[Federal Register Volume 67, Number 15 (Wednesday, January 23, 2002)]
[Notices]
[Pages 3201-3202]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 02-1524]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services


Privacy Act of 1974; Report of New Computer Matching Agreement

AGENCY: Department of Health and Human Services (HHS), Centers for 
Medicare & Medicaid Services (CMS) (formerly the Health Care Financing 
Administration).

ACTION: Notice of a New Computer Matching Agreement (CMA).

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SUMMARY: In accordance with the requirements of the Privacy Act of 
1974, we are proposing to establish a CMA between CMS and the State of 
California Department of Health Services (DHS) titled ``Disclosure of 
Medicare and Medicaid Information.''

EFFECTIVE DATES: CMS filed a CMA report with the Chair of the House 
Committee on Government Reform and Oversight, the Chair of the Senate 
Committee on Governmental Affairs, and the Administrator, Office of 
Information and Regulatory Affairs, Office of Management and Budget 
(OMB) on January 15, 2002. To ensure that all parties have adequate 
time in which to comment, the modified or altered system of records, 
including routine uses, will become effective 40 days from the 
publication of the notice, or from the date it was submitted to OMB and 
the Congress, whichever is later, unless CMS receives comments that 
require alterations to this notice.

ADDRESSES: The public should address comments to: Director, Division of 
Data Liaison and Distribution, CMS, Room N2-04-27, 7500 Security 
Boulevard, Baltimore, Maryland 21244-1850. Comments received will be 
available for review at this location, by appointment, during regular 
business hours, Monday through Friday from 9 a.m.-3 p.m., eastern 
standard time.

FOR FURTHER INFORMATION CONTACT: Howard Cohen, Health Insurance 
Specialist, Program Integrity Group, Office of Financial Affairs, CMS, 
Room C3-02-16, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. 
The telephone number is 410-786-9537.

SUPPLEMENTARY INFORMATION:

I. Description of the Matching Program

A. General

    The Computer Matching and Privacy Protection Act of 1988 (Pub. L. 
100-503), amended the Privacy Act (5 U.S.C. 552a) by describing the 
manner in which computer matching involving Federal agencies could be 
performed and adding certain protections for individuals applying for 
and receiving Federal benefits. Section 7201 of the Omnibus Budget 
Reconciliation Act of 1990 (Pub. L. 100-508) further amended the 
Privacy Act regarding protections for such individuals. The Privacy 
Act, as amended, regulates the use of computer matching by Federal 
agencies when records in a system of records are matched with other 
Federal, state, or local government records. It requires Federal 
agencies involved in computer matching programs to:

[[Page 3202]]

    1. Negotiate written agreements with the other agencies 
participating in the matching programs;
    2. Obtain the Data Integrity Board approval of the match 
agreements;
    3. Furnish detailed reports about matching programs to Congress and 
OMB;
    4. Notify applicants and beneficiaries that the records are subject 
to matching; and, 5. Verify match findings before reducing, suspending, 
terminating, or denying an individual's benefits or payments.

B. CMS Computer Matches Subject to the Privacy Act

    CMS has taken action to ensure that all Computer Matching Programs 
that this Agency participates in comply with the requirements of the 
Privacy Act of 1974, as amended.

    Dated: January 14, 2002.
Thomas A. Scully,
Administrator, Centers for Medicare & Medicaid Services.
CMA No. 2001-06

Name:
    Computer Matching Agreement between the Centers for Medicare & 
Medicaid Services and the State of California Department of Health 
Services entitled Disclosure of Medicare and Medicaid Information.

Security Classification:
    Level Three Privacy Act Sensitive.

Participating Agencies:
    The Centers for Medicare & Medicaid Services (CMS), and State of 
California Department of Health Services (DHS).

Authority for Conducting Matching Program:
    This Computer Matching Program (CMP) is executed to comply with the 
Privacy Act of 1974 (Title 5 United States Code (U.S.C.) sec. 552a), as 
amended, the Office of Management and Budget (OMB) Circular A-130, 
titled ``Management of Federal Information Resources'' published at 65 
FR 77677 (December 12, 2000), and OMB guidelines pertaining to computer 
matching (54 FR 25818 (June 19, 1989)).
    Authority for this matching program is given under the matching 
provisions of sections 1816, 1842, and 1874(b) of the Social Security 
Act (42 U.S.C. 1395h, 1395u, and 1395kk(b)).
    Authority for DHS to participate in this computer-matching program 
is given under the provisions of sections 10740, 10748, 10750, 14000, 
14000.3. 14000.4, 14005, 14005.4, 14100.1, 14200 of the California 
Welfare and Institutions Code, and 42 CFR 431.300 through 431.307. DHS 
is charged with administration of the Medicaid program in California 
and is the single state agency for such purpose. DHS may act as an 
agent or representative of the Federal government for any purpose in 
furtherance of DHS's functions or administration of the Federal funds 
granted to the state. In California, the Medi-Cal Act provides 
qualifying individuals with health care and related remedial or 
preventive services, including both Medicaid services and services 
authorized under state law that are not provided under Federal law. The 
program to provide all such services is known as the Medi-Cal program.

Purpose (S) of the Matching Program:
    The purpose of this agreement is to establish the conditions, 
safeguards, and procedures under which the CMS will conduct a computer 
matching program with DHS to study claims, billing, and eligibility 
information to detect suspected instances of fraud and abuse (F&A) in 
the State of California. CMS and DHS will provide a CMS contractor 
(hereinafter referred to as the ``Custodian'') with Medicare and 
Medicaid/Medi-Cal records pertaining to eligibility, claims, and 
billing which the Custodian will match in order to merge the 
information into a single database. Utilizing fraud detection software, 
the information will then be used to identify patterns of aberrant 
practices requiring further investigation. The following are examples 
of the type of aberrant practices that may constitute F&A by 
practitioners, providers, and suppliers in the State of California 
expected to be identified in this matching program: (1) Billing for 
provisions of more than 24 hours of services in one day, (2) providing 
treatment and services in ways more statistically significant than 
similar practitioner groups, and (3) up-coding and billing for services 
more expensive than those actually performed.

Categories of Records and Individuals Covered by the Match:
    This CMP will enhance the ability of CMS and DHS to detect F&A by 
matching claims data, eligibility, and practitioner, provider, and 
supplier enrollment records of Medicare beneficiaries, practitioners, 
providers, and suppliers in the State of California against records of 
Medicaid/Medi-Cal beneficiaries, practitioners, providers, and 
suppliers in the State of California.

Description of Records to be Used in the Matching Program:
    A. Systems of Records.
    The data for CMS are maintained in the following Systems:
    National Claims History (NCH), System No. 09-70-0005, was most 
recently published at 59 FR 19181 (April 22, 1994). NCH contains 
records needed to facilitate obtaining Medicare utilization review data 
that can be used to study the operation and effectiveness of the 
Medicare program. Matched data will be released to DHS pursuant to the 
routine use as set forth in the system notice.
    Enrollment Database, System No. 09-70-0502 (formerly known as the 
Health Insurance Master Record) published at 55 FR 37547 (September 12, 
1990). Matched data will be released to DHS pursuant to the routine use 
set forth in the system notice.
    Medicare Supplier Identification File, System No. 09-70-0530 
published at 57 FR 23420 (June 3, 1992). Matched data will be released 
to DHS pursuant to the routine use as set forth in the system notice.
    Unique Physician/Provider Identification Number (formerly known as 
the Medicare Physician Identification and Eligibility System), System 
No. 09-70-0525, published at 53 FR 50584 (Dec 16, 1988). Matched data 
will be released to DHS pursuant to the routine use as set forth in the 
system notice.
    Carrier Medicare Claims Record, System No. 09-70-0501 published at 
59 FR 37243 (July 21, 1994). Matched data will be released to DHS 
pursuant to the routine use as set forth in the system notice.
    B. The data for DHS are maintained in the following data files:
    ``Medi-Cal RFF035 File Paid Claims,'' ``Medi-Cal Combined Provider 
Master File;'' and ``Medi-Cal Eligibility File.

Inclusive Dates of the Match:
    The CMP shall become effective no sooner than 40 days after the 
report of the Matching Program is sent to OMB and Congress, or 30 days 
after publication in the Federal Register, which ever is later. The 
matching program will continue for 18 months from the effective date 
and may be extended for an additional 12 months thereafter, if certain 
conditions are met.
[FR Doc. 02-1524 Filed 1-22-02; 8:45 am]
BILLING CODE 4120-03-P