their UPINs for claims reimbursement. Physicians, 
suppliers, and laboratories will continue to report the physicians' 
base 6-digit identifier for ordering and referring requirements.
    The UPIN expansion will increase system standardization, identify 
providers across lines, facilitate development of provider data to 
support MTS, and permit HCFA to respond timely to and Federal 
initiative to implement standard, universal health care provider 
identifiers.
    Section 4164 (c) of the Omnibus Budget Reconciliation Act (OBRA) of 
1990 requires HCFA to ``publish a directory of the unique physician 
identification numbers (UPIN) of all physicians providing services for 
which payment may be made under Part B of Title XVIII of the Social 
Security Act and shall include in such directory the names, provider 
numbers, and business addresses of all listed physicians.'' The 
modification and expansion of the UPIN System will enable HFCA to 
execute regulations found at 42 Code of Federal Regulations (CFR) 
421.200 et seq., as well as the provisions of section 6204(b) of OBRA 
1989 (section 1833(q) of the Act) which help HCFA identify utilization 
patterns that deviate from professionally-established norms, both in 
the performance of services and in the referral of patients for other 
services or ordering of other services or suppliers. This requires 
laboratories and durable medical equipment (DME) suppliers, as well as 
consulting physicians, to show on the Medicare claim form the UPIN of 
the ordering or referring physician.
    HCFA will continue to publish an annual hard copy directory of 
UPINs for physicians which will assist in the identification of an 
ordering or referring physician. The directory will include the names, 
credentials, state licensed in, zip code, provider numbers, specialty, 
and business addresses of all listed physicians. HCFA will publish only 
the 6-digit base number in the directory at this time. The UPINs of 
practitioners and medical groups as well as the 4-digit location 
identifiers will not be published in the annual hard copy of the UPIN 
directory because these numbers will not be used for claims processing, 
are temporary, transitional internal-control numbers to assist HCFA to 
transfer locally-assigned carrier numbers to the MTS claims processing 
system, will not fit on existing billing forms, and may cause confusion 
as to which numbers should be noted on the claim form. The 10-digit 
UPINs of physician, practitioners and medical groups will be published 
annually in an electronic version of the UPIN directory.
    Enrollment information will be obtained from data currently 
available in carrier systems. The data will be researched, verified, 
and complied by carriers before submission to HCFA for assignment of 
UPINs. Duplicate data for two or more providers will be investigated by 
the carrier to determine if the identified providers are the same or 
different individuals. Once assured that no duplication exists, HCFA 
will notify each carrier of the assigned UPINs. The carriers will issue 
the UPINs to physicians, practitioners, and group practices.
    HCFA is also proposing to add the collection of tax identification 
numbers to the data maintained on physicians, practitioners, and 
medical group practices in this system. Carriers will be required to 
provide tax identification numbers (e.g., social security or employee 
identification number) for all physicians, practitioners, and groups to 
the UPIN system. Tax identification numbers are needed to assure 
accurate identification of carriers' physician, practitioner, and group 
records.
    The tax identification number provided by a carrier should be the 
one reported to the Internal Revenue Service and used in HCFA's 1099 
program. Carriers are currently collecting this information. Records 
will not be retrieved by tax identification numbers. Records are 
retrieved alphabetically by an individual's or group's name or UPIN. 
Any uses of social security numbers in data identification, retrieval, 
and analysis are in full compliance with section 7 of the Privacy Act. 
Data identification at the individual level is necessary to link 
information collected by HCFA to other data records in order to further 
the operation and effectiveness of the Medicare program.
    Also at this time, HCFA is proposing to add a new routine use 
(number 10) to this systems notice for the release of data to other 
Federal and state agencies. The Privacy Act (5 U.S.C. 552a) permits us 
to disclose information about an individual without consent of the 
individual for ``routine uses,'' that is, disclosure is permitted for 
purposes that are compatible with the purpose for which we have 
collected the information.
    The new proposed routine use would permit release of data to other 
Federal and to state agencies. This routine use has two purposes: 
First, disclosure would be permitted to other Federal and to state 
agencies to enhance the accuracy of Medicare's payment of health 
benefits through improved coordination of benefits and second, 
disclosure would be permitted to enable other Federal and state 
agencies to fulfill their own Medicare-related processing procedures.
    HCFA has recently received a number of requests from other Federal 
agencies, e.g., the Department of Labor, Veterans Affairs (Office of 
Civilian Health and Medical Programs of the Uniformed Services), and 
from state Medicaid agencies, asking for help in coordinating benefits 
and fulfilling their own Medicare-related processing procedures. To 
fulfill these requests requires the release of data from the UPIN 
system. A primary purpose of the Medicare program, for which this 
system of records was established, is to assure high quality and 
effective health care to Medicare beneficiaries. We believe that this 
purpose can be better accomplished through coordination of provider 
data between and among other Federal and state agencies. The proposed 
new routine use in the revised system meets the compatibility criteria, 
inasmuch as the information is collected for administering payments to 
providers in accordance with Title XVIII of the Social Security Act. We 
anticipate that disclosure under the routine use will not result in any 
unwarranted adverse effects on personal privacy.
    The routine use will be numbered (10) and will read as follows:

[[Page 20531]]

    (10) To another Federal or a state agency to: (1) Contribute to the 
accuracy of HCFA's proper payment of Medicare health benefits, or (2) 
enable such agency to administer a Federal or state health benefits 
program, or as necessary to enable such agency to fulfill a requirement 
of a Federal or state statute or regulation, if HCFA:
    a. Determines that the use or disclosure does not violate legal 
limitations under which the data were provided, collected, or obtained;
    b. Determines that the purpose for which the disclosure is be made 
cannot reasonably be accomplished unless the data are provided in 
individually identifiable form;
    c. Requires the recipient to:
    (1) Establish reasonable administrative, technical, and physical 
safeguards to prevent unauthorized use or disclosure of the record;
    (2) Make no further use or disclosure of the record except:
    (a) In emergency circumstances affecting the health or safety of 
any individual;
    (b) For use on another project under the same conditions and with 
written authorization from HCFA; and
    (c) When required by law;
    (d) Secures a written statement attesting to the next recipient's 
understanding of, and willingness to abide by the following provisions:
    (1) Not to use the data for purposes other than those for which the 
data were disclosed;
    (2) Not to publish or otherwise disclose the data in a form raising 
unacceptable possibilities that individuals could be identified (i.e., 
the data must not be individual-specific and must be aggregated to a 
level where no data cells have 10 or fewer individuals); and
    (3) Not to publish any aggregation of the data without HCFA's 
approval.
    The proposed new routine use for the MPIES (hereafter UPIN) system 
is consistent with the Privacy Act, 5 U.S.C. 552a(a)(7), since it is 
compatible with the purpose for which the data were collected. We are 
publishing the notice in its entirety below for the convenience of the 
reader.

    Dated: April 30, 1996.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
[FR Doc. 96-11260 Filed 5-6-96; 8:45 am]
BILLING CODE 4120-03-M