[Federal Register Volume 67, Number 141 (Tuesday, July 23, 2002)]
[Notices]
[Pages 48179-48184]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 02-18167]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services


Privacy Act of 1974; Report of Modified or Altered System

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

ACTION: Notice of modified or altered System of Records (SOR).

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SUMMARY: In accordance with the requirements of the Privacy Act of 
1974, we are proposing to modify or alter an SOR, ``Medicare Health 
Maintenance Organizations/Competitive Medical Plans Beneficiary 
Reconsideration System (MBRS),'' System No. 09-70-4003. We propose to 
change the name of the system to read ``Medicare Managed Care 
Beneficiary Reconsideration (RECON) System,'' to reflect the change in 
the programs related to this activity. The language in published 
routine use number 3 will be modified to more accurately reflect 
activities currently performed by contractors and consultants. We 
propose to delete published routine use number 5, pertaining to `` a 
state insurance commissioner * * *'' and an unnumbered routine use 
authorizing disclosure to the Social Security Administration (SSA). 
Access to the data for these activities will be accomplished by adding 
a new routine use which authorizes release of information in this 
system to ``another Federal and/or state agency, agency of a state 
government, an agency established by state law, or its fiscal agent.'' 
Disclosure of information to Quality Improvement Organizations (QIO) 
(formerly Peer Review Organizations) as stated in published routine use 
number 5 will be treated as a new routine use and prioritized as 
routine use number 4. We propose to modify the language of published 
routine use number 4 pertaining to ``a third party'' to limit 
disclosures authorized under this routine use and to provide clarity to 
the circumstances for disclosures. Third parties will be treated as a 
new routine use and prioritized as routine use number 3.
    The security classification previously reported as ``None'' will be 
modified to reflect that the data in this system are considered to be 
``Level Three Privacy Act Sensitive.'' We are modifying the language in 
the remaining routine uses to provide clarity to CMS's intention to 
disclose individual-specific information contained in this system. The 
routine uses will then be prioritized and reordered according to their 
proposed usage. We will also take the opportunity to update any 
sections of the system that were affected by recent reorganizations and 
to update language in the administrative sections to correspond with 
language used in other CMS SORs.
    The primary purpose of the system is to collect and maintain 
information necessary to process requests for reconsideration of 
service requests or claims by or on behalf of Medicare managed care 
enrollees, promote the effectiveness and integrity of the Medicare 
managed care program, and reply to future correspondence related to the 
case. Information in this system will also be disclosed to: (1) Support 
regulatory and policy functions performed within the Agency or by a 
contractor or consultant, (2) another Federal and/or state agency, 
agency of a state government, an agency established by state law, or 
its fiscal agent, (3) third party contacts, (4) QIOs, (5) support 
constituent requests made to a congressional representative, (6) 
support litigation involving the Agency related to this SOR, and (7) 
combat fraud and abuse in certain health care programs. We have 
provided background information about the modified system in the 
``Supplementary Information'' section below. Although the Privacy Act 
requires only that CMS provide an opportunity for interested persons to 
comment on the proposed routine uses, CMS invites comments on all 
portions of this notice. See ``Effective Dates'' section for comment 
period.

[[Page 48180]]


EFFECTIVE DATES: CMS filed a modified or altered system 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 June 17, 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: Beverly Sgroi, Health Insurance 
Specialist, Division of Hearings, Appeals & Dispute Resolution, Center 
for Beneficiary Choices, CMS, Mail-stop S1-05-06, 7500 Security 
Boulevard, Baltimore, Maryland 21244-1850. The telephone number is 410-
786-7638. The e-mail address is [email protected].

SUPPLEMENTARY INFORMATION:

I. Description of the Modified System of Records.

A. Statutory and Regulatory Basis for SOR

    In 1988, CMS established an SOR under the authority of Sec. 1872 of 
the Social Security Act (the Act) (Title 42 United States Code (U.C.S. 
section 1395mm). Notice of this system, MBRS, was published in the 
Federal Register (FR) 53 FR 35914 (Sept. 15, 1988), a routine use was 
added for the Social Security Administration (SSA) at 61 FR 6645 (Feb. 
21, 1996), three new fraud and abuse routine uses were added at 63 FR 
38414 (July 16, 1998), and then at 65 FR 50552 (Aug. 18, 2000), two of 
the fraud and abuse routine uses were revised and a third deleted.

II. Collection and Maintenance of Data in the System

A. Scope of the Data Collected

    The system contains information concerning Medicare beneficiaries 
who have been enrolled in a managed care program and who have requested 
an appeal by CMS, or any person who acts on behalf of these 
beneficiaries. The system contains the name and address of 
beneficiaries and the individual representing the beneficiary in this 
appeal process. It will also contain the beneficiary's social security 
number (SSN), health insurance claims number (HIC), health insurance 
plan name and address, health insurance plan number, medical records 
and statement of fact, service requests/claims data, date of service 
request/claim received by the health plan, dates of service, 
beneficiary enrollment form and disenrollment form, verification of 
enrollment status, date reconsideration request submitted to CMS, and 
dates of determination by plan and CMS.

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

    The Privacy Act permits us to disclose information without an 
individual's consent if the information is to be used for a purpose 
that is compatible with the purpose(s) for which the information was 
collected. Any such disclosure of data is known as a ``routine use.'' 
The government will only release RECON information that can be 
associated with an individual as provided for under ``Section III. 
Proposed Routine Use Disclosures of Data in the System.'' Both 
identifiable and non-identifiable data may be disclosed under a routine 
use.
    We will only collect the minimum personal data necessary to achieve 
the purpose of RECON. CMS has the following policies and procedures 
concerning disclosures of information that will be maintained in the 
system. Disclosure of information from the SOR will be approved only 
for the minimum information necessary to accomplish the purpose of the 
disclosure only after CMS:
    1. Determines that the use or disclosure is consistent with the 
reason that the data is being collected, e.g., collecting and 
maintaining information used in processing the claimant's appeal and 
information necessary to reply to future correspondence.
    2. Determines that:
    a. The purpose for which the disclosure is to be made can only be 
accomplished if the record is provided in individually identifiable 
form;
    b. The purpose for which the disclosure is to be made is of 
sufficient importance to warrant the effect and/or risk on the privacy 
of the individual that additional exposure of the record might bring; 
and
    c. There is a strong probability that the proposed use of the data 
would in fact accomplish the stated purpose(s).
    3. Requires the information recipient to:
    a. Establish administrative, technical, and physical safeguards to 
prevent unauthorized use of disclosure of the record;
    b. Remove or destroy at the earliest time all individually-
identifiable information; and
    c. Agree to not use or disclose the information for any purpose 
other than the stated purpose under which the information was 
disclosed.
    4. Determines that the data are valid and reliable.

III. Proposed Routine Use Disclosures of Data in the System

A. Entities Who May Receive Disclosures Under Routine Use

    These routine uses specify circumstances, in addition to those 
provided by statute in the Privacy Act of 1974, under which CMS may 
release information from the RECON without the consent of the 
individual to whom such information pertains. Each proposed disclosure 
of information under these routine uses will be evaluated to ensure 
that the disclosure is legally permissible, including but not limited 
to ensuring that the purpose of the disclosure is compatible with the 
purpose for which the information was collected. We are proposing to 
establish or modify the following routine uses for disclosures of 
information maintained in the system:
    1. To Agency contractors, or consultants who have been contracted 
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.
    We contemplate disclosing information under this routine use only 
in situations in which CMS may enter into a contractual or similar 
agreement with a third party to assist in accomplishing a CMS function 
relating to purposes for this system of records. CMS occasionally 
contracts out certain of its functions when doing so would contribute 
to effective and efficient operations. CMS must be able to give a 
contractor or consultant whatever information is necessary for the 
contractor or consultant to fulfill its duties. In these situations, 
safeguards are provided in the contract prohibiting the contractor or 
consultant from using or disclosing the information for any purpose 
other than that described in the contract and requires the contractor 
or consultant to return or destroy all information at the completion of 
the contract.

[[Page 48181]]

    2. To another Federal or state agency, agency of a state 
government, an agency established by state law, or its fiscal agent to:
    a. Contribute to the accuracy of CMS's 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 a health benefits 
program funded in whole or in part with Federal funds, and/or
    c. Assist Federal/state Medicaid programs within the state.
    Other Federal or state agencies in their administration of a 
Federal health program may require RECON information in order to 
support evaluations and monitoring of Medicare claims information of 
beneficiaries, including proper reimbursement for services provided.
    In addition, other state agencies in their administration of a 
Federal health program may require RECON information for the purposes 
of determining, evaluating and/or assessing cost, effectiveness, and /
or the quality of health care services provided in the state.
    SSA requires RECON data to enable them to assist in the 
implementation and maintenance of the Medicare program.
    State Insurance Commissioners or other state regulators with 
similar authority acting in a manner consistent with maintaining the 
integrity of the Medicare program may require RECON data to assist in 
accomplishing their activities.
    3. To third party contacts in situations where the party to be 
contacted has, or is expected to have information relating to the 
individual's capacity to manage his or her affairs or to his or her 
eligibility for, or an entitlement to, benefits under the Medicare 
program and,
    a. The individual is unable to provide the information being sought 
(an individual is considered to be unable to provide certain types of 
information when any of the following conditions exists: the individual 
is confined to a mental institution, a court of competent jurisdiction 
has appointed a guardian to manage the affairs of that individual, a 
court of competent jurisdiction has declared the individual to be 
mentally incompetent, or the individual's attending physician has 
certified that the individual is not sufficiently mentally competent to 
manage his or her own affairs or to provide the information being 
sought, the individual cannot read or write, cannot afford the cost of 
obtaining the information, a language barrier exists, or the custodian 
of the information will not, as a matter of policy, provide it to the 
individual), or
    b. The data are needed to establish the validity of evidence or to 
verify the accuracy of information presented by the individual, and it 
concerns one or more of the following: The individual's entitlement to 
benefits under the Medicare program, the amount of reimbursement, or 
any case in which the evidence is being reviewed as a result of 
suspected fraud and abuse, program integrity, quality appraisal, or 
evaluation and measurement of activities.
    Third party contacts require RECON information in order to provide 
support for the individual's entitlement to benefits under the Medicare 
program, to establish the validity of evidence or to verify the 
accuracy of information presented by the individual, and assist in the 
monitoring of Medicare claims information of beneficiaries, including 
proper reimbursement of services provided.
    4. To Quality Improvement Organizations (QIO) connection with 
review of claims, or in connection with studies or other review 
activities, conducted pursuant to Part B of Title XI of the Act and in 
performing affirmative outreach activities to individuals for the 
purpose of establishing and maintaining their entitlement to Medicare 
benefits or health insurance plans.
    QIOs will work to implement quality improvement programs, provide 
consultation to CMS, its contractors, and to state agencies. QIOs will 
assist the state agencies in related monitoring and enforcement 
efforts, assist CMS and intermediaries in program integrity assessment, 
and prepare summary information for release to CMS.
    5. To a Member of Congress or to a congressional staff member in 
response to an inquiry of the congressional office made at the written 
request of the constituent about whom the record is maintained.
    Beneficiaries sometimes request the help of a Member of Congress in 
resolving an issue relating to a matter before CMS. The Member of 
Congress then writes CMS, and CMS must be able to give sufficient 
information to be responsive to the inquiry.
    6. To the Department of Justice (DOJ), court or adjudicatory body 
when:
    a. The Agency or any component thereof, or
    b. Any employee of the Agency in his or her official capacity, or
    c. Any employee of the Agency in his or her individual capacity 
where the DOJ has agreed to represent the employee, or
    d. The United States Government,
    is a party to litigation or has an interest in such litigation, and 
by careful review, CMS determines that the records are both relevant 
and necessary to the litigation.
    Whenever CMS is involved in litigation, or occasionally when 
another party is involved in litigation and CMS's policies or 
operations could be affected by the outcome of the litigation, CMS 
would be able to disclose information to the DOJ, court or adjudicatory 
body involved.
    7. To a CMS contractor (including, but not limited to fiscal 
intermediaries and carriers) that assists in the administration of a 
CMS-administered health benefits program, or to a grantee of a CMS-
administered grant program, 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 or abuse in such program.
    We contemplate disclosing information under this routine use only 
in situations in which CMS may enter into a contract or grant with a 
third party to assist in accomplishing CMS functions relating to the 
purpose of combating fraud and abuse.
    CMS occasionally contracts out certain of its functions when doing 
so would contribute to effective and efficient operations. CMS must be 
able to give a contractor or grantee whatever information is necessary 
for the contractor or grantee to fulfill its duties. In these 
situations, safeguards are provided in the contract prohibiting the 
contractor or grantee from using or disclosing the information for any 
purpose other than that described in the contract and requiring the 
contractor or grantee to return or destroy all information.
    8. 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 
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 or abuse in such programs.
    Other agencies may require RECON information for the purpose of 
combating fraud and abuse in such Federally funded programs.

[[Page 48182]]

B. Additional Circumstances Affecting Routine Use Disclosures

    This SOR contains Protected Health Information as defined by HHS 
regulation ``Standards for Privacy of Individually Identifiable Health 
Information'' (45 CFR Parts 160 and 164, 65 FR 82462 (12-28-00), as 
amended by 66 FR 12434 (2-26-01)). Disclosures of Protected Health 
Information 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.''
    In addition, our policy will be to prohibit release even of non-
identifiable data, except pursuant to one of the routine uses, if there 
is a possibility that an individual can be identified through implicit 
deduction based on small cell sizes (instances where the patient 
population is so small that individuals who are familiar with the 
enrollees could, because of the small size, use this information to 
deduce the identity of the beneficiary).

IV. Safeguards

A. Administrative Safeguards

    The RECON system will conform to applicable law and policy 
governing the privacy and security of Federal automated information 
systems. These include but are not limited to: the Privacy Act of 1974, 
Computer Security Act of 1987, the Paperwork Reduction Act (PRA) of 
1995, the Clinger-Cohen Act of 1996, and OMB Circular A-130, Appendix 
III, ``Security of Federal Automated Information Resources.'' CMS has 
prepared a comprehensive system security plan as required by the Office 
and Management and Budget (OMB) Circular A-130, Appendix III. This plan 
conforms fully to guidance issued by the National Institute for 
Standards and Technology (NIST) in NIST Special Publication 800-18, 
``Guide for Developing Security Plans for Information Technology 
Systems.'' Paragraphs A-C of this section highlight some of the 
specific methods that CMS is using to ensure the security of this 
system and the information within it.
    Authorized users: Personnel having access to the system have been 
trained in Privacy Act and systems security requirements. Employees and 
contractors who maintain records in the system are instructed not to 
release any data until the intended recipient agrees to implement 
appropriate administrative, technical, procedural, and physical 
safeguards sufficient to protect the confidentiality of the data and to 
prevent unauthorized access to the data. In addition, CMS is monitoring 
the authorized users to ensure against excessive or unauthorized use. 
Records are used in a designated work area or workstation and the 
system location is attended at all times during working hours.
    To assure security of the data, the proper level of class user is 
assigned for each individual user as determined at the Agency level. 
This prevents unauthorized users from accessing and modifying critical 
data. The system database configuration includes five classes of 
database users:
     Database Administrator class owns the database objects; 
e.g., tables, triggers, indexes, stored procedures, packages, and has 
database administration privileges to these objects;
     Quality Control Administrator class has read and write 
access to key fields in the database;
     Quality Indicator Report Generator class has read-only 
access to all fields and tables;
     Policy Research class has query access to tables, but are 
not allowed to access confidential individual identification 
information; and
     Submitter class has read and write access to database 
objects, but no database administration privileges.

B. Physical Safeguards

    All server sites have implemented the following minimum 
requirements to assist in reducing the exposure of computer equipment 
and thus achieve an optimum level of protection and security for the 
RECON system:
    Access to all servers is controlled, with access limited to only 
those support personnel with a demonstrated need for access. Servers 
are to be kept in a locked room accessible only by specified management 
and system support personnel. Each server requires a specific log-on 
process. All entrance doors are identified and marked. A log is kept of 
all personnel who were issued a security card key and/or combination 
that grants access to the room housing the server, and all visitors are 
escorted while in this room. All servers are housed in an area where 
appropriate environmental security controls are implemented, which 
include measures implemented to mitigate damage to Automated 
Information System resources caused by fire, electricity, water and 
inadequate climate controls.
    Protection applied to the workstations, servers and databases 
include:
     User Log-ons--Authentication is performed by the Primary 
Domain Controller/Backup Domain Controller of the log-on domain.
     Workstation Names--Workstation naming conventions may be 
defined and implemented at the Agency level.
     Hours of Operation--May be restricted by Windows NT. When 
activated all applicable processes will automatically shut down at a 
specific time and not be permitted to resume until the predetermined 
time. The appropriate hours of operation are determined and implemented 
at the Agency level.
     Inactivity Log-out--Access to the NT workstation is 
automatically logged out after a specified period of inactivity.
     Warnings--Legal notices and security warnings display on 
all servers and workstations.
     Remote Access Services (RAS)--Windows NT RAS security 
handles resource access control. Access to NT resources is controlled 
for remote users in the same manner as local users, by utilizing 
Windows NT file and sharing permissions. Dial-in access can be granted 
or restricted on a user-by-user basis through the Windows NT RAS 
administration tool.

C. Procedural Safeguards

    All automated systems must comply with Federal laws, guidance, and 
policies for information systems security as stated previously in this 
section. Each automated information system should ensure a level of 
security commensurate with the level of sensitivity of the data, risk, 
and magnitude of the harm that may result from the loss, misuse, 
disclosure, or modification of the information contained in the system.

V. Effect of the Modified System of Records on Individual Rights

    CMS proposes to establish this system in accordance with the 
principles and requirements of the Privacy Act and will collect, use, 
and disseminate information only as prescribed therein. Data in this 
system will be subject to the authorized releases in accordance with 
the routine uses identified in this system of records.
    CMS will monitor the collection and reporting of RECON data. RECON 
information on individuals is completed by contractor personnel and 
submitted to CMS through standard systems located at different 
locations. CMS will utilize a variety of onsite and offsite edits and 
audits to increase the accuracy of RECON data.
    CMS will take precautionary measures (see item IV. above) to 
minimize the risks of unauthorized access to the records and the 
potential harm to individual privacy or other personal or property 
rights. CMS will

[[Page 48183]]

collect only that information necessary to perform the system's 
functions. In addition, CMS will make disclosure of identifiable data 
from the modified system only with consent of the subject individual, 
or his/her legal representative, or in accordance with an applicable 
exception provision of the Privacy Act.
    CMS, therefore, does not anticipate an unfavorable effect on 
individual privacy as a result of the disclosure of information 
relating to individuals.

    Dated: June 17, 2002.
Thomas A. Scully,
Administrator, Centers for Medicare & Medicaid Services.
System No. 09-70-4003

SYSTEM NAME:
    Medicare Managed Care Beneficiary Reconsideration (RECON) System 
No. 09-70-4003.

SECURITY CLASSIFICATION:
    Level Three Privacy Act Sensitive

SYSTEM LOCATION:
    CMS Data Center, 7500 Security Boulevard, North Building, First 
Floor, Baltimore, Maryland 21244-1850.

CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:
    The system contains information concerning Medicare beneficiaries 
who have been enrolled in a managed care program and who have requested 
an appeal by CMS, or any person who acts on behalf of these 
beneficiaries.

CATEGORIES OF RECORDS IN THE SYSTEM:
    The system contains the name and address of beneficiaries and the 
individual representing the beneficiary in this appeal process. It will 
also contain the beneficiary's social security number (SSN), health 
insurance claims number (HIC), health insurance plan name and address, 
health insurance plan number, medical records and statement of fact, 
service requests/claims data, date of service request/claim received by 
the health plan, dates of service, beneficiary enrollment form and 
disenrollment form, verification of enrollment status, date 
reconsideration request submitted to CMS, and dates of determination by 
plan and CMS.

AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
    Authority for the maintenance of this system of records is given 
under Secs. 1852, and 1876 of the Social Security Act (the Act) United 
States Code (U.S.C.) Secs. 1395w-22, and 1395mm).

PURPOSE(S) OF THE SYSTEM:
    The primary purpose of the SOR is to collect and maintain 
information necessary to process requests for reconsideration of 
service requests or claims by or on behalf of Medicare managed care 
enrollees, promote the effectiveness and integrity of the Medicare 
managed care program, and reply to future correspondence related to the 
case. Information in this system will also be disclosed to: (1) Support 
regulatory and policy functions performed within the Agency or by a 
contractor or consultant, (2) another Federal and/or state agency, 
agency of a state government, an agency established by state law, or 
its fiscal agent, (3) third party contacts, (4) Quality Improvement 
Organizations (QIO) (formerly Peer Review Organizations), (5) support 
constituent requests made to a congressional representative, (6) 
support litigation involving the Agency related to this SOR, and (7) 
combat fraud and abuse in certain health care programs.

ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES 
OR USERS AND THE PURPOSES OF SUCH USES:
    These routine uses specify circumstances, in addition to those 
provided by statute in the Privacy Act of 1974, under which CMS may 
release information from the RECON without the consent of the 
individual to whom such information pertains. Each proposed disclosure 
of information under these routine uses will be evaluated to ensure 
that the disclosure is legally permissible, including but not limited 
to ensuring that the purpose of the disclosure is compatible with the 
purpose for which the information was collected.
    This SOR contains Protected Health Information as defined by HHS 
regulation ``Standards for Privacy of Individually Identifiable Health 
Information'' (45 CFR Parts 160 and 164, 65 FR 82462 (12-28-00), as 
amended by 66 FR 12434 (2-26-01)). Disclosures of Protected Health 
Information 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.''
    In addition, our policy will be to prohibit release even of non-
identifiable data, except pursuant to one of the routine uses, if there 
is a possibility that an individual can be identified through implicit 
deduction based on small cell sizes (instances where the patient 
population is so small that individuals who are familiar with the 
enrollees could, because of the small size, use this information to 
deduce the identity of the beneficiary). We are proposing to establish 
or modify the following routine uses for disclosures of information 
maintained in the system:
    1. Agency contractors, or consultants who have been contracted 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.
    2. To another Federal or state agency, agency of a state 
government, an agency established by state law, or its fiscal agent to:
    a. Contribute to the accuracy of CMS's 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 a health benefits 
program funded in whole or in part with Federal funds, and/or
    c. Assist Federal/state Medicaid programs within the state.
    3. To third party contacts in situations where the party to be 
contacted has, or is expected to have information relating to the 
individual's capacity to manage his or her affairs or to his or her 
eligibility for, or an entitlement to, benefits under the Medicare 
program and,
    a. The individual is unable to provide the information being sought 
(an individual is considered to be unable to provide certain types of 
information when any of the following conditions exists: The individual 
is confined to a mental institution, a court of competent jurisdiction 
has appointed a guardian to manage the affairs of that individual, a 
court of competent jurisdiction has declared the individual to be 
mentally incompetent, or the individual's attending physician has 
certified that the individual is not sufficiently mentally competent to 
manage his or her own affairs or to provide the information being 
sought, the individual cannot read or write, cannot afford the cost of 
obtaining the information, a language barrier exists, or the custodian 
of the information will not, as a matter of policy, provide it to the 
individual), or
    b. The data are needed to establish the validity of evidence or to 
verify the accuracy of information presented by the individual, and it 
concerns one or more of the following: The individual's entitlement to 
benefits under the Medicare program, the amount of reimbursement, or 
any case in which the evidence is being reviewed as a result of 
suspected fraud and abuse, program integrity, quality appraisal, or 
evaluation and measurement of activities.
    4. To Quality Improvement Organizations in connection with review 
of claims, or in connection with

[[Page 48184]]

studies or other review activities, conducted pursuant to Part B of 
Title XI of the Act and in performing affirmative outreach activities 
to individuals for the purpose of establishing and maintaining their 
entitlement to Medicare benefits or health insurance plans.
    5. To a Member of Congress or to a congressional staff member in 
response to an inquiry of the congressional office made at the written 
request of the constituent about whom the record is maintained.
    6. To the Department of Justice (DOJ), court or adjudicatory body 
when:
    a. The Agency or any component thereof, or
    b. Any employee of the Agency in his or her official capacity, or
    c. Any employee of the Agency in his or her individual capacity 
where the DOJ has agreed to represent the employee, or
    d. The United States Government, is a party to litigation or has an 
interest in such litigation, and by careful review, CMS determines that 
the records are both relevant and necessary to the litigation.
    7. To a CMS contractor (including, but not limited to fiscal 
intermediaries and carriers) that assists in the administration of a 
CMS-administered health benefits program, or to a grantee of a CMS-
administered grant program, 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 or abuse in such program.
    8. 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 
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 or abuse in such programs.

POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING, 
AND DISPOSING OF RECORDS IN THE SYSTEM:
STORAGE:
    Computer diskette and on magnetic storage media.

RETRIEVABILITY:
    Information can be retrieved by the name, SSN, and/or HICN of 
claimant.

SAFEGUARDS:
    CMS has safeguards for authorized users and monitors such users to 
ensure against excessive or unauthorized use. Personnel having access 
to the system have been trained in the Privacy Act and systems security 
requirements. Employees who maintain records in the system are 
instructed not to release any data until the intended recipient agrees 
to implement appropriate administrative, technical, procedural, and 
physical safeguards sufficient to protect the confidentiality of the 
data and to prevent unauthorized access to the data.
    In addition, CMS has physical safeguards in place to reduce the 
exposure of computer equipment and thus achieve an optimum level of 
protection and security for the RECON system. For computerized records, 
safeguards have been established in accordance with the Department of 
Health and Human Services (HHS) standards and National Institute of 
Standards and Technology guidelines, e.g., security codes will be used, 
limiting access to authorized personnel. System securities are 
established in accordance with HHS, Information Resource Management 
Circular 10, Automated Information Systems Security Program; 
CMS Information Systems Security Policy, Standards, and Guidelines 
Handbook, and OMB Circular No. A-130, Appendix III.

RETENTION AND DISPOSAL:
    Records are maintained in a secure storage area with identifiers. 
Case records are transferred to and maintained in an archival file for 
a period of 15 years.

SYSTEM MANAGER AND ADDRESS:
    Director, Division of hearings, Appeals & Dispute Resolution, 
Center for Beneficiary Choices, CMS, 7500 Security Boulevard, Mailstop 
S1-05-06, Baltimore, Maryland 21244-1850.

NOTIFICATION PROCEDURE:
    For purpose of access, the subject individual should write to the 
system manager who will require the system name, HIC, address, date of 
birth, and sex, and for verification purposes, the subject individual's 
name (woman's maiden name, if applicable), and SSN. Furnishing the SSN 
is voluntary, but it may make searching for a record easier and prevent 
delay.

RECORD ACCESS PROCEDURE:
    For purpose of access, use the same procedures outlined in 
Notification Procedures above. Requestors should also reasonably 
specify the record contents being sought. (These procedures are in 
accordance with Department regulation 45 CFR 5b.5(a)(2)).

CONTESTING RECORD PROCEDURES:
    The subject individual should contact the system manager named 
above, and reasonably identify the record and specify the information 
to be contested. State the corrective action sought and the reasons for 
the correction with supporting justification. (These procedures are in 
accordance with Department regulation 45 CFR 5b.7).

RECORD SOURCE CATEGORIES:
    Sources of information contained in this records system is obtained 
from the reconsideration requests made by or on behalf of Medicare 
beneficiaries and from inquiries from congressional offices, health 
plans, providers, state insurance commissioners, state regulators, 
disenrollment surveys, Medicare carriers or intermediaries, and QIO 
records.

SYSTEMS EXEMPTED FROM CERTAIN PROVISIONS OF THE ACT:
    None.

[FR Doc. 02-18167 Filed 7-22-02; 8:45 am]
BILLING CODE 4120-03-P