(Medicare General Information, Eligibility, and Entitlement)

We expect that most requests from TriCare for information will involve primarily Part B Medicare operations in such areas as identification of physicians and other medical practitioners who may be engaging in providing excess services or fraud.  Before we release this information to a requ esting TriCare contractor that is not also a Medicare contractor, a Medicare contractor must have previously released the information in the administration of Title XVIII to:   An official of a medical or other applicable professional society or   An official  of a State licensing board, or   Any other officer, agency, establishment or department of the Federal Government charged with the duty of conducting an investigation to determine whether there has been a violation of any provision of Federal law (see 120  of this chapter).   We may also disclose to TriCare the types of data covered in 100.2 of this chapter, upon request when authorized by the beneficiary or the beneficiary's legal representat ive.  In addition, we will, upon request, make available to TriCare Economic Index Data (as prescribed by 405.502(a) and 405.504(a) of Regulations No. 5) that might affect the limits on prevailing charge levels.   130.3 - Procedures for Release  (Rev. 1, 09- 11-02)  TriCare fiscal agents desiring Medicare information will usually request it either through the TriCare headquarters in Denver or through the parallel RO.  The TriCare headquarters will refer the request to the parallel RO.  Should a Medicare con tractor receive a request directly from TriCare, it will refer the request to the RO.  The RO will meet with the TriCare fiscal agent and the Medicare contractor to determine exactly what is needed, impress upon the TriCare contractor that TriCare may not further disclose the information, and indicate the cost involved, if any.  (Also note that payment may be estimated or waived if collection would interfere with efficient administration.)  At the RO's discretion, the Medicare contractor and the TriCare fis cal agent may meet to discuss data and cost requirements without regional involvement.  Upon agreement about data and cost requirements, the RO will authorize release of the information from the Medicare contractor to the TriCare fiscal agent.   140 - Discl osure of Information About Providers and Suppliers by CMS  (Rev. 1, 09- 11-02)  In keeping with the spirit of the Freedom of Information Act and growing consumer interest in health care facilities and suppliers, CMS has made available to the public various final reports and other information regarding providers and suppliers.  Disclosure to the public by a contractor is limited, but the following guidelines indicate what information is available, to whom it may be released, and the source to which a requestor should be directed for information that the contractor is not authorized to release.   140.1 - Disclosure Necessary for Proper Administration of the Medicare Program (CMS)  (Rev. 1, 09- 11-02)  A.  Disclosure of Survey Information of the Joint Commission on Accreditation for Hospitals (JCAH), American Osteopathic Association (AOA), or any other National Accreditation Organization   The CMS may not disclose any accreditation survey made and released by the JCAH, AOA or other national accreditation organization except as prescribed by regulations.  Accreditation letters and accompanying Recommendations and Comments prepared by the JCAH, AOA or other national accreditation organization for the provider's accreditation survey are confidential and exempted from public disclosure.   A copy of the provider's most recent accreditation survey may be disclosed with the provider's authorization to any authorized representative, employee or agent of CMS for official use only in connection with the Medicare sample validation or substantial allegation survey program.  B.  Disclosure of Information About Hospitals, Skilled Nursing Facilities, Home Health Agencies, and Independent Laboratories   Information about a hospital, skilled nursing facility, or home health agency, as wel l as information about independent laboratories, providers of outpatient physical therapy (rehabilitation and public health agencies and clinics) and portable X -ray suppliers, may be disclosed without the authorization of the institution or organization when such disclosure is required for the proper performance of the duties of:   An officer or employee of the Department;   An officer or employee of a contractor; or   An officer or employee of a State agency when necessary to carry out their duties under State law in the licensing or approving of hospitals, skilled nursing facilities, home health agencies, or independent laboratories, etc.  Information obtained in the provider certification process is not to be disclosed to those not included in the above three categories, except as indicated in 140.3  below.  However, informa tion that a particular institution is participating in the program may be released; and information indicating the specialties for which title XVIII payment may be made for services of a particular independent laboratory may be released.  This information is usually available from the Directory of Medical Providers and Suppliers of Services published by the Government Printing Office.   C.  Contractors' Disclosure to Third Parties   Disclosure to third parties for program purposes of information about identif iable physicians and other suppliers who are natural persons is governed by the same restrictions and procedures as disclosure about named beneficiaries to third parties for program purposes.  (See 50 of this chapter.)   Information about unidentifiable individuals or about providers or corporate entities (e.g., clinics or independent laboratories), is not exempt from disclosure by section 1106 and regulations at 42 CFR, Part 401.  However, it is not to be disclosed by third parties to which information is disclosed for program purposes.  If the information the contractor discloses to third parties for program purposes is solely information that does not identify, or make identifiable, individua ls (e.g., aggregate statistics or records on providers and other corporate entities) the following sample letter is to be used instead of the letter in 50B  of this chapter.   Sample Letter fro m Contractor to Third Party   Dear   We are prepared to make available to your organization certain CMS records so that (state reason).   However, before making these records available to you, we must point out that by law all information derived in the admin istration of the Social Security Act is subject to the provisions of the Freedom of Information Act, which exempts from disclosure certain categories of records.  In order to assure that no records held confidential under the Freedom of Information Act are  disclosed, you must agree to meet the following conditions before we make any social security records available to you:    1. Any information we supply you will be used only for the specific purpose intended and for no other purpose.   2. All employees having  access to this material will be instructed as to its confidential nature.  3. An official of your company will assume responsibility for ensuring that the information is not revealed to any other party.   4. You must return the material to us as soon as you have finished the job, and you may not retain copies.  5. We must have a letter from a responsible official in your office agreeing to these conditions and assuming responsibility for carrying them out. Upon receipt of this letter from your organization, we  will make available to you the CMS records you requested.  Sincerely yours,   140.2 - Disclosure of Medicare Reports  (Rev. 1, 09- 11-02)  A.  Provider Survey Report and Related Information  Information concerning survey reports of providers or facilities, a s well as statements of deficiencies based on survey reports are available at the local social security office or the public health assistance office in the area where the facility is located.  The following data may be released under this provision.  The o fficial Medicare survey report;   Statement of deficiencies which have been conveyed to the provider following a survey;   Plans of correction, and pertinent comments submitted by the provider relating to Medicare deficiencies cited following a survey.  B.  Program Validation Review Reports and Other Formal Evaluation (CMS)   Upon written request, CMS makes available to the public official reports and other formal evaluations of the performance of providers.  After CMS prepares the survey reports and other for mal evaluations, it must provide the evaluated provider an opportunity (not to exceed 30 days) to review the report and submit comments on the accuracy of the findings and conclusions.  CMS must incorporate the provider's pertinent comments in the report.  Generally, the RO serving the area in which the provider is located releases Program validation review reports.  It will provide a copy of the report and the provider's comments to the contractors servicing the provider.  CMS may also make available to th e public, subject to certain possible exemptions, informal reports and other evaluations of the performance of providers prepared by the contractor.  The contractor refers requests for these reports to the Medicare regional office with a copy of the inform ation requested.   C. Provider Cost Reports ( A/B MAC (A) or (HHH) )  1. Requests for Disclosure   Requests by the public either to inspect or to obtain a copy of a provider cost report must be in writing and must identify the provider or class of providers and specific cost reports requested.   NOTE:   Personal salary information cannot be disclosed.  2. Ten Day Notice Requirement   A/B MACs (A) or (HHH) must respond in writing within 10 working days after receipt of the written request, advising the requestor of the date the reports will be available.  This date should be no earlier than 10 working days from the date of the contractor's response.  (For exceptions, see Exceptions To 10- Day Notice Requirement immediately below.)  A copy of this response must be s ent simultaneously to the provider, thus putting it on notice that its report has been requested and by whom.  (For exception, see 140.3 below.)  If the request is for a report submitted by a former owner of a participating facility, copies of the contractor's response should go to both the present and former owners.  If the request is for a report submitted by a provider no longer participating in the program, a copy of the contractor's response should be sent to the former provider. (For both former owners and former providers the copy of the response should be sent to the last known address of the party.)   If we cannot make the information available within a reasonable period of time, our response will include a brief explanation for the delay (e.g., because of the extent of searching, photocopying, or delay in securing reports from records retention centers).  In addition to the provider's copy, the contractor sends a copy to the CMS re gional office servicing the provider.  If a contractor receives a request for information concerning providers that it does not service, it will immediately forward such request to the CMS regional office servicing the provider and will inform the requeste r of its action.  The regional office forwards the request to the servicing contractor.   3. Exceptions to 10 Day Notice Requirement   No 10- day delay in furnishing cost reports is necessary in the case of requests from:   Federal or State agencies that need cost report information to carry out requirements of the Social Security Act (e.g., a State health planning agency under title XI ( 1122 ), or a Medicaid State agency under title XIX).  The Congress -  Requests from Congress are limited to those from the Congress as an official body (e.g., the Speaker of the House or the President of the Senate, or from the chairman of a committee or subcommittee of the House or Senate with jurisdiction related t o the information requested).  Requests from individual members of the House or Senate are considered requests from the public.   4. Information That Can Be Disclosed   CMS's rules limit disclosure to cost report documents that providers are required by regulations and instructions to submit.  In the case of a settled cost report, this includes the contractor's notice of program reimbursement.  Cost report documents include the statistical page, the settlement pages, trial balance of expenses, cost finding schedules, balance sheet, statement of income and expenses, and other schedules or documents required as part of the regular cost report process.  (Where a provider, after first obtaining program approval, submits equivalent documents in lieu of official pro gram documents, such documents are subject to the same disclosure rules as apply to official forms.)   Information That May Not Be Disclosed   If a provider chooses to submit with its cost report additional information not specifically required by regulations or instructions, the contractor should not disclose such information unless it is contained within an official document or the equivalent thereof. For example, some providers may submit supplementary analyses of certain expenses, details of the  professional component adjustment, financial statements (other than the statement of income and expenses and the balance sheet as required in accordance with cost reporting instructions), or income tax returns that are not required by the program.  These would not be disclosable by the contractor.   Except where a provider has not submitted an acceptable cost report and supplements are required to complete the report, any additional documents or schedules that the contractor requires the provider to submit in support of its cost representations are also not to be disclosed.  In addition, do not disclose audits, schedules, letters, notes, and comments; comments on results of desk reviews (including copies of the actual desk review documents); contractor notes  and comments (including transmittal letters); audit adjustment summaries that contractors and auditors are required to prepare; and information pertaining to an individual patient.  Contractors acknowledge such requests and refer them to the regional offi ce.