[Federal Register Volume 72, Number 88 (Tuesday, May 8, 2007)]
[Notices]
[Pages 26121-26126]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E7-8757]


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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).

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SUMMARY: In accordance with the requirements of the Privacy Act of 
1974, CMS is proposing to modify or alter existing system of records 
titled ``Complaints Against Health Insurance Issuers and Health Plans 
(CAHII),'' System No. 09-70-9005, established at 66 FR 9858, (February 
12, 2001). We propose to assign a new CMS identification number to this 
system to simplify the obsolete and confusing numbering system 
originally designed to identify the Bureau, Office, or Center that 
maintained information in the Health Care Financing Administration 
systems of records. The new assigned identifying number for this system 
should read: System No. 09-70-0516.
    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 2 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 propose to add 2 new routine uses authorizing disclosure to 
support a CMS contractor, consultant, or a grantee of a CMS-
administered grant program, when disclosure is deemed reasonably 
necessary by CMS to combat fraud, waste, and abuse in certain health 
care programs. The new routine use will be published as routine use 
number 6. We will add a second new routine use to support another 
Federal agency or to an instrumentality of any governmental 
jurisdiction within or under the control of the United States, when 
disclosure is deemed reasonably necessary by CMS to combat fraud, 
waste, and abuse in certain health care programs. This new routine use 
will be published as routine use number 7. We will broaden the scope of 
this system by including 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'' apply when ever the system collects 
or maintain PHI. This system may contain PHI. In addition, our policy 
to prohibit release if there is a possibility that an individual can be 
identified through ``small cell size'' will apply to the data disclosed 
from 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 Medicare 
Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) 
(Pub. L. 108-173) provisions and to update language in the 
administrative sections to correspond with language used in other CMS 
SORs.
    The primary purpose of this system is to collect and maintain 
information initiated by consumers complaints/reports to CMS that their 
health insurance issuers and/or non-Federal governmental health plans 
are in violation of one or more of the following statutes: Sec. Sec.  
2722 and 2761 of the Public Health Service (PHS) Act; the Mental Health 
Parity Act of 1996 (MHPA); the Newborns' and Mothers' Health Protection 
Act of 1996 (NMHPA); and, the Women's Health and Cancer Rights Act of 
1998 (WHCRA). Information maintained in this system will also be 
disclosed to: (1) Support regulatory, reimbursement, 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 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; (4) inform a health insurance issuer and/or health plan who 
has been named in a complaint/inquiry and is believed to be potentially 
in violation of relevant portions of the PHS; (5) support litigation 
involving the Agency; and (6) combat fraud, waste, and abuse in certain 
health benefits programs. We have provided background information about 
this new 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

[[Page 26122]]

all portions of this notice. See ``Effective Dates'' section for 
comment period.

DATES: Effective Dates: CMS filed a new system report with the Chair of 
the House Committee on Government Reform and Oversight, 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 April 12, 2007. 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: Dave Mlawsky, Health Insurance 
Specialist, Division of Employer Operations, Employer Policy and 
Operations Group, Center for Beneficiary Choices, CMS, 7500 Security 
Boulevard, Mail Stop S3-16-26, Baltimore, Maryland 21244-1850. The 
telephone number is 410-786-6851 or e-mail <a href="/cdn-cgi/l/email-protection#4a2e2b3c232e6427262b3d3921330a29273964222239642d253c"><span class="__cf_email__" data-cfemail="751114031c115b18191402061e0c351618065b1d1d065b121a03">[email protected]</span></a>.

SUPPLEMENTARY INFORMATION:

I. Description of the Modified or Altered System of Records

A. Statutory and Regulatory Basis for SOR

    Authority for maintenance of this system is given under Sec. Sec.  
2722 and 2761 of the Public Health Service (PHS) Act; the Mental Health 
Parity Act of 1996 (MHPA); the Newborns' and Mothers' Health Protection 
Act of 1996 (NMHPA); and the Women's Health and Cancer Rights Act of 
1998 (WHCRA) with respect to non-Federal governmental plans.

B. Collection and Maintenance of Data in the System

    This system will collect and maintain individually identifiable and 
other data collected on individuals/consumers who make complaints/
inquiries to CMS that their health insurance issuers and/or non-Federal 
governmental health plans are in violation of the PHS.
    The system contains information such as consumer's name, address, 
phone number, the name and address of their health plan or health 
insurance issuer, their plan ID number or social security number, the 
nature of their complaint/inquiry against their health plan or issuer, 
and any medical and other additional information that is necessary for 
CAHII to help resolve the consumer's complaint.

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 CAHII 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 CAHII. 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 collect and maintain 
information initiated by consumers complaints/reports to CMS that their 
health insurance issuers and/or non-Federal governmental health plans 
are in violation of the PHS;
    2. Determines that the purpose for which the disclosure is to be 
made can only be accomplished if the record is provided in individually 
identifiable form;
    a. 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
    b. 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. Modified Routine Use Disclosures of Data in the System

    A. The Privacy Act allows 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 compatible use of data is known as a ``routine 
use.'' The proposed routine uses in this system meet the compatibility 
requirement of the Privacy Act. We are proposing to establish the 
following routine use disclosures of information maintained in the 
system:
    1. To support Agency contractors, consultants, or grantees that 
have been contracted by the Agency to assist in accomplishment of a CMS 
function relating to the purposes for this system and who need 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 
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, consultant, or grantee 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 or consultant 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

[[Page 26123]]

    c. Refer a complaint or inquiry with respect to Title I of the 
Health Insurance Portability and Accountability Act of 1996 (HIPAA), 
the Mental Health Parity Act of 1996 (MHPA), the Newborns' and Mothers' 
Health Protection Act of 1996 (NMHPA), and the Women's Health and 
Cancer Rights Act of 1998 (WHCRA).
    CAHII shares enforcement responsibilities with the U.S. Department 
of Labor, the U.S. Department of Treasury and State regulatory bodies 
with respect to Title I of HIPAA, MHPA, NMHPA and WHCRA. CAHII's 
enforcement responsibilities are discussed in the ``Description of the 
New System of Records'' section above. The Department of Labor enforces 
Title I of HIPAA, MHPA, NMHPA and WHCRA with respect to private group 
health plans. The Department of Treasury may levy excise taxes against 
private group health plans that do not comply with these Acts, except 
for WHCRA. In States that are substantially enforcing Title I of PHS, 
MHPA, NMHPA and WHCRA, the appropriate State agency enforces these 
provisions with respect to health insurance issuers.
    Occasionally, CAHII will receive an inquiry or complaint related to 
one of these four Acts in situations where it is within Labor's or 
Treasury's or a State's, and not CAHII's, jurisdiction to resolve. In 
such cases, CAHII must disclose information from the system of records 
to the appropriate agency so they can perform their enforcement 
function.
    Other Federal or state agencies in their administration of a 
Federal health program may require CAHII 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 CAHII information for the purposes 
of determining, evaluating and/or assessing cost, effectiveness, and /
or the quality of health care services provided in the state.
    3. 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 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, 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 parties contacts require CAHII 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.
    4. To inform a health insurance issuer and/or health plan, who has 
been named in a complaint and is believed to be potentially in 
violation of relevant portions of the PHS Act.
    When individuals file complaints or inquiries asking CAHII to 
clarify or enforce their rights under Title I of the Health Insurance 
Portability and Accountability Act of 1996 (HIPAA), the Mental Health 
Parity Act of 1996 (MHPA), the Newborns' and Mothers' Health Protection 
Act of 1996 (NMHPA), and the Women's Health and Cancer Rights Act of 
1998 (WHCRA), CAHII often must disclose information maintained in this 
system of records to the individual's health insurance issuer or health 
plan in order for CAHII to satisfy its statutory charge to enforce 
these Federal Acts with respect to non-Federal governmental health 
plans in all States and health insurance issuers in some States.
    5. To assist the Department of Justice (DOJ), court or adjudicatory 
body when:
    a. The Agency or any component thereof, or
    b. Any employee of the Agency in his or her official capacity, or
    c. Any employee of the Agency in his or her individual capacity 
where the DOJ has agreed to represent the employee, or
    d. The United States Government is a party to litigation or has an 
interest in such litigation, and by careful review, CMS determines that 
the records are both relevant and necessary to the litigation 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.
    6. To support a CMS contractor 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.
    7. To support another Federal agency or to an instrumentality of 
any governmental jurisdiction within or under the control of the United 
States (including any state or local governmental agency), that 
administers, or that has the authority to investigate potential fraud, 
waste, or abuse in a program funded in whole or in part by Federal 
funds, when disclosure is deemed reasonably necessary by CMS to 
prevent, deter, discover, detect,

[[Page 26124]]

investigate, examine, prosecute, sue with respect to, defend against, 
correct, remedy, or otherwise combat fraud, waste or abuse in such 
programs.
    Other agencies may require CAHII information for the purpose of 
combating fraud, waste or abuse in such Federally-funded programs.

B. Additional Provisions 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 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 or Altered 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 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: April 12, 2007.
Charlene Frizzera,
Acting Chief Operating Officer Centers for Medicare & Medicaid 
Services.
System No. 09-70-0516.

System Name:
    <bullet> Complaints Against Health Insurance Issuers and Health 
Plans (CAHII),'' 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:
    This system will collect and maintain individually identifiable and 
other data collected on individuals/consumers who make complaints/
inquiries to CMS that their health insurance issuers and/or non-Federal 
governmental health plans are in violation of the PHS ACT.

Categories of Records in the System:
    The system contains information such as consumer's name, address, 
phone number, the name and address of their health plan or health 
insurance issuer, their plan ID number or social security number, the 
nature of their complaint/inquiry against their health plan or issuer, 
and any medical and other additional information that is necessary for 
CAHII to help resolve the consumer's complaint.

Authority for Maintenance of the System:
    Authority for maintenance of this system is given under Sec. Sec.  
2722 and 2761 of the Public Health Service (PHS) Act; the Mental Health 
Parity Act of 1996 (MHPA); the Newborns' and Mothers' Health Protection 
Act of 1996 (NMHPA); and the Women's Health and Cancer Rights Act of 
1998 (WHCRA) with respect to non-Federal governmental plans.

Purpose(s) of the System:
    The primary purpose of this system is to collect and maintain 
information initiated by consumers complaints/reports to CMS that their 
health insurance issuers and/or non-Federal governmental health plans 
are in violation of one or more of the following statutes: Sec. Sec.  
2722 and 2761 of the Public Health Service (PHS) Act; the Mental Health 
Parity Act of 1996 (MHPA); the Newborns' and Mothers' Health Protection 
Act of 1996 (NMHPA); and , the Women's Health and Cancer Rights Act of 
1998 (WHCRA). Information maintained in this system will also be 
disclosed to: (1) Support regulatory, reimbursement, 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 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; (4) inform a health insurance issuer and/or health plan who 
has been named in a complaint/inquiry and is believed to be potentially 
in violation of relevant portions of the PHS ACT; (5) support 
litigation involving the Agency; and (6) combat fraud, waste, and abuse 
in certain health benefits programs.

[[Page 26125]]

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 information is to be used for a purpose 
that is compatible with the purpose(s) for which the information was 
collected. Any such compatible use of data is known as a ``routine 
use.'' The proposed routine uses in this system meet the compatibility 
requirement of the Privacy Act. We are proposing to establish the 
following routine use disclosures of information maintained in the 
system:
    1. To support Agency contractors, consultants, or grantees that 
have been contracted by the Agency to assist in accomplishment of a CMS 
function relating to the purposes for this system and who need 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 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. Refer a complaint or with respect to Title I of the Health 
Insurance Portability and Accountability Act of 1996 (HIPAA), the 
Mental Health Parity Act of 1996 (MHPA), the Newborns' and Mothers' 
Health Protection Act of 1996 (NMHPA), and the Women's Health and 
Cancer Rights Act of 1998 (WHCRA).
    3. 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.
    4. To inform a health insurance issuer and/or health plan, who has 
been named in a complaint and is believed to be potentially in 
violation of relevant portions of the PHS Act.
    5. To assist the Department of Justice (DOJ), court or adjudicatory 
body when:
    a. The Agency or any component thereof, or
    b. any employee of the Agency in his or her official capacity, or
    c. any employee of the Agency in his or her individual capacity 
where the DOJ has agreed to represent the employee, or
    d. the United States Government is a party to litigation or has an 
interest in such litigation, and by careful review, CMS determines that 
the records are both relevant and necessary to the litigation 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.
    6. To support a CMS contractor 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 programs.
    7. To support another Federal agency or to an instrumentality of 
any governmental jurisdiction within or under the control of the United 
States (including any state or local governmental agency), that 
administers, or that has the authority to investigate potential fraud 
or abuse in a program funded in whole or in part by Federal funds, when 
disclosure is deemed reasonably necessary by CMS to prevent, deter, 
discover, detect, investigate, examine, prosecute, sue with respect to, 
defend against, correct, remedy, or otherwise combat fraud or abuse in 
such programs.
    B. Additional Provisions 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 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).

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., 
consumer's name or health insurance claims number, if, applicable.

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

[[Page 26126]]

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. 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 Policy, Employer Policy and Operations Group, 
Center for Beneficiary Choices, 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, 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 collected and maintained in this system are retrieved from 
individuals/consumers who file complaints/reports to CMS that their 
health insurance issuers and/or non-Federal governmental health plans 
are in violation of the PHS ACT.

Systems Exempted from Certain Provisions of the Act:
    None.
[FR Doc. E7-8757 Filed 5-7-07; 8:45 am]
BILLING CODE 4120-03-P


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