[Federal Register Volume 71, Number 214 (Monday, November 6, 2006)]
[Notices]
[Pages 64955-64961]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E6-18611]


=======================================================================
-----------------------------------------------------------------------

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers For Medicare & Medicaid Services


Privacy Act of 1974; Report of a Modified or Altered System

AGENCY: Centers for Medicare & Medicaid Services, HHS.

ACTION: Notice of a Modified or Altered System of Records (SOR).

-----------------------------------------------------------------------

SUMMARY: In accordance with the requirements of the Privacy Act of 
1974, we are proposing to modify or alter an existing system of records 
titled ``Common Working File (CWF),'' System No. 09-70-0526,'' most 
recently modified at 67 Federal Register (FR) 3210 (January 23, 2002). 
We propose to modify existing routine use number 1 that permits 
disclosure to agency contractors and consultants to include disclosure 
to CMS grantees who perform a task for the agency. CMS grantees, 
charged with completing projects or activities that require CMS data to 
carry out that activity, are classified separate from CMS contractors 
and/or consultants. The modified routine use will remain as routine use 
number 1.
    We will delete routine use number 8 authorizing disclosure to 
support constituent requests made to a congressional representative. If 
an authorization for the disclosure has been obtained from the data 
subject, then no routine use is needed. The Privacy Act allows for 
disclosures with the ``prior written consent'' of the data subject. We 
will modify existing routine use number 5 that permits disclosure to 
Peer Review Organizations (PRO). Organizations previously referred to 
as PROs will be renamed to read: Quality Improvement Organizations 
(QIO). Information will be disclosed to QIOs relating to assessing and 
improving quality of care as well as proper payment of claims. The 
modified routine use will remain as routine use number 5. We will 
broaden the scope of routine uses number 10 and 11, authorizing 
disclosures to combat fraud and abuse in the Medicare and Medicaid 
programs to include combating ``waste'' which refers to specific 
beneficiary/recipient practices that result in unnecessary cost to all 
Federally-funded health benefit programs.
    We are modifying the language in the remaining routine uses to 
provide a proper explanation as to the need for the routine use and 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 usage. We will also take 
the opportunity to update any sections of the system that were affected 
by the recent reorganization or because of the impact of the Medicare 
Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) 
(Public Law 108-173) provisions and to update language in the 
administrative sections to

[[Page 64956]]

correspond with language used in other CMS SORs.
    The primary purpose of the system of records is to properly pay 
medical insurance benefits to or on behalf of entitled beneficiaries. 
Information in this system will also be released to: (1) Support 
regulatory and policy functions performed within the Agency or by a 
contractor, consultant, or grantee; (2) assist another Federal or State 
agency, agency of a State government, an agency established by State 
law, or its fiscal agent; (3) assist third party contacts; (4) assist 
providers and suppliers of services directly or through fiscal 
intermediaries or carriers; (5) support Quality Improvement 
Organizations (QIO) or Quality Review Organizations; (6) assist 
insurance companies and other groups providing protection for their 
enrollees, or who are primary payers to Medicare in accordance with 42 
United States Code (U.S.C.) 1395y (b); (7) support an individual or 
organization for research, evaluation, or epidemiological projects; (8) 
support litigation involving the Agency related to this system of 
records; and (9) combat fraud, waste, and abuse in certain Federally-
funded health care programs. We have provided background information 
about the modified system in the ``Supplementary Information'' section 
below. Although the Privacy Act requires only that CMS provide an 
opportunity for interested persons to comment on the 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 Homeland Security & Governmental 
Affairs, and the Administrator, Office of Information and Regulatory 
Affairs, Office of Management and Budget (OMB) on 10/30/2006. To ensure 
that all parties have adequate time in which to comment, the modified 
system, 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 Congress, whichever is later, unless CMS receives comments that 
require alterations to this notice.

ADDRESSES: The public should address comments to: CMS Privacy Officer, 
Division of Privacy Compliance, Enterprise Architecture and Strategy 
Group, Office of Information Services, CMS, Room N2-04-27, 7500 
Security Boulevard, Baltimore, Maryland 21244-1850. Comments received 
will be available for review at this location, by appointment, during 
regular business hours, Monday through Friday from 9 a.m.-3 p.m., 
eastern time zone.

FOR FURTHER INFORMATION CONTACT: Richard Wolfsheimer, Health Insurance 
Specialist, Division of Systems Operations, Business Applications 
Management Group, Office of Information Services, CMS, Room N2-08-18, 
7500 Security Boulevard, Baltimore, Maryland 21244-1850. The telephone 
number is 410-786-6160.

SUPPLEMENTARY INFORMATION: 

I. Description of the Modified or Altered System of Records

A. Statutory and Regulatory Basis for System

    Authority for the maintenance of this system of records is given 
under the authority of sections 1816, and 1874 of Title XVIII of the 
Social Security Act (42 U.S.C. 1395h, and 1395kk).

B. Collection and Maintenance of Data in the System

    The system contains information on Medicare beneficiaries, on whose 
behalf providers have submitted claims for reimbursement on a 
reasonable cost basis under Medicare Part A and B, or are eligible, 
and/or individuals whose enrollment in an employer group health 
benefits plan covers the beneficiary. Information contained in this 
system consist of billing for medical and other health care services, 
uniform bill for provider services or equivalent data in an electronic 
format, and Medicare Secondary Payer (MSP) records containing other 
third party liability insurance information necessary for appropriate 
Medicare claims payment and other documents used to support payments to 
beneficiaries and providers of services. These forms contain the 
beneficiary's name, sex, health insurance claim number (HIC), address, 
date of birth, medical record number, prior stay information, provider 
name and address, physician's name, and/or identification number, 
warranty information when pacemakers are implanted or explanted, date 
of admission or discharge, other health insurance, diagnosis, surgical 
procedures, and a statement of services rendered for related charges 
and other data needed to substantiate claims.

II. Agency Policies, Procedures, and Restrictions on The Routine Use

    A. 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 CWF 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 CWF. CMS has the following policies and procedures 
concerning disclosures of information that will be maintained in the 
system. Disclosure of information from this system 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 that the data is being collected, e.g., to properly pay medical 
insurance benefits to or on behalf of entitled beneficiaries.
    2. Determines:
    a. That the purpose for which the disclosure is to be made can only 
be accomplished if the record is provided in individually identifiable 
form;
    b. that the purpose for which the disclosure is to be made is of 
sufficient importance to warrant the potential effect and/or risk on 
the privacy of the individual that additional exposure of the record 
might bring; and
    c. that 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; and
    b. remove or destroy at the earliest time all patient-identifiable 
information.
    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 CWF 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 propose to 
establish or

[[Page 64957]]

modify the following routine use disclosures of information maintained 
in the system:
    1. To agency contractors, consultants, or grantees, who have been 
engaged by the agency to assist in the performance of a service related 
to this collection and who need to have access to the records in order 
to perform the activity.
    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 function 
relating to purposes for this system.
    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, consultant or grantee 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, consultant or grantee from using or disclosing the 
information for any purpose other than that described in the contract 
and requires the contractor, consultant or grantee to return or destroy 
all information at the completion of the contract.
    Carriers and intermediaries occasionally work with contractors to 
identify and recover erroneous Medicare payments for which workers' 
compensation programs are liable.
    2. To another Federal or State agency, agency of a State 
government, an agency established by State law, or its fiscal agent 
pursuant to agreements with CMS to:
    a. Contribute to the accuracy of CMS's proper payment of Medicare 
benefits,
    b. enable such agency to administer a Federal health benefits 
program, or as necessary to enable such agency to fulfill a requirement 
of a Federal statute or regulation that implements a health benefits 
program funded in whole or in part with Federal funds, and/or
    c. assist Federal/State Medicaid programs within the State.
    Other Federal or State agencies in their administration of a 
Federal health program may require CWF information for the purposes of 
determining, evaluating, and/or assessing cost, effectiveness, and/or 
the quality of health care services provided in the State, to support 
evaluations and monitoring of Medicare claims information of 
beneficiaries, including proper reimbursement for services provided.
    The Treasury Department may require CWF data for investigating 
alleged theft, forgery, or unlawful negotiation of Medicare 
reimbursement checks.
    The United States Postal Service may require CWF data for 
investigating alleged forgery or theft of reimbursement checks.
    The Railroad Retirement Board requires CWF information to enable 
them to assist in the implementation and maintenance of the Medicare 
program.
    SSA requires CWF data to enable them to assist in the 
implementation and maintenance of the Medicare program.
    The Internal Revenue Service may require CWF data for the 
application of tax penalties against employers and employee 
organizations that contribute to Employer Group Health Plan or Large 
Group Health Plans that are not in compliance with 42 U.S.C. 1395y(b).
    Disclosure under this routine use shall be used by State Medicaid 
agencies pursuant to agreements with HHS for administration of State 
supplementation payments for determinations of eligibility for 
Medicaid, for enrollment of welfare recipients for medical insurance 
under section 1843 of the Act, for quality control studies, for 
determining eligibility of recipients of assistance under Titles IV, 
and XIX of the Act, and for the complete administration of the Medicaid 
program. CWF data will be released to the State only on those 
individuals who are patients under the services of a Medicaid program 
within the State or who are residents of that State.
    Occasionally State licensing boards require access to the CWF data 
for review of unethical practices or nonprofessional conduct.
    We also contemplate disclosing information under this routine use 
in situations in which State auditing agencies require CWF information 
for auditing of Medicare eligibility considerations. Disclosure of 
physicians' customary charge data are made to State audit agencies in 
order to ascertain the corrections of Title XIX charges and payments. 
CMS may enter into an agreement with State auditing agencies to assist 
in accomplishing functions relating to purposes for this system of 
records.
    State and other governmental workers' compensation agencies working 
with CMS to assure that workers' compensation payments are made where 
Medicare has erroneously paid and workers' compensation programs are 
liable.
    3. To third party contacts (without the consent of the individuals 
to whom the information pertains) in situations where the party to be 
contacted has, or is expected to have information relating to the 
individual's capacity to manage his or her affairs or to his or her 
eligibility for, or an entitlement to, benefits under the Medicare 
program and,
    a. The individual is unable to provide the information being sought 
(an individual is considered to be unable to provide certain types of 
information when any of the following conditions exists: the individual 
is confined to a mental institution, a court of competent jurisdiction 
has appointed a guardian to manage the affairs of that individual, a 
court of competent jurisdiction has declared the individual to be 
mentally incompetent, or the individual's attending physician has 
certified that the individual is not sufficiently mentally competent to 
manage his or her own affairs or to provide the information being 
sought, the individual cannot read or write, cannot afford the cost of 
obtaining the information, a language barrier exists, or the custodian 
of the information will not, as a matter of policy, provide it to the 
individual), or
    b. the data are needed to establish the validity of evidence or to 
verify the accuracy of information presented by the individual, and it 
concerns one or more of the following: The individual's entitlement to 
benefits under the Medicare program; and the amount of reimbursement; 
any case in which the evidence is being reviewed as a result of 
suspected fraud, waste, and abuse, program integrity, quality 
appraisal, or evaluation and measurement of program activities.
    Third parties contacts require CWF information in order to provide 
support for the individual's entitlement to benefits under the Medicare 
program; to establish the validity of evidence or to verify the 
accuracy of information presented by the individual or the 
representative of the applicant, and assist in the monitoring of 
Medicare claims information of beneficiaries, including proper 
reimbursement of services provided.
    Senior citizen volunteers working in the carriers and 
intermediaries' offices to assist Medicare beneficiaries' request for 
assistance may require access to CWF information.
    Occasionally fiscal intermediary/carrier banks, automated 
clearinghouses, VANS, and provider banks, to the extent necessary 
transfer to providers electronic remittance advice of Medicare 
payments, and with respect to provider banks, to the extent necessary 
to provide account

[[Page 64958]]

management services to providers using this information.
    4. To providers and suppliers of services dealing through fiscal 
intermediaries or carriers for the administration of Title XVIII of the 
Act.
    Providers and suppliers of services require CWF information in 
order to establish the validity of evidence, or to verify the accuracy 
of information presented by the individual as it concerns the 
individual's entitlement to benefits under the Medicare program, 
including proper reimbursement for services provided.
    Providers and suppliers of services who are attempting to validate 
items on which the amounts included in the annual Physician/Supplier 
Payment List, or other similar publications are based.
    5. To Quality Improvement Organizations ( QIO) in connection with 
review of claims, or in connection with studies or other review 
activities, conducted pursuant to Part A and Part B of Title XI of the 
Act and in performing affirmative outreach activities to individuals 
for the purpose of establishing and maintaining their entitlement to 
Medicare benefits or health insurance plans.
    QIOs will work to implement quality improvement programs, provide 
consultation to CMS, its contractors, and to State agencies. QIOs will 
assist the State agencies in related monitoring and enforcement 
efforts, assist CMS and Intermediaries and Carriers in program 
integrity assessment, and prepare summary information for release to 
CMS.
    6. To insurance companies, underwriters, third party administrators 
(TPA), employers, self-insurers, group health plans, health maintenance 
organizations (HMO), health and welfare benefit funds, managed care 
organizations, other supplemental insurers, non-coordinating insurers, 
multiple employer trusts, liability insurers, no-fault medical 
automobile insurers, workers' compensation carriers or plans, other 
groups providing protection against medical expenses without the 
beneficiary's authorization, and any entity having knowledge of the 
occurrence of any event affecting (a) An individual's right to any such 
benefit or payment, or (b) the initial right to any such benefit or 
payment, for the purpose of coordination of benefits with the Medicare 
program and implementation of the MSP provision at 42 U.S.C. 1395y(b). 
Information to be disclosed shall be limited to Medicare utilization 
data necessary to perform that specific function. In order to receive 
the information, they must agree to:
    a. Certify that the individual about whom the information is being 
provided is one of its insured or employees, or is insured and/or 
employed by another entity for whom they serve as a TPA;
    b. utilize the information solely for the purpose of processing the 
individual's insurance claims; and
    c. safeguard the confidentiality of the data and prevent 
unauthorized access.
    Other insurers may require CWF information in order to support 
evaluations and monitoring of Medicare claims information of 
beneficiaries, including proper reimbursement for services provided.
    7. To an individual or organization for research, evaluation, or 
epidemiological projects related to the prevention of disease or 
disability, the restoration or maintenance of health, or payment 
related projects.
    CWF data will provide for research, evaluations and epidemiological 
projects, a broader, longitudinal, national perspective of the status 
of Medicare beneficiaries. CMS anticipates that many researchers will 
have legitimate requests to use these data in projects that could 
ultimately improve the care provided to Medicare beneficiaries and the 
policy that governs the care.
    8. 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 and that 
the use of such records is deemed by the Agency to be for a purpose 
that is compatible with the purposes for which the Agency collected the 
records.
    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.
    9. To a CMS contractor (including, but not limited to fiscal 
intermediaries and carriers) that assists in the administration of a 
CMS-administered health benefits program, or to a grantee of a CMS-
administered grant program, when disclosure is deemed reasonably 
necessary by CMS to prevent, deter, discover, detect, investigate, 
examine, prosecute, sue with respect to, defend against, correct, 
remedy, or otherwise combat fraud, waste, 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, waste, or 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.
    10. 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, 
waste, 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 CWF information for the purpose of 
combating fraud, waste, and abuse in such Federally-funded programs.

B. Additional Circumstances Affecting Routine Use Disclosures

    To the extent this system contains Protected Health Information 
(PHI) as defined by HHS regulation ``Standards for Privacy of 
Individually Identifiable Health Information'' (45 CFR Parts 160 and 
164, Subparts A and E) 65 FR 82462 (12-28-00). Disclosures of such PHI 
that are otherwise 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.'' (See 45 CFR 164-512 (a) 
(1)).
    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

[[Page 64959]]

through implicit deduction based on small cell sizes (instances where 
the patient population is so small that individuals 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 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 may apply 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 National 
Institute of Standards and Technology publications; the HHS Information 
Systems Program Handbook and the CMS Information Security Handbook.

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

    CMS proposes to modify 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 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 of patients whose data are maintained in the system. 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 information relating to 
individuals.

    Dated: October 24, 2006.
John R. Dyer,
Chief Operating Officer, Centers for Medicare & Medicaid Services.
System No. 09-70-0526

System Name:
     Common Working File (CWF),'' HHS/CMS/OIS.

Security Classification:
    Level Three Privacy Act Sensitive Data.

System Location:
    The Centers for Medicare & Medicaid Services (CMS) Data Center, 
7500 Security Boulevard, North Building, First Floor, Baltimore, 
Maryland 21244-1850 and at CMS Host Sites located in Birmingham, 
Alabama, and Dallas, Texas.

Categories of Individuals Covered by the System:
    The system contains information on Medicare beneficiaries, on whose 
behalf providers have submitted claims for reimbursement on a 
reasonable cost basis under Medicare Part A and B, or are eligible, 
and/or individuals whose enrollment in an employer group health 
benefits plan covers the beneficiary.

Categories of Records in the System:
    Information contained in this system consist of billing for medical 
and other health care services, uniform bill for provider services or 
equivalent data in an electronic format, and Medicare Secondary Payer 
(MSP) records containing other third party liability insurance 
information necessary for appropriate Medicare claims payment and other 
documents used to support payments to beneficiaries and providers of 
services. These forms contain the beneficiary's name, sex, health 
insurance claim number (HIC), address, date of birth, medical record 
number, prior stay information, provider name and address, physician's 
name, and/or identification number, warranty information when 
pacemakers are implanted or explanted, date of admission or discharge, 
other health insurance, diagnosis, surgical procedures, and a statement 
of services rendered for related charges and other data needed to 
substantiate claims.

Authority for Maintenance of the System:
    Authority for the maintenance of this system of records is given 
under the authority of sections 1816, and 1874 of Title XVIII of the 
Social Security Act (42 United States Code (U.S.C.) 1395h, and 1395kk).

Purpose(S) of the System:
    The primary purpose of the system of records is to properly pay 
medical insurance benefits to or on behalf of entitled beneficiaries. 
Information in this system will also be released to: (1) Support 
regulatory and policy functions performed within the Agency or by a 
contractor, consultant, or grantee; (2) assist another Federal or State 
agency, agency of a State government, an agency established by State 
law, or its fiscal agent; (3) assist third party contacts; (4) assist 
providers and suppliers of services directly or through fiscal 
intermediaries or carriers; (5) support Quality Improvement 
Organizations (QIO) or Quality Review Organizations; (6) assist 
insurance companies and other groups providing protection for their 
enrollees, or who are primary payers to Medicare in accordance with 42 
U.S.C. 1395y (b); (7) support an individual or organization for 
research, evaluation, or epidemiological projects; (8) support 
litigation involving the Agency related to this system of records; and 
(9) combat fraud, waste, and abuse in certain Federally-funded health 
care programs.

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 CWF 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 propose to 
establish or modify the following routine use disclosures of 
information maintained in the system:
    1. To agency contractors, consultants, or grantees, who have been 
engaged by the agency to assist in the performance

[[Page 64960]]

of a service related to this collection and who need to have access to 
the records in order to perform the activity.
    2. To another Federal or State agency, agency of a State 
government, an agency established by State law, or its fiscal agent 
pursuant to agreements with CMS to:
    a. Contribute to the accuracy of CMS's proper payment of Medicare 
benefits,
    b. enable such agency to administer a Federal health benefits 
program, or as necessary to enable such agency to fulfill a requirement 
of a Federal statute or regulation that implements a health benefits 
program funded in whole or in part with Federal funds, and/or
    c. assist Federal/State Medicaid programs within the State.
    3. To third party contacts (without the consent of the individuals 
to whom the information pertains) in situations where the party to be 
contacted has, or is expected to have information relating to the 
individual's capacity to manage his or her affairs or to his or her 
eligibility for, or an entitlement to, benefits under the Medicare 
program and,
    a. The individual is unable to provide the information being sought 
(an individual is considered to be unable to provide certain types of 
information when any of the following conditions exists: The individual 
is confined to a mental institution, a court of competent jurisdiction 
has appointed a guardian to manage the affairs of that individual, a 
court of competent jurisdiction has declared the individual to be 
mentally incompetent, or the individual's attending physician has 
certified that the individual is not sufficiently mentally competent to 
manage his or her own affairs or to provide the information being 
sought, the individual cannot read or write, cannot afford the cost of 
obtaining the information, a language barrier exist, or the custodian 
of the information will not, as a matter of policy, provide it to the 
individual), or
    b. the data are needed to establish the validity of evidence or to 
verify the accuracy of information presented by the individual, and it 
concerns one or more of the following: The individual's entitlement to 
benefits under the Medicare program; and the amount of reimbursement; 
any case in which the evidence is being reviewed as a result of 
suspected fraud, waste, and abuse, program integrity, quality 
appraisal, or evaluation and measurement of program activities.
    4. To providers and suppliers of services dealing through fiscal 
intermediaries or carriers for the administration of Title XVIII of the 
Act.
    5. To Quality Improvement Organizations ( QIO) in connection with 
review of claims, or in connection with studies or other review 
activities, conducted pursuant to Part A and 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.
    6. To insurance companies, underwriters, third party administrators 
(TPA), employers, self-insurers, group health plans, health maintenance 
organizations (HMO), health and welfare benefit funds, managed care 
organizations, other supplemental insurers, non-coordinating insurers, 
multiple employer trusts, liability insurers, no-fault medical 
automobile insurers, workers' compensation carriers or plans, other 
groups providing protection against medical expenses without the 
beneficiary's authorization, and any entity having knowledge of the 
occurrence of any event affecting (a) An individual's right to any such 
benefit or payment, or (b) the initial right to any such benefit or 
payment, for the purpose of coordination of benefits with the Medicare 
program and implementation of the MSP provision at 42 U.S.C. 1395y (b). 
Information to be disclosed shall be limited to Medicare utilization 
data necessary to perform that specific function. In order to receive 
the information, they must agree to:
    a. Certify that the individual about whom the information is being 
provided is one of its insured or employees, or is insured and/or 
employed by another entity for whom they serve as a TPA;
    b. utilize the information solely for the purpose of processing the 
individual's insurance claims; and
    c. safeguard the confidentiality of the data and prevent 
unauthorized access.
    7. To an individual or organization for research, evaluation, or 
epidemiological projects related to the prevention of disease or 
disability, the restoration or maintenance of health, or payment 
related projects.
    8. 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 and that 
the use of such records is deemed by the Agency to be for a purpose 
that is compatible with the purposes for which the Agency collected the 
records.
    9. To a CMS contractor (including, but not limited to fiscal 
intermediaries and carriers) that assists in the administration of a 
CMS-administered health benefits program, or to a grantee of a CMS-
administered grant program, when disclosure is deemed reasonably 
necessary by CMS to prevent, deter, discover, detect, investigate, 
examine, prosecute, sue with respect to, defend against, correct, 
remedy, or otherwise combat fraud, waste, or abuse in such program.
    10. 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, 
waste, 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, waste, or abuse in such programs.
    B. Additional Circumstances Affecting Routine Use Disclosures
    To the extent this system contains Protected Health Information 
(PHI) as defined by HHS regulation ``Standards for Privacy of 
Individually Identifiable Health Information'' (45 CFR Parts 160 and 
164, Subparts A and E) 65 Federal Register 82462 (12-28-00). 
Disclosures of such PHI that are otherwise 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.'' (See 45 CFR 164-512(a)(1)).
    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 small 
cell sizes (instances where the patient population is so small that 
individuals could, because of the small size, use this information to 
deduce the identity of the beneficiary).

[[Page 64961]]

Policies and Practices for Storing, Retrieving, Accessing, Retaining, 
and Disposing of Records in the System:
Storage:
    Records are maintained on paper, computer diskette and on magnetic 
storage media.

Retrievability:
    Information can be retrieved by the beneficiary's name, HIC, and 
assigned unique physician identification number.

Safeguards:
    CMS has safeguards in place for authorized users and monitors such 
users to ensure against 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 may apply 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 National 
Institute of Standards and Technology publications; the HHS Information 
Systems Program Handbook and the CMS Information Security Handbook.

Retention and Disposal:
    Records are maintained in a secure storage area with identifiers. 
Records are closed at the end of the calendar year in which paid, then 
destroyed 6 years and 3 months after final payment/action. All claims-
related records are encompassed by the document preservation order and 
will be retained until notification is received from DOJ.

System Manager and Address:
    Director, Division of Systems Operations, Business Applications 
Management Group, Office of Information Services, CMS, Room N2-08-18, 
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, assigned card key 
number, and building/secure area, and for verification purposes, the 
subject individual's name (woman's maiden name, if applicable), and 
SSN. Furnishing the SSN is voluntary, but it may make searching for a 
record easier and prevent delay.

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

Contesting Records Procedures:
    The subject individual should contact the system manager named 
above, and reasonably identify the records 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).

Records Source Categories:
    Sources of information contained in this records system is 
furnished by the individual. In most cases, the identifying information 
is provided to the physician by the individual. Information is obtained 
from other CMS systems of records and data systems: Health Insurance 
Master Record, Intermediary Medicare Claims Records, Carrier Medicare 
Claims Records, MSP Record, Third Party Liability Record, Medicare 
Entitlement Record, Health Maintenance Organization Record, Hospice 
Record, and in the case of some MSP situations, through third party 
contacts. The medical information is provided by the providers of 
medical services.

Systems Exempted from Certain Provisions of the Act:
    None.

 [FR Doc. E6-18611 Filed 11-3-06; 8:45 am]
BILLING CODE 4120-03-P