[Federal Register Volume 69, Number 197 (Wednesday, October 13, 2004)]
[Notices]
[Pages 60883-60884]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-22902]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services


Privacy Act of 1974; Renewal of Computer Matching Program (Match 
No. 2001-06)

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

ACTION: Notice of renewal 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 renewal of a CMP that CMS 
plans to conduct with the State of California Department of Health 
Services (DHS). 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.

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 October 1, 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, Enterprise Databases Group, Office 
of Information Services, CMS, Mail stop 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: Douglass Brown, Health Insurance 
Specialist, Division of Methods and Strategy, Program Integrity Group, 
Office of Financial Management, CMS, Mail-stop C3-02-16, 7500 Security 
Boulevard, Baltimore Maryland 21244-1850. The telephone number is (410) 
786-0028 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 (Pub. L. 
100-503), amended the Privacy Act (5 U.S.C. Sec.  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: October 1, 2004.
Mark B. McClellan,
Administrator.
Computer Match No. 2001-06

NAME:
    ``Computer Matching Agreement Between the Centers for Medicare & 
Medicaid Services (CMS) and the State of California Department of 
Health Services (DHS) 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 
California Department of Health Services.

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.) section 552a), 
as amended, 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 
(54 FR 25818, June 19, 1989).
    Authority for this matching program is given under the matching 
provisions of Sec. Sec.  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 Sec. Sec.  10740, 10748, 10750, 14000, and 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 CMS will conduct a computer 
matching program

[[Page 60884]]

with the State of California, DHS, and under which DHS will participate 
in a computer matching program with CMS, to study claims, billing, and 
eligibility information to detect suspected instances of Medicare and 
Medicaid fraud and abuse (F&A) in the State of California. CMS and DHS 
will provide Electronic Data Systems (EDS), 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 California expected to be identified in 
this matching program: (1) Billing for provision 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:
    Systems of Records (SOR).
    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 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 was 
most recently published in the Federal Register, 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, was most recently published in the Federal Register 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 in 
the Federal Register 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.
    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 Record 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. 04-22902 Filed 10-12-04; 8:45 am]
BILLING CODE 4120-03-P