53666 Federal Register / Vol. 70, No. 174 / Friday, September 9, 2005 / Notices 

Dated: August 25, 2005. 

Michelle Shortt, 

Director, Regulations Development Group, 

Office of Strategic Operations and Regulatory 

Affairs. 

[FR Doc. 05–17735 Filed 9–8–05; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[HHS Computer Match No. 0508; CMS 

Computer Match No. 2005–05] 

Privacy Act of 1974 

AGENCY: Department of Health and 

Human Services (HHS), Centers for 

Medicare & Medicaid Services (CMS). 

ACTION: Notice of Computer Matching 

Program (CMP). 

SUMMARY: In accordance with the 

requirements of the Privacy Act of 1974, 

as amended, this notice establishes a 

CMP that CMS plans to conduct with 

the Florida Agency for Health Care 

Administration (AHCA). We have 

provided background information about 

the proposed matching program in the 

SUPPLEMENTARY INFORMATION section 

below. The Privacy Act requires that 

CMS provide an opportunity for 

interested persons to comment on the 

proposed matching program. We may 

defer implementation of this matching 

program if we receive comments that 

persuade us to defer implementation. 

See EFFECTIVE DATES section below for 

comment period. 

EFFECTIVE DATES: CMS filed a report of 

the CMP 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 09/01/2005. We will not 

disclose any information under a 

matching agreement until 40 days after 

filing a report to OMB and Congress or 

30 days after publication. 

ADDRESSES: The public should address 

comments to: CMS Privacy Officer, 

Division of Privacy Compliance Data 

Development, Enterprise Databases 

Group, Office of Information Services, 

CMS, Mail-stop 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: 

Lourdes Grindal Miller, Health 

Insurance Specialist, Program Integrity 

Group, Office of Financial Management, 

CMS, Mail-stop C3–02–16, 7500 

Security Boulevard, Baltimore Maryland 

21244–1850. The telephone number is 

410–786–1022 and e-mail is 

Lourdes.grindalmiller@cms.hhs.gov. 

SUPPLEMENTARY INFORMATION: 

Description of the Matching Program 

A. General 

The Computer Matching and Privacy 

Protection Act of 1988 (Public Law 

(Pub. L.) 100–503), amended the Privacy 

Act (5 U.S.C. 552a) by describing the 

manner in which computer matching 

involving Federal agencies could be 

performed and adding certain 

protections for individuals applying for 

and receiving Federal benefits. 

Section 7201 of the Omnibus Budget 

Reconciliation Act of 1990 (Pub. L. 101–

508) further amended the Privacy Act 

regarding protections for such 

individuals. The Privacy Act, as 

amended, regulates the use of computer 

matching by Federal agencies when 

records in a system of records are 

matched with other Federal, state, or 

local government records. It requires 

Federal agencies involved in computer 

matching programs to: 

1. Negotiate written agreements with 

the other agencies participating in the 

matching programs; 

2. Obtain the Data Integrity Board 

approval of the match agreements; 

3. Furnish detailed reports about 

matching programs to Congress and 

OMB; 

4. Notify applicants and beneficiaries 

that the records are subject to matching; 

and, 

5. Verify match findings before 

reducing, suspending, terminating, or 

denying an individual’s benefits or 

payments. 

B. CMS Computer Matches Subject to 

the Privacy Act 

CMS has taken action to ensure that 

all CMPs that this Agency participates 

in comply with the requirements of the 

Privacy Act of 1974, as amended. 

Dated: August 30, 2005. 

John R. Dyer, 

Chief Operating Officer, Centers for Medicare 

& Medicaid Services. 

CMS COMPUTER MATCH No. 2005–05 

NAME: 

‘‘Computer Matching Agreement 

(CMA) Between the Centers for 

Medicare & Medicaid Services (CMS) 

and the State of Florida Agency for 

Health Care Administration (AHCA) 

titled ‘‘Disclosure of Medicare and 

Medicaid Information.’’

SECURITY CLASSIFICATION: 

Level Three Privacy Act Sensitive. 

PARTICIPATING AGENCIES: 

The Centers for Medicare & Medicaid 

Services, and State of Florida Agency 

for Health Care Administration. 

AUTHORITY FOR CONDUCTING MATCHING

PROGRAM: 

This CMA is executed to comply with 

the Privacy Act of 1974 (Title 5 United 

States Code (U.S.C.) § 552a), as 

amended, (as amended by Public Law 

(Pub. L.) 100–503), the Computer 

Matching and Privacy Protection Act 

(CMPPA) of 1988), the Office of 

Management and Budget (OMB) 

Circular A–130, titled ‘‘Management of 

Federal Information Resources’’ at 65 

Federal Register (FR) 77677 (December 

12, 2000), 61 FR 6435 (February 20, 

1996), and OMB guidelines pertaining 

to computer matching at 54 FR 25818 

(June 19, 1989). 

This Agreement provides for 

information matching fully consistent 

with the authority of the Secretary of the 

Department of Health and Human 

Services (Secretary). Section 1816 of the 

Social Security Act (the Act) permits the 

Secretary to contract with Fiscal 

Intermediaries (FI) to ‘‘make such audits 

of the records of providers as may be 

necessary to insure that proper 

payments are made under this part,’’

and to ‘‘perform such other functions as 

are necessary to carry out this 

subsection’’ (42 U.S.C. 1395h(a)). 

Section 1842 of the Act provides that 

the Secretary may contract with entities 

known as carriers to ‘‘make such audits 

of the records of providers of services as 

may be necessary to assure that proper 

payments are made’’ (42 U.S.C. 

1395u(a)(1)(C)); ‘‘assist in the 

application of safeguards against 

unnecessary utilization of services 

furnished by providers of services and 

other persons to individuals entitled to 

benefits’’ (42 U.S.C. 1395u(a)(2)(B)); and 

‘‘to otherwise assist * * * in 

discharging administrative duties 

necessary to carry out the purposes of 

this part’’ (42 U.S.C. 1395u(a)(4)). 

Furthermore, § 1874(b) of the Act 

authorizes the Secretary to contract with 

any person, agency, or institution to 

secure on a reimbursable basis such 

special data, actuarial information, and 

other information as may be necessary 

in the carrying out of his functions 

under this title (42 U.S.C. 1395kk(b)). 

Section 1893 of the Act establishes 

the Medicare Integrity Program, under 

Federal Register / Vol. 70, No. 174 / Friday, September 9, 2005 / Notices 53667 

which the Secretary may contract with 

eligible entities to conduct a variety of 

program safeguard activities, including 

fraud review employing equipment and 

software technologies that surpass the 

existing capabilities of FIs and carriers 

(42 U.S.C. 1395ddd)). The contracting 

entities are called Program Safeguards 

Contractors. 

Pursuant to § 409.902, Florida 

Statutes (F.S.), AHCA is charged with 

the administration of the Medicaid 

program in Florida, and is the single 

state agency for such purpose. AHCA is 

required to operate a program to oversee 

the activities of Florida Medicaid 

recipients and providers to ensure that 

fraudulent and abusive behavior occurs 

to the minimum extent possible 

(§ 409.913, F.S.). 

AHCA’s disclosure of the Medicaid 

data pursuant to this agreement is for 

purposes directly connected with the 

administration of the Medicaid program, 

in compliance with 42 CFR 431.300 

through 431.307. Those purposes are the 

detection, prosecution and deterrence of 

fraud and abuse (F&A) in the Medicaid 

program. 

PURPOSE(S) OF THE MATCHING PROGRAM: 

The purpose of this agreement is to 

establish the conditions, safeguards, and 

procedures under which CMS will 

conduct a computer matching program 

with AHCA to study claims, billing, and 

eligibility information to detect 

suspected instances of Medicare and 

Medicaid F&A in the State of Florida. 

CMS and AHCA will provide EDS, a 

CMS contractor (hereinafter referred to 

as the ‘‘Custodian’’) with Medicare and 

Medicaid records pertaining to 

eligibility, claims, and billing which the 

Custodian will match in order to merge 

the information into a single database. 

Utilizing fraud detection software, the 

information will then be used to 

identify patterns of aberrant practices 

requiring further investigation. The 

following are examples of the type of 

aberrant practices that may constitute 

F&A by practitioners, providers, and 

suppliers in the State of Florida 

expected to be identified in this 

matching program: (1) Billing for 

provisions of more than 24 hours of 

services in one day, (2) providing 

treatment and services in ways more 

statistically significant than similar 

practitioner groups, and (3) up-coding 

and billing for services more expensive 

than those actually performed. 

CATEGORIES OF RECORDS AND INDIVIDUALS

COVERED BY THE MATCH: 

This CMP will enhance the ability of 

CMS and AHCA to detect F&A by 

matching claims data, eligibility, and 

practitioner, provider, and supplier 

enrollment records of Medicare 

beneficiaries, practitioners, providers, 

and suppliers in the State of Florida 

against records of Florida Medicaid 

beneficiaries, practitioners, providers, 

and suppliers in the State of Florida. 

DESCRIPTION OF RECORDS TO BE USED IN THE

MATCHING PROGRAM: 

The data for CMS are maintained in 

the following Systems of Records: 

National Claims History (NCH), System 

No. 09–70–0005 was most recently 

published in the Federal Register, at 67 

FR 57015 (September 6, 2002.) NCH 

contains records needed to facilitate 

obtaining Medicare utilization review 

data that can be used to study the 

operation and effectiveness of the 

Medicare program. Matched data will be 

released to AHCA pursuant to the 

routine use as set forth in the system 

notice. 

Carrier Medicare Claims Record, 

System No. 09–70–0501 was published 

in the Federal Register at 67 FR 54428 

(August 22, 2002). Matched data will be 

released to AHCA pursuant to the 

routine use as set forth in the system 

notice. 

Enrollment Database, System No. 09–

70–0502 was published in the Federal 

Register at 67 FR 3203 (January 23, 

2002). Matched data will be released to 

AHCA pursuant to the routine use set 

forth in the system notice. 

Intermediary Medicare Claims 

Record, System No. 09–70–0503 was 

published in the Federal Register at 67 

FR 65982 (October 29, 2002). Matched 

data will be released to AHCA pursuant 

to the routine use as set forth in the 

system notice. 

Unique Physician/Provider 

Identification Number, System No. 09–

70–0525, was most recently published 

in the Federal Register at 69 FR 75316 

(December 16, 2004). Matched data will 

be released to AHCA pursuant to the 

routine use as set forth in the system 

notice. 

Medicare Supplier Identification File, 

System No. 09–70–0530 was most 

recently published in the Federal 

Register, at 67 FR 48184 (July 23, 2002). 

Matched data will be released to AHCA 

pursuant to the routine use as set forth 

in the system notice. 

Medicare Beneficiary Database, 

System No. 09–70–0536 was published 

in the Federal Register at 67 FR 63392 

(December 6, 2001). Matched data will 

be released to AHCA pursuant to the 

routine use as set forth in the system 

notice. 

The data for AHCA are maintained in 

the following data files: Claims File 

Layouts HIPAA Version, Download File 

Record File-Claims, Recipient File 

Layout, Provider File Layout. 

INCLUSIVE DATES OF THE MATCH: 

The CMP shall become effective no 

sooner than 40 days after the report of 

the Matching Program is sent to OMB 

and Congress, or 30 days after 

publication in the Federal Register, 

which ever is later. The matching 

program will continue for 18 months 

from the effective date and may be 

extended for an additional 12 months 

thereafter, if certain conditions are met. 

[FR Doc. 05–17846 Filed 9–8–05; 8:45 am] 

BILLING CODE 4120–03–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

Privacy Act of 1974; Report of a New 

System of Records 

AGENCY: Department of Health and 

Human Services (HHS), Centers for 

Medicare & Medicaid Services (CMS). 

ACTION: Notice of a new System of 

Records (SOR). 

SUMMARY: In accordance with the 

requirements of the Privacy Act of 1974, 

we are proposing to create a new SOR 

titled, ‘‘Data Collection Secondary to 

Coverage Decision (DCSCD) System, 

HHS/CMS/OCSQ, System No. 09–70–

0547.’’ National Coverage 

Determinations (NCDs) are 

determinations by the Secretary with 

respect to whether or not a particular 

item or service is covered nationally 

under title XVIII of the Social Security 

Act (the Act) § 1869(f)(1)(B). In order to 

be covered by Medicare, an item or 

service must fall within one or more 

benefit categories contained within Part 

A or Part B, and must not be otherwise 

excluded from coverage. Moreover, with 

limited exceptions, the expenses 

incurred for items or services must be 

‘‘reasonable and necessary for the 

diagnosis or treatment of illness or 

injury or to improve the functioning of 

a malformed body member,’’

§ 1862(a)(1)(A). CMS has determined 

that the evidence is adequate to 

conclude that certain identified 

diagnoses are reasonable and necessary 

in several patient groups where certain 

criteria for these patients have been met. 

The reasonable and necessary 

determination requires that patients 

meet the criteria and are consistent with 

the trials discussed. Collection of these 

data elements allows that determination 

to be made. We are particularly