[Federal Register: December 16, 2004 (Volume 69, Number 241)]
[Notices]
[Page 75316-75323]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr16de04-52]
-----------------------------------------------------------------------
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 proposed modification or alteration to a system of
records (SOR).
-----------------------------------------------------------------------
SUMMARY: In accordance with the requirements of the Privacy Act of
1974, we are proposing to modify or alter an SOR, ``Unique Physician/
Practitioner Identification Number (UPIN) (formerly known as the
Medicare Physician Identification and Eligibility System),'' System No.
09-70-0525. We propose to delete published routine use number 1
authorizing disclosure to contractors for refining or processing
records, and in connection with Automated Data Processing software or a
telecommunication system containing or supporting records in the
system, number 3 authorizing disclosure to the Railroad Retirement
Board (RRB), number 6 authorizing disclosure to the Department of
Justice (DOJ) for investigating and prosecuting violations of the
Social Security Act (the Act), number 7 authorizing disclosure to state
licensing boards for review of unethical practices or non-professional
conduct, and an unnumbered routine use authorizing disclosure to the
Social Security Administration (SSA). Disclosures that were previously
permitted under published routine use number 1 will now be authorized
under proposed routine use number 2. Proposed routine use number 2 will
release information to ``agency contractors or consultants'' who have
been engaged by the agency to assist in accomplishment of a CMS
function related to this system of records (SOR).
Disclosures previously permitted under published routine uses
number 3, 7, and to the SSA will be authorized by proposed routine use
number 3, which will release information to ``another Federal and/or
state agency, agency of a state government, an agency established by
state law, or its fiscal agent.'' Disclosures authorizing release to
DOJ for investigating and prosecuting violations of the Act will be
carried out under proposed routine use number 9, which authorizes
release of data to ``combat fraud and abuse.'' We propose to add 3 new
routine uses to provide disclosure of records when all
[[Page 75317]]
requirements have been met: number 1, to provide beneficiaries and
other individuals with the identification of each physician or non-
physician practitioner assigned a UPIN and who are participating in the
Medicare program; number 2, to provide records to contractors who need
to have access to records in order to assist CMS; number 3, to provide
records to fiscal intermediaries and state and Federal agencies to
contribute to the accuracy of Medicare payments, enable CMS to
administer benefits programs and/or comply with Federal statutes or
regulations, and to assist Medicaid programs within the state. The
language in previous routine uses numbered 2, 4, 5, and 8 has been
modified. Routine uses previously numbered 2, 5, 8, 9, and 10 have been
renumbered as 6, 7, 5, 8 and 9 respectively.
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 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 a recent reorganization 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 maintain unique identification
of each physician, non-physician practitioner, or medical group
practice requesting or receiving Medicare payment. Information
retrieved from this SOR will be used to: (1) Provide beneficiaries and
other individuals with the identification of each physician or non-
physician practitioner assigned an unique identification number and who
are participating in the Medicare program; (2) support regulatory,
reimbursement, and policy functions performed within the agency or by a
contractor or consultant; (3) assist another Federal and/or state
agency, agency of a state government, an agency established by state
law, or its fiscal agent; (4) assist Quality Improvement Organizations;
(5) provide the American Medical Association with information needed
for them to assist us in identifying physicians; (6) support
constituent requests made to a congressional representative; (7)
support litigation involving the agency; and (8) 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
modifications to the 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 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 14, 2004. To ensure that all
parties have adequate time in which to comment, the modified system of
records, 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: Director, Division of
Privacy Compliance Data Development, 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
daylight time.
FOR FURTHER INFORMATION CONTACT: Kimberly Brandt, Acting, Director,
Program Integrity Group, Office of Financial Management, CMS, 7500
Security Boulevard, C3-02-17, Baltimore, Maryland 21244-1850. The
telephone number is (410) 786-1909.
SUPPLEMENTARY INFORMATION:
I. Description of the Modified System of Records
A. Statutory and Regulatory Basis For System of Records
In 1988, CMS modified an SOR under the authority of sections 1842
(r)-(42 U.S.C. 1395u) of Public Law 101-508; 1861(s)(1)-(42 U.S.C.
1395x); sections 1833 (q)(1)-(42 U.S.C. 1395l); 1842(b)(18)-(42 U.S.C.
1395u); (1842 (h)(4) & (5)-(42 U.S.C. 1395u); and 4164 of Omnibus
Budget Reconciliation Act of 1990 (OBRA). Section 1871 (a)(1)-(42
U.S.C. 1395hh) provides that the Secretary shall prescribe such
regulations as may be necessary to carry out the administration of the
insurance program under Title XVIII. Section 1833 (d)-(42 U.S.C.
1395l), prohibits making payment under Part B for services which are
payable under Part A. Notice for this system, ``Unique Physician/
Practitioner Identification Number (UPIN),'' System No. 09-70-0525, was
most recently published in full at 54 FR 28119 (July 5, 1989), an
expanded function and purpose of system and name change are at 61 FR
20528, (May 7, 1996), an unnumbered routine use was added for the
Social Security Administration (SSA) at 61 FR 6645 (Feb. 21, 1996),
three new fraud and abuse routine uses were added at 63 FR 38414 (July
16, 1998), and then at 65 FR 50552 (Aug. 18, 2000), two of the fraud
and abuse routine uses were revised and a third deleted. UPIN contains
records of all physicians, non-physician practitioners and medical
group practice as defined by section 1861(r)-(42 U.S.C. 1395x), 1877(h)
(4)-(42 U.S.C. 1395) of Title XVIII of the Act, who provide services
for which payment is made under Medicare. By uniquely identifying all
Part B health professional and practitioners and groups, CMS believes
we will eliminate the possibility of double payment.
Medicare carriers currently identify physicians, non-physician
practitioners and groups using their own individual systems of assigned
numbers. These individualized systems allow for Physician
Identification Numbers (PIN) ranging from 4 to 16 alphabetic and/or
numeric characters. Some carriers assign separate PINs to the same
physician providing medical services in more than one locality, office
or practice and lack the capability to cross reference the PIN and
related physician data (e.g., group affiliation).
Other carriers maintain a single PIN or cross-referenced PIN for
each physician practicing within the carrier's geographic area of
responsibility. The assignment of a unique, nationwide identification
number will help eliminate the possibility of double billing where
physicians, non-physician practitioners, and groups can furnish medical
services in, as well as bill for these services from several locations
or states which are in different carrier jurisdictions. In addition,
independent physicians who have been found to be ineligible for
Medicare payments in one area, location or state are prevented from
receiving inappropriate or illegal payment in one or more other areas,
locations or states.
In order to rectify the problems inherent in these individualized
identification systems, CMS proposed to expand the Registry under
Congressional mandate (Section 9202 of the Consolidated Omnibus
Reconciliation Act of 1985, Public Law 99272), that created a uniform
record
[[Page 75318]]
system under UPIN. The proposed changes to this national system or
Registry of Unique Physician/Practitioner Identification Number will
enable CMS to more readily identify all physicians, non-physician
practitioners, and group practices deemed ineligible for Medicare
payments and maintain more comprehensive data on physician credentials.
II. Collection and Maintenance of Data in the System
A. Scope of the Data Collected
The records contain a UPIN for each physician, non-physician
practitioner, and medical group practices defined by sections 1124(A)-
(42 U.S.C. 1320A-3), 1861(r), 1842(b)(18)(ii)(iii)(iv)(v)(r), and
1877(h)(4) of the Act who request or receive Medicare reimbursement for
medical services. The system contains a UPIN, tax identification, and
social security number for each physician, non-physician practitioner
and medical group. Also, the system contains information concerning a
provider's birth date, place of residence, medical education, and
eligibility information necessary for Medicare reimbursement.
B. Agency Policies, Procedures, and Restrictions on the Routine Use
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 UPIN information that can be
associated with each physician, non-physician practitioner and medical
group practices 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. Identifiable
data includes individual records with UPIN information and identifiers.
Non-identifiable data includes individual records with UPIN information
and masked identifiers or UPIN information with identifiers stripped
out of the file.
We will only disclose the minimum personal data necessary to
achieve the purpose of UPIN. CMS has the following policies and
procedures concerning disclosures of information that will be
maintained in the system. In general, disclosure of information from
the system of records will be approved only for the minimum information
necessary to accomplish the purpose of the disclosure after CMS:
1. Determines that the use or disclosure is consistent with the
reason that the data is being collected; e.g., assure accurate
identification of each physician, non-physician practitioner, or
medical group practice requesting or receiving Medicare payment.
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:
a. Establish administrative, technical, and physical safeguards to
prevent unauthorized use of disclosure of the record;
b. remove or destroy at the earliest time all patient-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 UPIN 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 provide beneficiaries and other individuals, the
identification of each physician or non-physician practitioner who have
been assigned a Unique Physician/Practitioner Identification Number
(UPIN) and who are participating in the Medicare program.
Beneficiaries and providers often request the help of Medicare
contractors (carriers and intermediaries) in the proper identification
of physicians and non-physician providers participating in the Medicare
program. The Secretary of HHS is required under provision of section
1863 of the Act to provide to the public certain information maintained
in this system that serves this purpose.
2. 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 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 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.
Carriers and intermediaries occasionally work with contractors to
identify and recover erroneous Medicare payments for which workers'
compensation programs are liable.
3. To assist 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 UPIN 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
[[Page 75319]]
proper reimbursement for services provided.
RRB requires UPIN information to enable them to assist in the
implementation and maintenance of the Medicare program.
SSA requires UPIN data to enable them to assist in the
implementation and maintenance of the Medicare program.
The Internal Revenue Service may require UPIN 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).
State and other governmental worker's compensation agencies working
with CMS to assure that workers' compensation payments are made where
Medicare has erroneously paid and workers' compensation programs are
liable.
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 XVIII of the Act, and for the complete administration of the
Medicaid program.
Occasionally state licensing boards require access to the UPIN 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 UPIN information
for auditing of Medicaid eligibility considerations. Disclosure of
physicians' customary charge data are made to state audit agencies in
order to ascertain the correctness of Title XVIII charges and payments.
CMS may enter into an agreement with state auditing agencies to assist
in accomplishing functions relating to the purposes for this SOR.
4. To assist Quality Improvement Organizations (QIO) 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 state agencies. QIOs will
assist the state agencies in related monitoring and enforcement
efforts, assist CMS and intermediaries in program integrity assessment,
and prepare summary information for release to CMS.
5. To provide the American Medical Association (AMA), for the
purpose of assisting CMS to identify medical doctors when CMS is unable
to establish an identity, provided the AMA agrees to:
a. Use the information provided by CMS solely to identify a medical
doctor;
b. Make no copies of the information it receives from the CMS,
except for one back-up copy;
c. Return such information to CMS upon completion of its matching
operation, and erase the back-up copy;
d. Establish appropriate administrative, technical, and physical
safeguards to prevent unauthorized use or disclosure of the records;
and,
e. Sign a written statement attesting to its understanding of, and
willingness to abide by these provisions.
CMS exchanges information with the AMA for the purpose of
attempting to identify medical doctors when the UPIN Registry is unable
to establish identity after matching carrier-submitted data to the data
extract provided by the AMA. The AMA would attempt to establish medical
doctor identity by matching the UPIN data to data maintained in the AMA
Physician Master File.
6. To support a Member of Congress or 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.
Beneficiaries and other individuals often request the help of a
Member of Congress in resolving an 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.
7. 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.
8. 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.
9. 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.
Other agencies may require UPIN 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,
[[Page 75320]]
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 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 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 of Records 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. 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 monitor the collection and reporting of UPIN data. UPIN
information on individuals is completed by contractor personnel and
submitted to CMS through standard systems located at different
locations. CMS will utilize a variety of onsite and offsite edits and
audits to increase the accuracy of UPIN data.
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. CMS will collect only that information necessary to perform the
system's functions. In addition, CMS will make disclosure of
identifiable data from the modified 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 14, 2004.
Mark B. McClellan,
Administrator, Centers for Medicare & Medicaid Services.
System No. 09-70-0525
SYSTEM NAME:
Unique Physician/Practitioner Identification Number (UPIN), HHS/
CMS/OFM.
SECURITY CLASSIFICATION:
Level Three Privacy Act Sensitive.
SYSTEM LOCATION:
CMS Data Center, 7500 Security Boulevard, North Building, First
Floor, Baltimore, Maryland 21244-1850. The system is also located at
CMS contractors and agents at various locations (see Appendix A).
CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:
All physicians, non-practitioners and medical groups practices,
defined by sections 1124(A), 1861(r), 1842(b)(I)(ii)(iii)(iv)(v)(r),
and 1877(h)(4) of the Act who request or receive Medicare reimbursement
for medical services.
CATEGORIES OF RECORDS IN THE SYSTEM:
The system contains a UPIN, tax identification, and social security
number (SSN) for each physician, non-physician practitioner and medical
group. Also, the system contains information concerning a provider's
birth date, place of residence, medical education, and eligibility
information for Medicare reimbursement.
AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
Section 1842(r) of Pub. L. 101-508; sections 1833(q)(1),
1842(b)(18), (1842 (h)(4), and (5), 1861(s)(I), and 4146 of Title XVIII
of the Act.
PURPOSE(S) OF THE SYSTEM:
The primary purpose of the SOR is to maintain unique identification
of each physician, non-physician practitioner, or medical group
practice requesting or receiving Medicare payment. Information
retrieved from this SOR will be used to: (1) Provide beneficiaries and
other individuals with the identification of each physician or non-
physician practitioner assigned an unique identification number and who
are participating in the Medicare program; (2) support regulatory,
reimbursement, and policy functions performed within the agency or by a
contractor or consultant; (3) assist another Federal and/or state
agency, agency of a state government, an agency established by state
law, or its fiscal agent; (4) assist Quality Improvement Organizations;
(5) provide the American Medical Association with information needed
for them to assist us in identifying physicians; (6) support
constituent requests made to a congressional representative; (7)
support litigation involving the agency; and (8) combat fraud 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:
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 UPIN 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.
[[Page 75321]]
This SOR 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 (Dec. 28, 00), as
amended by 66 FR 12434 (Feb. 26, 01)). 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 non-
identifiable data, except pursuant to one of the routine uses, if 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 who are familiar with the
enrollees could, because of the small size, use this information to
deduce the identity of the beneficiary). We propose to establish or
modify the following routine use disclosures of information maintained
in the system:
1. To provide beneficiaries and other individuals of the
identification of each physician or non-physician practitioner who have
been assigned a Unique Physician/Practitioner Identification Number
(UPIN) and who are participating in the Medicare program.
2. 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 system of records and who need to
have access to the records in order to assist CMS.
3. To assist 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.
4. 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.
5. To provide the American Medical Association (AMA), for the
purpose of assisting CMS to identify medical doctors when CMS is unable
to establish an identity, provided the AMA agrees to:
a. Use the information provided by CMS solely to identify a medical
doctor;
b. Make no copies of the information it receives from the CMS,
except for one back-up copy;
c. Return such information to CMS upon completion of its matching
operation, and erase the back-up copy;
d. Establish appropriate administrative, technical, and physical
safeguards to prevent unauthorized use or disclosure of the records;
and
e. Sign a written statement attesting to its understanding of, and
willingness to abide by these provisions.
6. To support a Member of Congress or 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.
7. 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.
8. 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.
9. 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.
POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING,
AND DISPOSING OF RECORDS IN THE SYSTEM:
STORAGE:
All records are stored on magnetic media.
RETRIEVABILITY:
The records are retrieved alphabetically by the provider name,
social security number or by their assigned UPIN.
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:
CMS and the repository of the National Archive and Records
Administration (NARA) will retain identifiable UPIN assessment data for
a total period not to exceed fifteen (15) years.
[[Page 75322]]
SYSTEM MANAGER AND ADDRESS:
Director, Program Integrity Group, Office of Financial Management,
CMS, 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, health insurance
claim number, 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), address, date of birth, and sex.
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:
CMS obtains the identifying information in this system from
carriers. Information in these records concerning the eligibility of
physicians, practitioners, and medical groups for Medicare
reimbursement is obtained either directly from such entities through
Medicare Regional Offices, contractors, PRO, Department of Justice,
state or local judicial systems, medical licensing and certification
agencies or organizations, medical societies and medical associations.
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 and the Social Security
Administration 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 MS, P.O. Box 23035, 3545
Lakeland Drive, Jackson, MI 39225-3035.
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 SW., 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.
[[Page 75323]]
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.
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 43216-6788.
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 (C0), 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.
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. 04-27529 Filed 12-15-04; 8:45 am]
BILLING CODE 4120-03-P