[Federal Register Volume 69, Number 241 (Thursday, December 16, 2004)]
[Notices]
[Pages 75323-75329]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-27530]
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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).
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 Hearings
and Appeals System (MHAS), System No. 09-70-5001.'' We propose to
broaden the scope of this system to support additional levels of claim
determination appeals administered by CMS pursuant to Title XVIII of
the Social Security Act (the Act). We propose to change the name of the
system from MHAS to the ``Medicare Appeals System'' (MAS) to more
closely reflect the new and broadened scope of activities that will
become a part of this system. We propose to further broaden the scope
of this system with the inclusions of support for appeals processes for
both the Medicare Fee-for-Service (FFS) appeals at the Qualified
Independent Contractors (QIC) and Medicare Advantage appeals at the
Independent Review Entity (IRE) Second Level Appeal. As an orderly
timetable will permit, CMS will explore the possibility of extending
the scope of MAS to include all five appeal levels:
Affiliated Contractors (Carriers and Fiscal Intermediaries) and
Medicare Advantage Organizations (MAO)--the First Level Appeal; QIC and
IRE--the Second Level Appeal; ALJ Hearing--the Third Level Appeal;
Medicare Departmental Appeals Board (DAB) Hearing--the Fourth Level
Appeal; and Federal District Court Judicial Review--the Fifth Level
Appeal.
In the interim, before deployment of the MAS, CMS has developed a
mid-tier, client server-based system known as the Medicare Case
Tracking System (MCATS). MCATS will be utilized if the MAS is not
available to collect and track appeals data, including status,
timelines, and decision data. It has the capability to provide summary
reports for data analysis, and will comply with applicable security and
privacy rules, regulations, and policies.
We propose to broaden the scope of activities covered by this
system with the inclusion of related activities presented in the 2
published CMS systems identified below: (1) ``Reconsideration and
Hearing Case Files (Part A)--Hospital Insurance Program,'' System No.
09-70-0508 (published 47 FR 45725 (Oct. 13, 1982)), and (2) ``Review
and Fair Hearing Case Files (Part B)--Supplementary Medical Insurance
Program,'' System No. 09-70-0512 (47 FR 45727 (Oct. 13, 1982)). These 2
systems will be discontinued with the completion of this proposed
[[Page 75324]]
modification to MAS since they will duplicate many of the same
functions.
We propose to delete published routine use number 4 authorizing
disclosure to the Department of Justice (DOJ), and an unnumbered
routine use authorizing disclosure to SSA. Access to the data for these
activities will be accomplished by the addition of a new routine use
authorizing release of information in this system to ``another Federal
agency.'' In addition, we propose to add a new routine use for QIO to
ensure that payment is only made for medically necessary services and
to investigate beneficiary complaints about quality of care. We will
also add 2 new routine uses to combat fraud and abuse in certain health
care programs.
The security classification previously reported as ``None'' will be
modified to reflect that the data in this system is considered to be
``Level Three Privacy Act Sensitive.'' We are modifying the language in
the remaining routine uses to provide an easy to read format and to
increase uniformity where appropriate 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 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 purposes of the system is to collect and maintain
information necessary to: (1) Process the initial, organization, and
reconsidered determination requests, ``Request For Hearing or Appeal,''
made by an appellant or appealing party, as required for the review of
determinations by FFS and MAOs; (2) track appeal data, including
status, timeliness, and decisions; and (3) reply to future
correspondence related to the case. Information in this system will
also be disclosed to: support regulatory and policy functions performed
within the Agency or by a contractor or consultant; assist another
Federal agency; assist QIO; support constituent requests made to a
congressional representative; support litigation involving the agency
related to this SOR; 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.
DATES: 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 October 1, 2004. To ensure
that all parties have adequate time in which to comment, the modified
or altered SOR, including routine uses, will become effective 30 days
from the publication of the notice, or 40 days 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
Privacy Compliance Data Development, Enterprises 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: Michael Crochunis, Director, Division
of Appeals Operations, Health Plan Policy Group, Center for Beneficiary
Choices, CMS, Room S1-05-06, 7500 Security Boulevard, Baltimore,
Maryland 21244-1850. The telephone number is 410-786-3203.
SUPPLEMENTARY INFORMATION:
I. Description of the Modified System
Statutory and Regulatory Basis for SOR
In 1987, CMS established this SOR under the authority of sections
205, 1155, 1156, 1869, and 1872 of the Act. Notice of this system,
``Medicare Hearings and Appeals Systems (MHAS), System No. 09-70-
5001,'' was published at 52 FR 34846 (Sept. 15, 1987), and an
unnumbered routine use for disclosure to SSA was added at 61 FR 6645
(Feb. 21, 1996). Additional authority for the maintenance of this
system is given under of sections 205 of Title II, sections 1155 and
1156 of Title XI, sections 1812, 1814, 1816, 1842, 1869, and 1872 of
Title XVIII of the Act, as amended (42 United States Code (U.S.C.)
sections 405, 1320c-4, 1320c-5, 1395d, 1395f, 1395h, 1395u, 1395ff, and
1395ii).
II. Collection and Maintenance of Data in the System
A. Scope of the Data Collected
The system contains information concerning Medicare beneficiaries,
physicians, providers, and other persons involved in furnishing
services to health insurance beneficiaries. Information on
beneficiaries consist of name, address, social security numbers (SSN),
health insurance claims numbers (HICN), medical services, equipment and
supplies for which Medicare reimbursement is requested, and materials
used to determine amount of benefits allowable under Medicare.
Information on appellants, physicians, and other persons consist of
name, work address, work phone number, an assigned provider
identification number, specialty, medical services for which Medicare
reimbursement is requested, and materials used to determine amounts of
benefits allowable under Medicare.
B. Agency Policies, Procedures, and Restrictions on the Routine Uses
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 MAS 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 MAS. 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 appellant's hearing or
appeal, to track a particular case, 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
[[Page 75325]]
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, legally permissible-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 MAS 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 support 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 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 all information that 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 assist another Federal agency in the accomplishment of a CMS
function relating to the purposes for this SOR and who need to have
access to the records in order to support CMS.
DOJ may require MAS data to assist them in investigating and
prosecuting violations of the Act to which criminal penalties attach,
or other criminal statutes as they pertain to certain programs
authorized by the Act, and for representing the Secretary of the
Department of Health and Human Services.
We contemplate disclosing information under this routine use only
in situations in which CMS may enter into a contractual or similar
agreement with another Federal agency to assist in accomplishing CMS
functions relating to purposes for this SOR.
3. To assist Quality Improvement Organizations in 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 ensure that payment is
only made for medically necessary services. QIOs will assist in related
monitoring and enforcement efforts, assist CMS and intermediaries in
program integrity assessment, investigate beneficiary complaints about
quality of care, and prepare summary information for release to CMS.
4. To support 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 sometimes request the help of a Member of Congress in
resolving some 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.
5. To support 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.
6. To support 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.
7. To support 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,
[[Page 75326]]
remedy, or otherwise combat fraud or abuse in such programs.
Other agencies may require MAS information for the purpose of
combating fraud and abuse in such Federally funded programs.
B. Additional Circumstances Affecting Routine Use Disclosures
This system 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),
Subparts A and E. 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 data
not directly identifiable, except pursuant to one of the routine uses
or if required by law, if we determine there is a possibility that an
individual can be identified through implicit deduction based on data
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
CMS has safeguards in place 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
information security requirements. Employees who maintain records in
this system are instructed not to release data until the intended
recipient agrees to implement appropriate management, operational and
technical safeguards sufficient to protect the confidentiality,
integrity and availability of the information and information systems
and to prevent unauthorized access.
This system will conform to all applicable Federal laws and
regulations and Federal, HHS and CMS policies and standards as they
relate to information security and data privacy. These laws and
regulations include but are not limited to: the Privacy Act of 1974;
the Federal Information Security Management Act of 2002; the Computer
Fraud and Abuse Act of 1986; the Health Insurance Portability and
Accountability Act of 1996; the E-Government Act of 2002, the Clinger-
Cohen Act of 1996; the Medicare Modernization Act of 2003, and the
corresponding implementing regulations. OMB Circular A-130, Management
Of Federal Resources, Appendix III, Security of Federal Automated
Information Resources also applies. Federal, HHS, and CMS policies and
standards include but are not limited to: All pertinent NIST
publications; the HHS Automated Information Systems Security Handbook
and the CMS Information Security Handbook.
V. Effect of the Modified System 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. We will only
disclose the minimum personal data necessary to achieve the purpose of
MAS. Disclosure of information from the SOR will be approved only to
the extent necessary to accomplish the purpose of the disclosure. CMS
has assigned a higher level of security clearance for the information
in this system to provide added security and protection of data in this
system.
CMS will take precautionary measures 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 from the proposed 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: October 1, 2004.
Mark B. McClellan,
Administrator, Centers for Medicare & Medicaid Services.
System No. 09-70-5001
System Name:
``Medicare Appeals System (MAS),'' HHS/CMS/CBC.
Security Classification:
Level Three Privacy Act Sensitive.
System Location:
CMS Data Center, 7500 Security Boulevard, North Building, First
Floor, Baltimore, Maryland 21244-1850. This system is also located in
locations listed in appendix A.
Categories of Individuals Covered By the System:
The system contains information concerning Medicare beneficiaries,
and physicians and other persons involved in furnishing services to
health insurance beneficiaries.
Categories of Records in the System:
Information contained in this system include beneficiary's name,
address, social security number (SSN), health insurance claims number
(HICN), medical services, equipment, and supplies for which Medicare
reimbursement is requested, and materials used to determine amount of
benefits allowable under Medicare. Information on physicians and other
persons consists of name, work address, work phone number, an assigned
provider identification number, specialty, medical services for which
Medicare reimbursement is requested, materials used to determine
amounts of benefits allowable under Medicare.
Authority for Maintenance of the System:
Authority for the maintenance of this SOR is given under section
205 of Title II, sections 1155 and 1156 of Title XI, sections 1812,
1814, 1816, 1842, 1869, and 1872 of Title XVIII of the Social Security
Act (the Act), as amended (42 United States Code (U.S.C.) sections 405,
1320c-4, 1320c-5, 1395d, 1395f, 1395h, 1395u, 1395ff, and 1395ii).
Purpose(s) of the System:
The primary purpose of the system is to collect and maintain
information necessary to: (1) Process the initial, organization, and
reconsidered determination requests, ``Request For Hearing or Appeal,''
made by an appellant or appealing party, as required for the review of
determinations by Fee-for-Service and Medicare Advantage Organizations;
(2) track appeal data, including status, timeliness, and decisions; and
(3) reply to future correspondence related to the case. Information in
this system will also be disclosed to: support regulatory and policy
functions performed within the Agency or by a contractor or consultant;
assist another Federal agency; assist QIO; support constituent requests
made to a congressional representative; support litigation involving
the agency related to this SOR; and, combat fraud and abuse in certain
health benefits programs.
[[Page 75327]]
Routine Uses of Records Maintained in the System, Including Categories
or Users and the Purposes of Such Uses
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 MAS 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 support 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 SOR and who need to have access to
the records in order to assist CMS.
2. To assist another Federal agency in the accomplishment of a CMS
function relating to the purposes for this SOR and who need to have
access to the records in order to support CMS.
3. To assist Quality Improvement Organizations in 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.
4. To assist 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.
5. To assist 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.
6. To assist 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.
7. To assist 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.
B. Additional Circumstances Affecting Routine Use Disclosures
This system 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)),
Subparts A and E. 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 data
not directly identifiable, except pursuant to one of the routine uses
or if required by law, if we determine there is a possibility that an
individual can be identified through implicit deduction based on data
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.
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, HICN, and assigned
provider number.
Safeguards:
CMS has safeguards in place 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
information security requirements. Employees who maintain records in
this system are instructed not to release data until the intended
recipient agrees to implement appropriate management, operational and
technical safeguards sufficient to protect the confidentiality,
integrity and availability of the information and information systems
and to prevent unauthorized access.
This system will conform to all applicable Federal laws and
regulations and Federal, HHS, and CMS policies and standards as they
relate to information security and data privacy. These laws and
regulations include but are not limited to: the Privacy Act of 1974;
the Federal Information Security Management Act of 2002; the Computer
Fraud and Abuse Act of 1986; the Health Insurance Portability and
Accountability Act of 1996; the E-Government Act of 2002, the Clinger-
Cohen Act of 1996; the Medicare Modernization Act of 2003, and the
corresponding implementing regulations. OMB Circular A-130, Management
Of Federal Resources, Appendix III, Security of Federal Automated
Information Resources also applies. Federal, HHS, and CMS policies and
standards include but are not limited to: all pertinent NIST
publications; the HHS Automated Information Systems Security Handbook
and the CMS Information Security Handbook.
Retention and Disposal:
Records are maintained in a secure storage area with identifiers.
Disposal occurs ten years after the final determination of the case is
completed.
System Manager and Address:
Director, Division of Appeals Operations, Health Plan Policy Group,
Center for Beneficiary Choices, CMS, Room S1-05-06, 7500 Security
Boulevard, 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, HICN, address, date of
birth, and sex, and for verification purposes, the subject individual's
name (woman's maiden name, if applicable), social security number
(SSN). Furnishing the SSN is voluntary, but it may make searching for a
record easier and prevent delay.
[[Page 75328]]
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 include
data collected from the individual on the completed form requesting a
Medicare hearing or appeal. In addition, information contained in this
SOR may be obtained from Medicare carriers or intermediaries and
Quality Improvement Organizations records.
Systems Exempted From Certain Provisions of the Act:
None.
Appendix A. Health Insurance Claims
Medicare records are maintained at the CMS Central Office (see
section 1 below for the address). Health Insurance Records of the
Medicare program can also be accessed through a representative of
the CMS Regional Office (see section 2 below for addresses).
Medicare claims records are also maintained by private insurance
organizations that share in administering provisions of the health
insurance programs. These private insurance organizations, referred
to as carriers and intermediaries, are under contract to the Centers
for Medicare & Medicaid Services to perform specific task in the
Medicare program (see section three below for addresses for
intermediaries, section four addresses the carriers, and section
five addresses the Payment Safeguard Contractors.
1. Central Office Address
CMS Data Center, 7500 Security Boulevard, North Building, First
Floor, Baltimore, Maryland 21244-1850.
2. CMS Regional Offices
BOSTON REGION--Connecticut, Maine, Massachusetts, New
Hampshire, Rhode Island, Vermont. John F. Kennedy Federal Building,
Room 1211, Boston, Massachusetts 02203. Office Hours: 8:30 a.m.-5
p.m.
NEW YORK REGION--New Jersey, New York, Puerto Rico,
Virgin Islands. 26 Federal Plaza, Room 715, New York, New York
10007, Office Hours: 8:30 a.m.-5 p.m.
PHILADELPHIA REGION--Delaware, District of Columbia,
Maryland, Pennsylvania, Virginia, West Virginia. Post Office Box
8460, Philadelphia, Pennsylvania 19101. Office Hours: 8:30 a.m.-5
p.m.
ATLANTA REGION--Alabama, North Carolina, South
Carolina, Florida, Georgia, Kentucky, Mississippi, Tennessee. 101
Marietta Street, Suite 702, Atlanta, Georgia 30223, Office Hours:
8:30 a.m.-4:30 p.m.
CHICAGO REGION--Illinois, Indiana, Michigan, Minnesota,
Ohio, Wisconsin. Suite A--824, Chicago, Illinois 60604. Office
Hours: 8 a.m.-4:45 p.m.
DALLAS REGION--Arkansas, Louisiana, New Mexico,
Oklahoma, Texas, 1200 Main Tower Building, Dallas, Texas. Office
Hours: 8 a.m.-4:30 p.m.
KANSAS CITY REGION--Iowa, Kansas, Missouri, Nebraska.
New Federal Office Building, 601 East 12th Street--Room 436, Kansas
City, Missouri 64106. Office Hours: 8 a.m.-4:45 p.m.
DENVER REGION--Colorado, Montana, North Dakota, South
Dakota, Utah, Wyoming. Federal Office Building, 1961 Stout St--Room
1185, Denver, Colorado 80294. Office Hours: 8 a.m.-4:30 p.m.
SAN FRANCISCO REGION--American Samoa, Arizona,
California, Guam, Hawaii, Nevada. Federal Office Building, 10 Van
Ness Avenue, 20th Floor, San Francisco, California 94102. Office
Hours: 8 a.m.-4:30 p.m.
SEATTLE REGION--Alaska, Idaho, Oregon, Washington. 1321
Second Avenue, Room 615, Mail Stop 211, Seattle, Washington 98101.
Office Hours: 8 a.m.-4:30 p.m.
3. Intermediary Addresses (Hospital Insurance)
Medicare Coordinator, Assoc. Hospital Serv. Maine (ME
BC), 2 Gannett Drive South Portland, ME 04106-6911.
Medicare Coordinator, Anthem New Hampshire, 300 Goffs
Falls Road, Manchester, NH 03111-0001.
Medicare Coordinator, BC/BS Rhode Island (RI BC), 444
Westminster Street, Providence, RI 02903-3279.
Medicare Coordinator, Empire Medicare Services, 400 S.
Salina Street, Syracuse, NY 13202.
Medicare Coordinator, Cooperativa, P.O. Box 363428, San
Juan, PR 00936-3428.
Medicare Coordinator, Maryland B/C, P.O. Box 4368, 1946
Greenspring Ave., Timonium, MD 21093.
Medicare Coordinator, Highmark, P5103, 120 Fifth Avenue
Place, Pittsburgh, PA 15222-3099.
Medicare Coordinator, United Government Services, 1515
N. Rivercenter Dr., Milwaukee, WI 53212.
Medicare Coordinator, Alabama B/C, 450 Riverchase
Parkway East, Birmingham, AL 35298.
Medicare Coordinator, Florida B/C, 532 Riverside Ave.,
Jacksonville, FL 32202-4918.
Medicare Coordinator, Georgia B/C, P.O. Box 9048, 2357
Warm Springs Road, Columbus, GA 31908.
Medicare Coordinator, Mississippi B/C B MS, P.O. Box
23035, 3545 Lakeland Drive, Jackson, MI 9225-3035.
Medicare Coordinator, North Carolina B/C, P.O. Box
2291, Durham, NC 27702-2291.
Medicare Coordinator, Palmetto GBA A/RHHI, 17
Technology Circle, Columbia, SC 29203-0001.
Medicare Coordinator, Tennessee B/C, 801 Pine Street,
Chattanooga, TN 37402-2555.
Medicare Coordinator, Anthem Insurance Co. (Anthm IN),
P.O. Box 50451, 8115 Knue Road, Indianapolis, IN 46250-1936.
Medicare Coordinator, Arkansas B/C, 601 Gaines Street,
Little Rock, AR 72203.
Medicare Coordinator, Group Health of Oklahoma, 1215
South Boulder, Tulsa, OK 74119-2827.
Medicare Coordinator, TrailBlazer, P.O. Box 660156,
Dallas, TX 75266-0156.
Medicare Coordinator, Cahaba GBA, Station 7, 636 Grand
Avenue, Des Moines, IA 50309-2551.
Medicare Coordinator, Kansas B/C, P.O. Box 239, 1133
Topeka Ave., Topeka, KS 66629-0001.
Medicare Coordinator, Nebraska B/C, P.O. Box 3248, Main
PO Station, Omaha, NE 68180-0001.
Medicare Coordinator, Mutual of Omaha, P.O. Box 1602,
Omaha, NE 68101.
Medicare Coordinator, Montana B/C, P.O. Box 5017, Great
Falls Div., Great Falls, MT 59403-5017.
Medicare Coordinator, Noridian, 4510 13th Avenue S.W.,
Fargo, ND 58121-0001.
Medicare Coordinator, Utah B/C, P.O. Box 30270, 2455
Parleys Way, Salt Lake City, UT 84130-0270.
Medicare Coordinator, Wyoming B/C, 4000 House Avenue,
Cheyenne, WY 82003.
Medicare Coordinator, Arizona B/C, P.O. Box 37700,
Phoenix, AZ 85069.
Medicare Coordinator, UGS, P.O. Box 70000, Van Nuys, CA
91470-0000.
Medicare Coordinator, Regents BC, P.O. Box 8110 M/S D-
4A, Portland, OR 97207-8110.
Medicare Coordinator, Premera BC, P.O. Box 2847,
Seattle, WA 98111-2847.
4. Medicare Carriers
Medicare Coordinator, NHIC, 75 Sargent William Terry
Drive, Hingham, MA 02044.
Medicare Coordinator, B/S Rhode Island (RI BS), 444
Westminster Street, Providence, RI 02903-2790.
Medicare Coordinator, Trailblazer Health Enterprises,
Meriden Park, 538 Preston Ave., Meriden, CT 06450.
Medicare Coordinator, Upstate Medicare Division, 11
Lewis Road, Binghamton, NY 13902.
Medicare Coordinator, Empire Medicare Services, 2651
Strang Blvd., Yorktown Heights, NY 10598.
Medicare Coordinator, Empire Medicare Services, NJ, 300
East Park Drive, Harrisburg, PA 17106.
Medicare Coordinator, Triple S, 1441 F.D.,
Roosevelt Ave., Guaynabo, PR 00968.
Medicare Coordinator, Group Health Inc., 4th Floor, 88
West End Avenue, New York, NY 10023.
Medicare Coordinator, Highmark, P.O. Box 89065, 1800
Center Street, Camp Hill, PA 17089-9065.
Medicare Coordinator, Trailblazers Part B, 11150
McCormick Drive, Executive Plaza 3 Suite 200, Hunt Valley, MD 21031.
[[Page 75329]]
Medicare Coordinator, Trailblazer Health Enterprises,
Virginia, P.O. Box 26463, Richmond, VA 23261-6463. United Medicare
Coordinator, Tricenturion, 1 Tower Square, Hartford, CT 06183.
Medicare Coordinator, Alabama B/S, 450 Riverchase
Parkway East, Birmingham, AL 35298.
Medicare Coordinator, Cahaba GBA, 12052 Middleground
Road, Suite A, Savannah, GA 31419.
Medicare Coordinator, Florida B/S, 532 Riverside Ave,
Jacksonville, FL 32202-4918.
Medicare Coordinator, Administar Federal, 9901
Linnstation Road, Louisville, KY 40223.
Medicare Coordinator, Palmetto GBA, 17 Technology
Circle, Columbia, SC 29203-0001.
Medicare Coordinator, CIGNA, 2 Vantage Way, Nashville,
TN 37228.
Medicare Coordinator, Railroad Retirement Board, 2743
Perimeter Parkway, Building 250, Augusta, GA 30999.
Medicare Coordinator, Cahaba GBA, Jackson Miss, P.O.
Box 22545, Jackson, MI 39225-2545.
Medicare Coordinator, Adminastar Federal (IN), 8115
Knue Road, Indianapolis, IN 46250-1936.
Medicare Coordinator, Wisconsin Physicians Service,
P.O. Box 8190, Madison, WI 53708-8190.
Medicare Coordinator, Nationwide Mutual Insurance Co.,
P.O. Box 16788, 1 Nationwide Plaza, Columbus, Oh 3216-6788.
Medicare Coordinator, Arkansas B/S, 601 Gaines Street,
Little Rock, AR 72203.
Medicare Coordinator, Arkansas-New Mexico, 601 Gaines
Street, Little Rock, AR 72203.
Medicare Coordinator, Palmetto GBA--DMERC, 17
Technology Circle, Columbia, SC 29203-0001.
Medicare Coordinator, Trailblazer Health Enterprises,
901 South Central Expressway, Richardson, TX 75080.
Medicare Coordinator, Nordian, 636 Grand Avenue, Des
Moines, IA 50309-2551.
Medicare Coordinator, Kansas B/S, P.O. Box 239, 1133
Topeka Ave., Topeka, KS 66629-0001.
Medicare Coordinator, Kansas B/S--NE, P.O. Box 239,
1133 Topeka Ave., Topeka, KS 66629-0239.
Medicare Coordinator, Montana B/S, P.O. Box 4309,
Helena, MT 59601.
Medicare Coordinator, Nordian, 4305 13th Avenue South,
Fargo, ND 58103-3373.
Medicare Coordinator, Noridian BCBSND (CO), 730 N.
Simms 100, Golden, CO 80401-4730.
Medicare Coordinator, Noridian BCBSND (WY), 4305 13th
Avenue South, Fargo, ND 58103-3373.
Medicare Coordinator, Utah B/S, P.O. Box 30270, 2455
Parleys Way, Salt Lake City, UT 84130-0270.
Medicare Coordinator, Transamerica Occidental, P.O. Box
54905, Los Angeles, CA 90054-4905.
Medicare Coordinator, NHIC--California, 450 W. East
Avenue, Chico, CA 95926.
Medicare Coordinator, Cigna, Suite 254, 3150
Lakeharbor, Boise, ID 83703.
Medicare Coordinator, Cigna, Suite 506, 2 Vantage Way,
Nashville, TN 37228.
5. Payment Safeguard Contractors
Medicare Coordinator, Aspen Systems Corporation, 2277
Research Blvd., Rockville, MD 20850.
Medicare Coordinator, DynCorp Electronic Data Systems
(EDS), 11710 Plaza America Drive 5400 Legacy Drive, Reston, VA
20190-6017.
Medicare Coordinator, Lifecare Management Partners
Mutual of Omaha Insurance Co. 6601 Little River Turnpike, Suite 300
Mutual of Omaha Plaza, Omaha, NE 68175.
Medicare Coordinator, Reliance Safeguard Solutions,
Inc., P. O. Box 30207 400 South Salina Street, 2890 East Cottonwood
Pkwy. Syracuse, NY 13202.
Medicare Coordinator, Science Applications
International, Inc., 6565 Arlington Blvd. P. O. Box 100282, Falls
Church, VA.
Medicare Coordinator, California Medical Review, Inc.
Integriguard Division Federal Sector Civil Group One Sansome Street,
San Francisco, CA 94104-4448.
Medicare Coordinator, Computer Sciences Corporation
Suite 600 3120 Timanus Lane, Baltimore, MD 21244.
Medicare Coordinator, Electronic Data Systems (EDS),
11710 Plaza America Drive 5400 Legacy Drive, Plano, TX 75204.
Medicare Coordinator, TriCenturion, L.L.C., P. O. Box
100282, Columbia, SC 29202.
[FR Doc. 04-27530 Filed 12-15-04; 8:45 am]
BILLING CODE 4120-03-P