[Federal Register Volume 73, Number 38 (Tuesday, February 26, 2008)]
[Notices]
[Pages 10255-10260]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E8-3564]


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

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers For Medicare & Medicaid Services


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

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

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 SOR titled, ``1-
800 Medicare Helpline (HELPLINE), System No. 09-70-0535,'' modified at 
68 Federal Register 25379 (May 12, 2003). We propose to modify existing 
routine use number 2 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 6 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.
    We will broaden the scope of published routine uses number 8 and 9, 
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. Finally, we will 
delete the section titled ``Additional Circumstances Affecting Routine 
Use Disclosures,'' that addresses ``Protected Health Information 
(PHI)'' and ``small cell size.'' The requirement for compliance with 
HHS regulation ``Standards for Privacy of Individually Identifiable 
Health Information'' does not apply because this system does not 
collect or maintain PHI. In addition, our policy to prohibit release if 
there is a possibility that an individual can be identified through 
``small cell size'' is not applicable to the data maintained in this 
system.
    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 MMA and to 
update language in the administrative sections to correspond with 
language used in other CMS SORs.
    The primary purpose of the SOR is to provide general information to

[[Page 10256]]

beneficiaries and future beneficiaries so that they can make informed 
Medicare decisions, maintain information on Medicare enrollment for the 
administration of the Medicare program, including the following 
functions: Ensuring proper Medicare enrollment, claims payment, 
Medicare premium billing and collection, coordination of benefits by 
validating and verifying the enrollment status of beneficiaries, and 
validating and studying the characteristics of persons enrolled in the 
Medicare program including their requirements for information. 
Information retrieved from this SOR will also be disclosed to: (1) 
Support regulatory, reimbursement, and policy functions performed 
within the Agency or by contractors, consultants, or CMS grantees; (2) 
assist another Federal or state agency, agency of a state government, 
an agency established by state law, or its fiscal agent; (3) assist 
providers and suppliers of services for administration of Title XVIII 
of the Act; (4) assist third parties where the contact is expected to 
have information relating to the individual's capacity to manage his or 
her own affairs; (5) assist other insurers for processing individual 
insurance claims; (6) support litigation involving the Agency; and (7) 
combat fraud, waste, and abuse in certain health benefits programs. We 
have provided background information about the modified system in the 
``Supplementary Information'' section below. Although the Privacy Act 
requires only that CMS provide an opportunity for interested persons to 
comment on the proposed routine uses, CMS invites comments on all 
portions of this notice. See ``Effective Dates'' section for comment 
period.

EFFECTIVE DATES: CMS filed a modified/altered system report with the 
Chair of the House Committee on Oversight and Government Reform, the 
Chair of the Senate Committee on Homeland Security and Governmental 
Affairs, and the Administrator, Office of Information and Regulatory 
Affairs, Office of Management and Budget (OMB) on February 12, 2008. To 
ensure that all parties have adequate time in which to comment, the new 
SOR, including routine uses, will become effective 40 days from the 
publication of the notice, or from the date it was submitted to OMB and 
the Congress, whichever is later, unless CMS receives comments that 
require alterations to this notice.

ADDRESSES: The public should address comments to: 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: Kenneth Taylor, Division of Call 
Center Operations, Customer Teleservice Operations Group, Office of 
Beneficiary Information Services, CMS, 7500 Security Boulevard, C2-26-
20, Baltimore, Maryland 21244-1850. The telephone number is 410-786-
6736 or contact by e-mail [email protected].

SUPPLEMENTARY INFORMATION:

I. Description of the Modified or Altered System of Records

A. Statutory and Regulatory Basis for SOR

    Authority for maintenance of the system is given under sections 
1102, 1804(b), and 1851(d) of the Social Security Act (42 United States 
Code (U.S.C.) 1302, 1395b-2(b), and 1395w-21(d)), and OMB Circular A-
123, Internal Control Systems, and Title 42 U.S.C. section 1395w-21 (d) 
(Pub. L. 105-3, the Balanced Budget Act of 1997).

B. Collection and Maintenance of Data in the System

    Information is collected on individuals age 65 or over who have 
been, or currently are, entitled to health insurance (Medicare) 
benefits under Title XVIII of the Act or under provisions of the 
Railroad Retirement Act, individuals under age 65 who have been, or 
currently are, entitled to such benefits on the basis of having been 
entitled for not less than 24 months to disability benefits under Title 
II of the Act or under the Railroad Retirement Act, individuals who 
have been, or currently are, entitled to such benefits because they 
have ESRD, individuals age 64 and 8 months or over who are likely to 
become entitled to health insurance (Medicare) benefits upon attaining 
age 65, and individuals under age 65 who have at least 21 months of 
disability benefits who are likely to become entitled to Medicare upon 
the 25th month of their being disabled. The collected information will 
contain name, address, telephone number, health insurance claim (HIC) 
number, geographic location, race/ethnicity, sex, date of birth, as 
well as, background information relating to Medicare or Medicaid 
issues. The HELPLINE will also maintain a caller history for purposes 
of re-contacts by customer service representatives or CMS, contain 
information related to Medicare enrollment and entitlement, group 
health plan enrollment data, as well as, background information 
relating to Medicare or Medicaid issues.

II. Agency Policies, Procedures, and Restrictions on Routine Uses

    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 HELPLINE 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 HELPLINE. CMS has the following policies and procedures 
concerning disclosures of information that will be maintained in the 
system. Disclosure of information from the SOR will be approved only to 
the extent necessary to accomplish the purpose of the disclosure and 
only after CMS:
    1. Determines that the use or disclosure is consistent with the 
reason data is being collected; e.g., to provide general information to 
beneficiaries and future beneficiaries so that they can make informed 
Medicare decisions, maintain information on Medicare enrollment for the 
administration of the Medicare program, including the following 
functions: Ensuring proper Medicare enrollment, claims payment, 
Medicare premium billing and collection, coordination of benefits by 
validating and verifying the enrollment status of beneficiaries, and 
validating and studying the characteristics of persons enrolled in the 
Medicare program including their requirements for information.
    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 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:

[[Page 10257]]

    a. Establish administrative, technical, and physical safeguards to 
prevent unauthorized use or disclosure of the record;
    b. Remove or destroy at the earliest 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. The Privacy Act allows us to disclose information without an 
individual's consent if the 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 HELPLINE 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, consultants, or CMS grantees who 
have been contracted by the Agency to assist in accomplishment of a CMS 
function relating to the purposes for this SOR and who need to have 
access to the records in order to assist CMS.
    We contemplate disclosing information under this routine use only 
in situations in which CMS may enter into a contractual or similar 
agreement with a third party to assist in accomplishing a CMS function 
relating to purposes for this SOR.
    CMS occasionally contracts out certain of its functions when doing 
so would contribute to effective and efficient operations. CMS must be 
able to give contractors, consultants, or CMS grantees whatever 
information is necessary for the contractors, consultants, or CMS 
grantees to fulfill its duties. In these situations, safeguards are 
provided in the contract prohibiting the contractors, consultants, or 
CMS grantees from using or disclosing the information for any purpose 
other than that described in the contract and requires the contractors, 
consultants, or CMS grantees to return or destroy all information at 
the completion of the contract.
    2. To assist another Federal or state agency, agency of a state 
government, an agency established by state law, or its fiscal agent 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 HELPLINE information in order to 
support evaluations and monitoring of Medicare claims information of 
beneficiaries, including proper reimbursement for services provided;
    In addition, other state agencies in their administration of a 
Federal health program may require HELPLINE information for the 
purposes of determining, evaluating and/or assessing cost, 
effectiveness, and/or the quality of health care services provided in 
the state;
    Disclosure under this routine use shall be used by state Medicaid 
agencies pursuant to agreements with the HHS for determining Medicaid 
and Medicare eligibility, for quality control studies, for determining 
eligibility of recipients of assistance under Titles IV, XVIII, and XIX 
of the Act, and for the administration of the Medicaid program. 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.
    We also contemplate disclosing information under this routine use 
in situations in which state auditing agencies require HELPLINE 
information for auditing state Medicaid eligibility considerations. CMS 
may enter into an agreement with state auditing agencies to assist in 
accomplishing functions relating to purposes for this SOR.
    3. To assist providers and suppliers of services directly or 
through fiscal intermediaries or carriers for the administration of 
Title XVIII of the Social Security Act.
    Providers and suppliers of services require HELPLINE 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.
    4. To assist third party contacts 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, the amount of reimbursement, and 
in cases in which the evidence is being reviewed as a result of 
suspected fraud and abuse, program integrity, quality appraisal, or 
evaluation and measurement of activities.
    Third party contacts require HELPLINE 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, and assist in 
the monitoring of Medicare claims information of beneficiaries, 
including proper reimbursement of services provided.
    5. To assist insurance companies, third party administrators (TPA), 
employers, self-insurers, managed care organizations, other 
supplemental insurers, non-coordinating insurers, multiple employer 
trusts, group health plans (i.e., health maintenance organizations 
(HMOs) or a competitive medical plan (CMP) with a Medicare contract, or 
a Medicare-approved health care prepayment plan (HCPP)), directly or 
through a contractor, and other groups providing protection for their

[[Page 10258]]

enrollees. Information to be disclosed shall be limited to Medicare 
entitlement data. 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 
identified individual's insurance claims; and
    c. Safeguard the confidentiality of the data and prevent 
unauthorized access.
    Other insurers, TPAs, HMOs, and HCPPs may require HELPLINE 
information in order to support evaluations and monitoring of Medicare 
claims information of beneficiaries, including proper reimbursement for 
services provided.
    6. 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 and that 
the use of such records by the DOJ, court or adjudicatory body is 
compatible with the purpose 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.
    7. To support a CMS contractor (including, but not limited to FIs 
and carriers) that assists in the administration of a CMS-administered 
health benefits program, or to a grantee of a CMS-administered grant 
program, when disclosure is deemed reasonably necessary by CMS to 
prevent, deter, discover, detect, investigate, examine, prosecute, sue 
with respect to, defend against, correct, remedy, or otherwise combat 
fraud, waste or abuse in such programs.
    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.
    8. To assist another Federal agency or 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, and 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, and abuse in such programs.
    Other agencies may require HELPLINE information for the purpose of 
combating fraud, waste, and abuse in such Federally funded programs.

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: February 13, 2008.
Charlene Frizzera,
Chief Operating Officer, Centers for Medicare & Medicaid Services.
SYSTEM NO. 09-70-0535

SYSTEM NAME:
    ``1-800 Medicare Helpline (HELPLINE),'' HHS/CMS/CBC.

SECURITY CLASSIFICATION:
    Level Three Privacy Act Sensitive Data.

SYSTEM LOCATION:
    CMS Data Center, 7500 Security Boulevard, North Building, First 
Floor, Baltimore, Maryland 21244-1850 and at various other contractor 
locations.

CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:
    Information is collected on individuals age 65 or over who have 
been, or currently are, entitled to health

[[Page 10259]]

insurance (Medicare) benefits under Title XVIII of the Act or under 
provisions of the Railroad Retirement Act, individuals under age 65 who 
have been, or currently are, entitled to such benefits on the basis of 
having been entitled for not less than 24 months to disability benefits 
under Title II of the Act or under the Railroad Retirement Act, 
individuals who have been, or currently are, entitled to such benefits 
because they have ESRD, individuals age 64 and 8 months or over who are 
likely to become entitled to health insurance (Medicare) benefits upon 
attaining age 65, and individuals under age 65 who have at least 21 
months of disability benefits who are likely to become entitled to 
Medicare upon the 25th month of their being disabled.

CATEGORIES OF RECORDS IN THE SYSTEM:
    The collected information will contain name, address, telephone 
number, health insurance claim (HIC) number, geographic location, race/
ethnicity, sex, date of birth, as well as, background information 
relating to Medicare or Medicaid issues. The HELPLINE will also 
maintain a caller history for purposes of re-contacts by customer 
service representatives or CMS, contain information related to Medicare 
enrollment and entitlement, group health plan enrollment data, as well 
as, background information relating to Medicare or Medicaid issues.

AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
    Authority for maintenance of the system is given under sections 
1102, 1804(b), and 1851(d) of the Social Security Act (42 United States 
Code (U.S.C.) 1302, 1395b-2(b), and 1395w-21(d)), and OMB Circular A-
123, Internal Control Systems, and Title 42 U.S.C. section 1395w-21(d) 
(Pub. L. 105-3, the Balanced Budget Act of 1997).

PURPOSE(S) OF THE SYSTEM:
    The primary purpose of the SOR is to provide general information to 
beneficiaries and future beneficiaries so that they can make informed 
Medicare decisions, maintain information on Medicare enrollment for the 
administration of the Medicare program, including the following 
functions: Ensuring proper Medicare enrollment, claims payment, 
Medicare premium billing and collection, coordination of benefits by 
validating and verifying the enrollment status of beneficiaries, and 
validating and studying the characteristics of persons enrolled in the 
Medicare program including their requirements for information. 
Information retrieved from this SOR will also be disclosed to: (1) 
Support regulatory, reimbursement, and policy functions performed 
within the Agency or by contractors, consultants, or CMS grantees; (2) 
assist another Federal or state agency, agency of a state government, 
an agency established by state law, or its fiscal agent; (3) assist 
providers and suppliers of services for administration of Title XVIII 
of the Act; (4) assist third parties where the contact is expected to 
have information relating to the individual's capacity to manage his or 
her own affairs; (5) assist other insurers for processing individual 
insurance claims; (6) support litigation involving the Agency; and (7) 
combat fraud, waste, and abuse in certain health benefits programs.

ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES 
OR USERS AND THE PURPOSES OF SUCH USES:
    A. The Privacy Act allows us to disclose information without an 
individual's consent if the 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 HELPLINE 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, consultants, or CMS grantees who 
have been contracted by the Agency to assist in accomplishment of a CMS 
function relating to the purposes for this SOR and who need to have 
access to the records in order to assist CMS.
    2. To assist another Federal or state agency, agency of a state 
government, an agency established by state law, or its fiscal agent 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 assist providers and suppliers of services directly or 
through fiscal intermediaries or carriers for the administration of 
Title XVIII of the Social Security Act.
    4. To assist third party contacts 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, the amount of reimbursement, and 
in cases in which the evidence is being reviewed as a result of 
suspected fraud and abuse, program integrity, quality appraisal, or 
evaluation and measurement of activities.
    5. To assist insurance companies, third party administrators (TPA), 
employers, self-insurers, managed care organizations, other 
supplemental insurers, non-coordinating insurers, multiple employer 
trusts, group health plans (i.e., health maintenance organizations 
(HMOs) or a competitive medical plan (CMP) with a Medicare contract, or 
a Medicare-approved health care prepayment plan (HCPP)), directly or 
through a contractor, and other groups providing protection for their 
enrollees. Information to be disclosed shall be limited to Medicare 
entitlement data. 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;

[[Page 10260]]

    b. Utilize the information solely for the purpose of processing the 
identified individual's insurance claims; and
    c. Safeguard the confidentiality of the data and prevent 
unauthorized access.
    6. 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 and that 
the use of such records by the DOJ, court or adjudicatory body is 
compatible with the purpose for which the agency collected the records.
    7. To support a CMS contractor (including, but not limited to FIs 
and carriers) that assists in the administration of a CMS-administered 
health benefits program, or to a grantee of a CMS-administered grant 
program, when disclosure is deemed reasonably necessary by CMS to 
prevent, deter, discover, detect, investigate, examine, prosecute, sue 
with respect to, defend against, correct, remedy, or otherwise combat 
fraud, waste or abuse in such programs.
    8. To assist another Federal agency or 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, and 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, and abuse in such programs.

POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING, 
AND DISPOSING OF RECORDS IN THE SYSTEM:
STORAGE:
    All records are stored on electronic media.

RETRIEVABILITY:
    The collected data are retrieved by an individual identifier; e.g., 
beneficiary name or HICN, and unique provider 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:
    CMS will retain information for a total period not to exceed 6 
years and 3 months. All claims-related records are encompassed by the 
document preservation order and will be retained until notification is 
received from DOJ.

SYSTEM MANAGER AND ADDRESSES:
    Director, Division of Call Center Operations, Customer Teleservice 
Operations Group, Office of Beneficiary Information Services, CMS, 7500 
Security Boulevard, C2-26-20, 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, employee 
identification number, tax identification number, national provider 
number, and for verification purposes, the subject individual's name 
(woman's maiden name, if applicable), HICN, and/or 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 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).

RECORDS SOURCE CATEGORIES:
    The data contained in these records are furnished by the 
individual, or in the case of some situations, through third party 
contacts that make calls to 1-800 Medicare Helpline. Updating 
information is also obtained from the following CMS systems of records: 
Enrollment Data Base (09-70-0502), Common Working File (09-70-0525), 
and the Master Beneficiary Record maintained by the Social Security 
Administration (SSA System of Records SSA/ORSIS 60-0090).

SYSTEMS EXEMPTED FROM CERTAIN PROVISIONS OF THE ACT:
    None.

 [FR Doc. E8-3564 Filed 2-25-08; 8:45 am]
BILLING CODE 4120-03-P