[Federal Register Volume 67, Number 141 (Tuesday, July 23, 2002)]
[Notices]
[Pages 48189-48194]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 02-18169]


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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 (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, ``Intern and Resident 
Information System (IRIS), No. 09-70-0524.'' We will broaden the scope 
of this system to include information on interns and residents (IRs) 
required in Title 42 Code of Federal Regulations (CFR) Sec. 412.105 
(Special treatment: Hospitals that incur indirect costs for graduate 
medical education programs) and 42 CFR 413.86 (Direct graduate medical 
education payments). We are also deleting published routine use number 
3 authorizing disclosures to contractors, number 6 authorizing 
disclosures to researchers, and an unnumbered routine use which 
authorizes the release of information to the Social Security 
Administration (SSA).
    Proposed routine use number 1 will now cover disclosures previously 
allowed by routine use number 3 pertaining to contractors. Access to 
the data from this system to SSA will be accomplished by adding a new 
routine use number 4, 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.'' 
Routine use number 6 authorizing release to researchers is being 
deleted because the very specific nature of the data collected is not 
sought for research purposes.
    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 the recent reorganization 
and to update language in the administrative sections to correspond 
with language used in other CMS SORs.
    The primary purpose of the SOR is to ensure that no IRs are counted 
by the Medicare program as more than one full-time equivalent (FTE) 
employee in the calculation of payments for the costs of direct 
graduate medical education (GME) and indirect medical education (IME). 
Information retrieved from this SOR will also be disclosed to: support 
regulatory, reimbursement, and policy functions performed within the 
Agency or by a contractor or consultant, providers and suppliers of 
services, third-party contacts where necessary to establish or verify 
information, another Federal and/or state agency, agency of a state 
government, an agency established by state law, or its fiscal agent, 
support constituent requests made to a congressional representative, 
support litigation involving the Agency, and combat fraud and abuse in 
certain health benefits 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.

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 24, 2002. To ensure that all 
parties have adequate time in which to comment, the modified or altered 
SOR, 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 (DDLD), 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 am.-3 pm., Eastern 
daylight time.

FOR FURTHER INFORMATION CONTACT: Milton Jacobson, Division of Financial 
Integrity, Office of Financial Management, CMS, Room C3-14-00, 7500 
Security Boulevard, Baltimore, Maryland 21244-1850. The telephone 
number is 410-786-7553.

SUPPLEMENTARY INFORMATION:

I. Description of the Modified System

A. Statutory and Regulatory Basis for the SOR

    In 1990, CMS established a SOR under the authority of sections 
1886(d)(5)(B) and 1886(h) of the Social Security Act (the Act) (42 
U.S.C. 1395ww(d)(5)(B) and 1395ww(h)). Notice of this system, ``Intern 
and Resident Information System,'' System No. 09-70-0524, was published 
in the Federal Register (FR) at 55 FR 51163-51165 (Dec. 12, 1990). An 
unnumbered routine use was added for SSA at 61 FR 6645 (Feb. 21, 1996), 
three new fraud and abuse routine uses were added at 63

[[Page 48190]]

FR 38414 (July 16, 1998), and then at 65 FR 50552 (Aug. 18, 2000), two 
of the fraud and abuse routine uses was revised and a third deleted. 
This system was established to ensure that no IRs are counted by the 
Medicare program as more than one FTE employee in the calculation of 
payments for the costs of direct GME and IME. The system contains 
information on IRs in accordance with 42 CFR 413.86(I) for GME and 42 
CFR 412.105(f)(2) for IME. This information includes names and social 
security numbers of IRs who worked at the hospital in approved GME 
programs during the hospital's cost reporting period. It also discloses 
information on each IRs medical specialty (e.g., type of residency 
program), and the number of years each IRs has completed in all types 
of residency programs. Hospitals are required to submit the information 
on IRIS diskettes along with their cost reports to their fiscal 
intermediaries (FI) in accordance with 42 CFR 413.24(f)(5)(I).
    The FIs are the primary user of information from IRIS diskettes. 
They use the information to detect duplicates of IRs being over 
reported by two or more of their serviced hospitals. FIs with confirmed 
duplicates of over reported IR at their serviced hospitals can make 
adjustments to FTE counts of these IRs on cost report settlements.
    The FI also use IRIS diskettes for transmitting data on 
consolidated diskettes to CMS. CMS uploads the data into its mainframe 
computer for data storage and retrieval purposes. The computer is used 
to create duplicate reports of over reported IRs for the FI and CMS.

II. Collection and Maintenance of Data in the System

A. Scope of the Data Collected

    The system includes the following information for each IR: name, 
social security number; name of medical, osteopathic, or podiatric 
school graduated from and date of graduation, type of dental degree and 
date of graduation, type of residency program for the medical 
specialty, number of years completed in all types of residency 
programs, foreign medical school graduation date and certification 
date, name of employer (e.g., hospital, university, corporation) paying 
the salary, the percentage of time spent working in either the 
inpatient areas of the hospital subject to the Prospective Payment 
System or in the outpatient areas of the hospital or in a non-hospital 
setting under agreement with the hospital for IME, the percentage of 
time spent working in any area of the hospital complex or in a non-
provider setting under agreement with the hospital for GME, the start 
and end dates assigned to the hospital and any hospital-based providers 
(assignment periods) during the hospital's cost reporting period, the 
start and end dates assigned to any non-hospital or non-provider 
setting in connection with approved residency programs (assignment 
periods) during the hospital's cost reporting period, and the full-time 
or part-time percentage during each assignment period.

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 IRIS 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 disclose the minimum personal data necessary to 
achieve the purpose of IRIS. 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 to the extent necessary to accomplish the purpose of 
the disclosure and only after CMS:
    1. Determines that the use or disclosure is consistent with the 
reason data is being collected; e.g., that no IRs are counted by the 
Medicare program as more than one full-time equivalent (FTE) employee 
in the calculation of payments for the costs of direct graduate medical 
education (GME) and indirect medical education (IME).
    2. Determines that the purpose for which the disclosure is to be 
made can only be accomplished if the record is provided in individually 
identifiable form;
    a. 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
    b. 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 patient-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 IRIS 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 use 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 SOR 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 SOR.
    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.
    2. To providers and suppliers of services (and their authorized 
billing agents) directly or dealing through fiscal intermediaries or 
carriers, for

[[Page 48191]]

administration of provisions of Title XVIII of the Social Security Act.
    We contemplate disclosing information under this routine use only 
in situations in which CMS may enter into a contractual agreement with 
providers and suppliers of services to assist in accomplishing CMS 
functions relating to purposes for this SOR.
    3. To third-party contacts where necessary to establish or verify 
information provided on or by IRs.
    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 CMS functions 
relating to purposes for this system of records.
    4. To another Federal or state agency, agency of a state 
government, an agency established by state law, or its fiscal agent:
    a. To contribute to the accuracy of CMS's proper payment of 
Medicare benefits,
    b. To 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.
    Other Federal or state agencies in their administration of a 
Federal health program may require IRIS information in order to support 
evaluations and monitoring of reimbursement for services provided.
    SSA may require IRIS data to enable it to assist in the 
implementation and maintenance of the Medicare program.
    State licensing boards may require IRIS data to enable them to 
assist in the review of activities related to IRs in their state.
    The Medicare Payment Advisory Commission and Congressional Budget 
Office may require IRIS data to assist in certain budgetary and 
planning activities related to IR status.
    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.
    Individuals may 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 FIs 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 IRIS information for the purpose of 
combating fraud and abuse in such Federally funded programs.

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 IRIS 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 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 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,

[[Page 48192]]

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 patient 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 
IRIS 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 
which grant 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.
    There are several levels of security found in the IRIS system. 
Windows NT provides much of the overall system security. The Windows NT 
security model is designed to meet the C2-level criteria as defined by 
the U.S. Department of Defense's Trusted Computer System Evaluation 
Criteria document (DoD 5200.28-STD, December 1985). Netscape Enterprise 
Server is the security mechanism for all transmission connections to 
the system. As a result, Netscape controls all information access 
requests. Anti-virus software is applied at both the workstation and NT 
server levels.
    Access to different areas on the Windows NT server are maintained 
through the use of file, directory and share level permissions. These 
different levels of access control provide security that is managed at 
the user and group level within the NT domain. The file and directory 
level access controls rely on the presence of an NT File System hard 
drive partition. This provides the most robust security and is tied 
directly to the file system. Windows NT security is applied at both the 
workstation and NT server levels.

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 SOR 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 IRIS data. IRIS 
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 IRIS 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 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 24, 2002.
Thomas A. Scully,
Administrator, Centers for Medicare & Medicaid Services.
System No. 09-70-0524

SYSTEM NAME:
    ``Intern and Resident Information System (IRIS),'' HHS/CMS/OFM.

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:
    Interns and residents (IRs) in programs approved under 42 CFR

[[Page 48193]]

413.85, working in all areas of the hospital complex, or other 
freestanding providers, as well as non-hospital or non-provider 
settings on or after July 1, 1985.

CATEGORIES OF RECORDS IN THE SYSTEM:
    The system includes the following information for each IR: name, 
social security number, name of medical, osteopathic, or podiatric 
school graduated from and date of graduation, type of dental degree and 
date of graduation, type of residency program for the medical 
specialty, number of years completed in all types of residency 
programs, foreign medical school graduation date and certification 
date, name of employer (e.g., hospital, university, corporation) paying 
the salary, the percentage of time spent working in either the 
inpatient areas of the hospital subject to PPS or in the outpatient 
areas of the hospital or in a non-hospital setting under agreement with 
the hospital for IME, the percentage of time spent working in any area 
of the hospital complex or in a non-provider setting under agreement 
with the hospital for GME, the start and end dates assigned to the 
hospital and any hospital-based providers (assignment periods) during 
the hospital's cost reporting period, the start and end dates assigned 
to any non-hospital or non-provider setting in connection with approved 
residency programs (assignment periods) during the hospital's cost 
reporting period, and the full-time or part-time percentage during each 
assignment period.

AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
    Authority for maintenance of the system is given under the 
provisions of Secs. 1886(d)(5)(B) and 1886 (h) of (the Act) (42 U.S.C. 
195ww(d)(5)(B) and 1395ww (h).

PURPOSE(S) OF THE SYSTEM:
    The primary purpose of the system of records is to ensure that no 
IRs is counted by the Medicare program as more than one FTE employee in 
the calculation of payments for the costs of direct GME and IME. 
Information retrieved from this system of records will also be 
disclosed to: providers and suppliers of services, third-party contacts 
where necessary to establish or verify information, support regulatory, 
reimbursement, and policy functions performed within the Agency or by a 
contractor or consultant, another Federal or state agency to enable 
such agency to administer a Federal health benefits program, or 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, support constituent requests made to a 
congressional representative, support litigation involving the Agency, 
and combat fraud and abuse in certain health benefits 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 IRIS 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 have provided a 
brief explanation of the routine uses we are proposing to establish or 
modify for disclosures of information maintained in the system:
    1. To Agency contractors, or consultants 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.
    2. To providers and suppliers of services (and their authorized 
billing agents) directly or dealing through fiscal intermediaries or 
carriers, for administration of provisions of Title XVIII.
    3. To third-party contacts where necessary to establish or verify 
information provided on or by IRs.
    4. To another Federal or state agency, agency of a state 
government, an agency established by state law, or its fiscal agent:
    a. To contribute to the accuracy of CMS's proper payment of 
Medicare benefits, and/or
    b. To 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.
    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 FIs 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 name and social security number of 
the IR.

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.

[[Page 48194]]

    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 IRIS. 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. Systems securities are 
established in accordance with the Department of Health and Human 
Services (HHS), Information Resource Management Circular 10, 
Automated Information Systems Security Program; CMS Automated 
Information Systems Guide, Systems Securities Policies, and OMB 
Circular No. A-130 (revised), Appendix III.

RETENTION AND DISPOSAL:
    Records are maintained in a secure storage area with identifiers. 
Disposal occurs three years from the last action on the hospital's cost 
report, and should be coordinated with disposal of the reports.

SYSTEM MANAGER AND ADDRESS:
    Director, Division of Financial Integrity, Office of Financial 
Management, CMS, 7500 Security Boulevard, C3-14-00, Baltimore, Maryland 
21244-1850.

NOTIFICATION PROCEDURE:
    For purpose of access, the subject individual should write to the 
systems manager who will require the system name, SSN, address, date of 
birth, sex, and for verification purposes, the subject individual's 
name (woman's maiden name, if applicable). 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:
    Data for this system is collected from IRIS diskettes as 
transmitted by the hospitals.

SYSTEMS EXEMPTED FROM CERTAIN PROVISIONS OF THE ACT:
    None.

[FR Doc. 02-18169 Filed 7-22-02; 8:45 am]
BILLING CODE 4120-03-P