[Federal Register Volume 69, Number 65 (Monday, April 5, 2004)]
[Notices]
[Pages 17673-17675]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-7629]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services


Privacy Act of 1974; Computer Matching Program (Match No. 2003-
06)

AGENCY: Centers for Medicare & Medicaid Services (CMS), Department of 
Health and Human Services (HHS).

ACTION: Notice of Computer Matching Program (CMP).

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SUMMARY: In accordance with the requirements of the Privacy Act of 
1974, as amended, this notice announces the establishment of a CMP that 
CMS plans to conduct with the New Jersey Division of Medical Assistance 
and Health Services (DMAHS). We have provided background information 
about the proposed matching program 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 
matching program, CMS invites comments on all portions of this notice. 
See EFFECTIVE DATES section below for comment period.

EFFECTIVE DATES: CMS filed a report of the CMP 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 March 23, 2004. We will not disclose any information under a 
matching agreement until 40 days after filing a report to OMB and 
Congress or 30 days after publication. We may defer implementation of 
this matching program if we receive comments that persuade us to defer 
implementation.

ADDRESSES: The public should address comments to: Director, Division of 
Privacy Compliance Data Development (DPCDD), Enterprise Databases 
Group, Office of Information Services, CMS, Mailstop 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 daylight time.

FOR FURTHER INFORMATION CONTACT: Lourdes Grindal Miller, Health 
Insurance Specialist, Centers for Medicare & Medicaid Services, Office 
of Financial Management, Program Integrity Group, Mailstop C3-02-16, 
7500 Security Boulevard, Baltimore Maryland 21244-1850. The telephone

[[Page 17674]]

number is (410) 786-1022 and e-mail is [email protected].

SUPPLEMENTARY INFORMATION:

I. Description of the Matching Program

A. General

    The Computer Matching and Privacy Protection Act of 1988 (Public 
Law(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:
    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 CMPs that this Agency 
participates in comply with the requirements of the Privacy Act of 
1974, as amended.

    Dated: March 23, 2004.
Dennis Smith,
Acting Administrator, Centers for Medicare & Medicaid Services.
Computer Match No. 2003-06

NAME:
    ``Computer Matching Agreement Between the Centers for Medicare & 
Medicaid Services (CMS) and the State of New Jersey Division of Medical 
Assistance and Health Services (DMAHS) for Disclosure of Medicare and 
Medicaid Information.''

SECURITY CLASSIFICATION:
    Level Three Privacy Act Sensitive.

PARTICIPATING AGENCIES:
    The Centers for Medicare & Medicaid Services, and State of New 
Jersey Division of Medical Assistance and Health Services.

AUTHORITY FOR CONDUCTING MATCHING PROGRAM:
    This CMA is executed to comply with the Privacy Act of 1974 (Title 
5 United States Code (U.S.C. 552a), (as amended by Public Law (Pub. L.) 
100-503, the Computer Matching and Privacy Protection Act (CMPPA) of 
1988), the Office of Management and Budget (OMB) Circular A-130, titled 
``Management of Federal Information Resources'' at 65 FR 77677 
(December 12, 2000), and OMB guidelines pertaining to computer matching 
at 54 FR 25818 (June 19, 1989).
    This Agreement provides for information matching fully consistent 
with the authority of the Secretary of the Department of Health and 
Human Services (Secretary). Section 1816 of the Social Security Act 
(the Act) permits the Secretary to contract with fiscal intermediaries 
to ``make such audits of the records of providers as may be necessary 
to ensure that proper payments are made under this part,'' and to 
``perform such other functions as are necessary to carry out this 
subsection'' (42 U.S.C. 1395h(a)).
    Section 1842 of the Act provides that the Secretary may contract 
with entities known as carriers to ``make such audits of the records of 
providers of services as may be necessary to assure that proper 
payments are made'' (42 U.S.C. 1395u(a)(1)(C)); ``assist in the 
application of safeguards against unnecessary utilization of services 
furnished by providers of services and other persons to individuals 
entitled to benefits'' (42 U.S.C. 1395u(a)(2)(B)); and ``to otherwise 
assist * * * in discharging administrative duties necessary to carry 
out the purposes of this part'' (42 U.S.C. 1395u(a)(4)).
    Furthermore, section 1874(b) of the Act authorizes the Secretary to 
contract with any person, agency, or institution to secure on a 
reimbursable basis such special data, actuarial information, and other 
information as may be necessary in the carrying out of his functions 
under this title (42 U.S.C. 1395kk(b)).
    Section 1893 of the Act establishes the Medicare Integrity Program, 
under which the Secretary may contract with eligible entities to 
conduct a variety of program safeguard activities, including fraud 
review employing equipment and software technologies that surpass the 
existing capabilities of Fiscal Intermediaries and carriers (42 U.S.C. 
1395ddd). The contracting entities are called Program Safeguards 
Contractors (PSC).
    DMAHS is charged with the administration of the Medicaid program in 
New Jersey and is the single state agency for such purpose (New Jersey 
Statutes Annotated (N.J.S.A.) Sec.  30:4D-5). DMAHS may act as an agent 
or representative of the Federal government for any purpose in 
furtherance of DMAHS's functions or administration of the Federal funds 
granted to the state. In New Jersey, DMAHS 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 New Jersey Medical Assistance 
Program (NJMAP).
    DMAHS's disclosure of data pursuant to this agreement is for 
purposes directly connected with the administration of the Medicaid 
Program, in compliance with N.J.S.A. Sec.  30:4D-7g, New Jersey 
Administrative Code 10:49-9.7(b), 42 U.S.C. 1396a(a)(7), 42 CFR 431.300 
et seq., and 45 CFR 205.50-205.60, and other applicable statutes and 
regulations. Those purposes are the detection, prosecution and 
deterrence of fraud and abuse (F&A) in the Medicaid program, and the 
enforcement of state law relating to the provisions of program 
services.

PURPOSE(S) OF THE MATCHING PROGRAM:
    The purpose of this agreement is to establish the conditions, 
safeguards, and procedures under which the Centers for Medicare & 
Medicaid Services (CMS) will conduct a computer matching program with 
the State of New Jersey, Department of Human Services (NJDHS), Division 
of Medical Assistance and Health Services (DMAHS) to study claims, 
billing, and eligibility information to detect suspected instances of 
Medicare and Medicaid fraud and abuse (F&A) in the State of New Jersey. 
CMS and NJDHS will provide Electronic Data Systems Corporation, a CMS 
contractor (hereinafter referred to as the ``Custodian''), with 
Medicare and Medicaid 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 New Jersey

[[Page 17675]]

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 DMAHS 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 New Jersey against records of 
New Jersey Medicaid beneficiaries, practitioners, providers, and 
suppliers in the State of New Jersey.

DESCRIPTION OF RECORDS TO BE USED IN THE MATCHING PROGRAM:
    The release of the data for CMS are maintained in the following 
SOR: National Claims History (NCH), System No. 09-70-0005 was most 
recently published in the Federal Register, at 67 FR 57015 (September 
6, 2002). 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 
DMAHS pursuant to the routine use as set forth in the system notice.
    Carrier Medicare Claims Record, System No. 09-70-0501 published in 
the Federal Register at 67 FR 54428 (August 22, 2002). Matched data 
will be released to DMAHS 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 67 FR 3203 (January 23, 
2002). Matched data will be released to DMAHS pursuant to the routine 
use set forth in the system notice.
    Intermediary Medicare Claims Record, System No. 09-70-0503 
published in the Federal Register at 67 FR 65982 (October 29, 2002). 
Matched data will be released to DMAHS 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, was most recently published in the Federal Register at 
53 FR 50584 (December 16, 1988). Matched data will be released to DMAHS 
pursuant to the routine use as set forth in the system notice.
    Medicare Supplier Identification File, System No. 09-70-0530 was 
most recently published in the Federal Register, at 67 FR 48184 (July 
23, 2002). Matched data will be released to DMAHS pursuant to the 
routine use as set forth in the system notice.
    Medicare Beneficiary Database, System No. 09-70-0536 published in 
the Federal Register at 67 FR 63392 (December 6, 2001). Matched data 
will be released to DMAHS pursuant to the routine use as set forth in 
the system notice.
    The data for DMAHS are maintained in the following data files: The 
data that the New Jersey Medicaid Program resides primarily on the 
Mainframe computer system of the UNISYS, the Fiscal Agent for the 
Medicaid Program. This data includes not only eligibility, and claims 
data, but also all other data necessary to process the claim such as 
client, provider, and reference information. DMAHS also maintains a 
shared Data Warehouse that contains five years of claims activity 
records in an Oracle relational database. Data from the Fiscal Agent is 
transmitted monthly to the shared Data Warehouse for use in reporting, 
analysis and decision support. All or part of these elements may be 
used in this data-matching program.

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. 04-7629 Filed 4-2-04; 8:45 am]
BILLING CODE 4120-03-P