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                              SORN 09-70-0514
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SORN 09-70-0514








  
  
    

  
      





**System Name:**"Medicare Provider Analysis and Review (MEDPAR) HHS/CMS/OIS."

**Security Classification:**Level Three Privacy Act Sensitive Data.

**System Location(s):**

Centers for Medicare & Medicaid Services (CMS) Data Center, 7500 Security Boulevard, North Building, First Floor, Baltimore, Maryland 21244-1850.

**Categories of Individuals Covered by the System:**The MEDPAR contains a summary of all services rendered to a Medicare beneficiary, from the time of admission through discharge, for a stay in an inpatient hospital and/or Skilled Nursing Facilities (SNF), Supplemental Security Income (SSI) entitlement information that CMS receives from the Social Security Administration on Medicare beneficiaries who have had stays at inpatient hospitals and SNF, and enrollment data on Medicare beneficiaries.

**Categories of Records in the System:**The MEDPAR contains information necessary for appropriate Medicare claim processing. It also contains, but is not limited to, the Medicare health insurance claim number (HICN), gender, race, age (no date of birth), zip code, state and county for Medicare beneficiaries who have received inpatient hospital and SNF services.

**Authority for Maintenance of the System:**Authority for maintenance of this system is given under sections 1102(a), 1871, and 1886(d)(5)(F) of the Social Security Act, (Title 42 United States Code (U.S.C.) §§ 1302(a), 1395hh, and 1395ww(d)(5)(F)). Authority is also given under section 951 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Pub. L. 108-173).

**Purpose(s):**The primary purpose of the system is to collect and maintain information for all services rendered during Medicare beneficiary stays in an inpatient hospital and/or Skilled Nursing Facilities, so as to enable CMS and its contractors to facilitate research on the quality and effectiveness of care provided, update annual hospital Inpatient Prospective Payment System (IPPS) rates, and to calculate Supplemental Security Income ratios for hospitals that are paid under the hospital IPPS and serve a disproportionate share of low-income patients, (hospitals that serve a disproportionate share of low-income patients are entitled to increased reimbursement under the IPPS). Information retrieved from this system will also be disclosed to: (1) Support regulatory, reimbursement, and policy functions performed within the agency or by a contractor or consultant; (2) provide system data to a hospital that has an appeal properly pending before the Provider Reimbursement Review Board (PRRB) or before an intermediary; (3) provide system data when all requirements have been met to a hospital that may be entitled to disproportioned share hospital payments and makes a requests in accordance with section 951 of the MMA; (4) assist another Federal or state agency with information to enable such agency to administer a Federal health benefits program, or 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; (5) support constituent requests made to a Congressional representative; (6) support litigation involving the agency; (7) facilitate research on the quality and effectiveness of care provided; and, (8) combat fraud and abuse in certain Federally-funded health benefits programs.

**Routine Uses of Records Maintained in the System, Including Categories of 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 agency contractors, or consultants who have been engaged by the agency to assist in the performance of a service related to this system of records and who need to have access to the records in order to perform the activity.

2. To a hospital that has an appeal properly pending before the Provider Reimbursement Review Board, or before an intermediary, on the issue of whether it is entitled to disproportionate share hospital payments, or the amount of such payments. As a condition of disclosure under this routine use, CMS will require the recipient of the information to:

a. Establish reasonable administrative, technical, and physical safeguards to prevent unauthorized access, use, or disclosure of the record or any part thereof;

b. Remove or destroy the information that allows the subject individual(s) to be identified at the earliest time at which removal or destruction can be accomplished consistent with the purpose of the request;

c. Refrain from using or disclosing the information for any purpose other than the stated purpose under which the information was disclosed; and

d. Attest in writing that it understands the foregoing provisions, and is willing to abide by the foregoing provisions and any additional provisions that CMS deems appropriate in the particular circumstances.

3. To a hospital that may be entitled to disproportionate share hospital payments, or the amount of such payments, for cost reporting periods that span December 8, 2004, and beyond. As a condition of disclosure under this routine use, CMS will require the recipient of the information to:

a. Establish reasonable administrative, technical, and physical safeguards to prevent unauthorized access, use or disclosure of the record or any part thereof;

b. Remove or destroy the information that allows the subject individual(s) to be identified at the earliest time at which removal or destruction can be accomplished consistent with the purpose of the request;

c. Refrain from using or disclosing the information for any purpose other than the stated purpose under which the information was disclosed; and

d. Attest in writing that it understands the foregoing provisions, and is willing to abide by the foregoing provisions and any additional provisions that CMS deems appropriate in the particular circumstances.

4. To another Federal or state agency to:

a. Contribute to the accuracy of CMS' proper payment of Medicare benefits, and/or

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.

5. To an individual or organization for research, evaluation, or epidemiological projects related to the prevention of disease or disability, or the restoration or maintenance of health, and for payment related projects.

6. To a member of Congress or to a Congressional staff member in response to an inquiry of the Congressional office made at the written request of the constituent about whom the record is maintained.

7. To the Department of Justice (DOJ), court or adjudicatory body when:

a. The agency or any component thereof, or

b. Any employee of the agency in his or her official capacity, or

c. Any employee of the agency in his or her individual capacity where the DOJ has agreed to represent the employee, or

d. The United States Government is a party to litigation or has an interest in such litigation, and by careful review, CMS determines that the records are both relevant and necessary to the litigation and that the use of such records by the DOJ, court or adjudicatory body is compatible with the purpose for which the agency collected the records.

8. To a CMS contractor (including, but not necessarily 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 another Federal agency or to an instrumentality of any governmental jurisdiction within or under the control of the United States (including any State or local governmental agency), that administers, or that has the authority to investigate potential fraud or abuse in, a health benefits program funded in whole or in part by Federal funds, when disclosure is deemed reasonably necessary by CMS to prevent, deter, discover, detect, investigate, examine, prosecute, sue with respect to, defend against, correct, remedy, or otherwise combat fraud or abuse in such programs.

**B. Additional 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 who are familiar with the enrollees could, because of the small size, use this information to deduce the identity of the beneficiary).

**Policies and Practices for Storing, Retrieving, Accessing, Retaining, and Disposing of Records in the System—**

**Storage:**All records are stored on magnetic media.

**Retrievability:**The Medicare records are retrieved by HICN of the beneficiary.

**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 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 identifiable MEDPAR data for a total period not to exceed 25 years. All claims-related records are encompassed by the document preservation order and will be retained until notification is received from DOJ.

**System Manager(s) and Address(es):**

Director, Division of Acute Care, Hospital and Ambulatory Provider Group, Center for Medicare Management, CMS, Room C4-08- 06, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

**Notification Procedure:**For purpose of access, the subject individual should write to the system manager who will require the system name, HICN, address, age, gender, and for verification purposes, the subject individual's name (woman's maiden name, if applicable) and social security number (SSN). Furnishing the SSN is voluntary, but it may make searching for a record easier and prevent delay.

**Record Access Procedures:**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's National Claims History system of records, enrollment data on Medicare beneficiaries, and SSI eligibility information from the Social Security Administration.

**System Exempted from Certain Provisions of the Act:**None.

                    
  


Content created by Freedom of Information Act (FOIA) Division Content last reviewed December 21, 2017 Back to top
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