evekhm/cms_iom_500 huggingface dataset:
(Medicare General Information, Eligibility, and Entitlement)
B. Disclosure to Third Parties   In the administration of the program, the contractor may want to avail itself of the services of third parties such as auditors, court reporters, public stenographers, microfilm processors, or companies developing equipment for use in the program.  The arrangement between the contractor and such third parties, even where it is of short duration, is in the nature of an agreement supplementing its contract with the Secretary. Under such an arrangement, disclosure to the se parties of necessary information that relates to, and is used in, the administration of title XVIII of the Social Security Act is permitted as provided by 1106 of the Social Security Act and Regulation No. 1.  However, when the contractor enters into a n agreement with these parties, it will inform them that 401.1 of Regulation No. 1 precludes the disclosure of any information on identifiable individuals.  It will call their attention to the penalty clause of 1106(a).  It will call attention to these p rovisions by letter (see below), and obtain a written agreement to comply with the disclosure provisions before releasing any information.  Sample Letter to Third Party   Dear   We are prepared to make available to your organization certain social security records so that (state reason).   However, before making these records available, we must point out that by law, all information derived on identifiable individuals in the administration of the Social Security Act is confidential and may be disclosed to othe rs only under very restrictive circumstances.  Regulation No. 1 of the Social Security Administration which governs disclosure of official records and information precludes you from disclosing any information on identifiable individuals.  You should also note that 1106(a) of the Social Security Act imposes criminal penalties for unauthorized disclosure.   Any social security records which do not identify or make identifiable any individuals are not subject to these restrictions, but may be restricted under  the provisions of the Freedom of Information Act.   In order to comply with the requirements of the Social Security Act and Freedom of Information Act you must agree to the following conditions before we can make any social security records available to yo u:  Any information which is turned over to you will be used only for the specific purpose intended.  All employees having access to this material will be instructed as to its confidential nature.   An official of your company will assume the responsibility  for ensuring that the information is not revealed to another.   The material must be returned to us as soon as you have finished the job.
(Medicare General Information, Eligibility, and Entitlement)
An official of your company will assume the responsibility  for ensuring that the information is not revealed to another.   The material must be returned to us as soon as you have finished the job.   We must have a letter from a responsible official in your office agreeing to these conditions and assuming responsibi lity for carrying them out.   Upon receipt of such letter, the social security records will be made available to you.  Sincerely yours,   60 - Disclosure of Information  (Rev. 123, Issued: 05- 10-19, Effective: 06- 11-19, Implementation: 06- 11-19)  For more information related to disclosure of PII and PHI, please refer to Pub. 100- 9, Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 6, section 80.  70 - Disclosure of Information after the Death of a Beneficiary (Contractors)  (Rev. 1, 09- 11-02)  The contractor may disclose information concerning the fact, date, or circumstances of death when efficient administration permits.  The request must be in writing and must state why the information is sought.  Additional information may be dis closed to a surviving relative or an authorized representative of that relative, the legal representative of the estate, or to a probate court for the purpose of appointing a legal representative of the decedent's estate.  The contractor must exercise care, however, to see that it discloses no information which would appear to be detrimental to the individual or the individual's estate, i.e., unusual place or manner of death or information which could create a liability to the individual's estate.   The cont ractor may disclose medical information, in form and detail consistent with proper and efficient administration of the program, when such disclosure is reasonably necessary for a title XVIII purpose. (See 50  of this chapter for further information concerning the disclosure of non- medical and medical information when necessary for a program purpose.)
(Medicare General Information, Eligibility, and Entitlement)
The contractor may disclose medical information obtained in the administration of title XVIII to a surviving relative or legal representative of the estate of the individual or to others for other than a title XVIII purpose, when such information is necessary for a determination as to what supplementary benefits or services such deceased individual  was eligible to receive under a private or public hospital or medical insurance program which is consistent with the purposes and objectives of title XVIII.  The contractor may disclose such information only if the individual has consented to such disclos ure or a surviving relative or the legal representative of the estate consents.  (See 80.1  "Release of Title XVIII Claims Information for Complementary Insurance Purposes" in this chapter.)   80 - Disclosure to Third Parties for Other than Program Purposes (Contractors)  (Rev. 1, 09- 11-02)  A. Non -medical Information   Non-medical information about an individual may be disclosed for other than a program purpose, to persons or organizations desi gnated by the individual, if the individual authorizes disclosure, and if disclosure is consistent with the proper and efficient administration of the Act.   B. Disclosure of Medical Information to a Physician, Institution, or Other Supplier of Services   The contractor may disclose medical information to a supplier of medical services solely for the purpose of the beneficiary's care or treatment.  Such supplier will be informed that the information is being furnished in connection with the treatment of the b eneficiary and that its use should be restricted to that purpose.   C. Disclosure to the Source of Medical Evidence   Occasionally in the course of reviewing medical evidence submitted to substantiate a claim, contractor medical personnel may discover a medi cal condition of which the source of the information is unaware.  (For purposes of this section, the "source" of the information is the part submitting the evidence.) In cases where a serious or potentially serious condition is found, the contractor may wi sh to inform the source of the information.  If the source of the information indicates that the beneficiary is not institutionalized and the identity of the beneficiary's current physician is not known, the source should recommend that the beneficiary con sult a physician or institution of the beneficiary's choice for further treatment.  D. Disclosure to a Source of Medical Services other Than the Source of the Information
(Medicare General Information, Eligibility, and Entitlement)
D. Disclosure to a Source of Medical Services other Than the Source of the Information   Medical information may also be disclosed, upon request, to the beneficiary's physic ian or to a medial institution at which the beneficiary is or was a patient when such physician or institution is not the source of the information.  However, consent for the release must be obtained from the beneficiary.   80.1 - Release for Title XVIII Claims Information for Complementary Insurance Purposes (Contractors)  (Rev. 1, 09- 11-02)  The contractor may not release or use information obtained in the administration of the Medicare program for non -program activities.  Howev er, when the beneficiary has given written authorization the contractor is permitted to release certain information to its complementary insurance program under specific conditions in its capacity as insurance writer or administrator, or to other insurers for complementary health benefits purposes.  Under no circumstances may the contractor use the knowledge of an individual's entitlement or benefit utilization information for purposes of dropping an individual from a group health insurance plan.  A. Inform ation That May be Released   Subject to necessary authorizations, copies, extracts, or summaries of only the following records may be released:    Provider billing forms (e.g., Form CMS -1450);   Explanation of benefits for Part B Provider Services, or denial le tters; and   Information on date of entitlement to Part A, or date of enrollment under Part B, or the date Part B coverage began.   Requests for other information desired for complementary insurance purposes should be referred to the RO.   B. Form of Authoriz ation   The contractor must make certain that information is not released without the required authorization.  This authorization may be either indicated on the billing and admission form or on a dated statement from the beneficiary.  Where the authorizatio n is on a dated statement it must:
(Medicare General Information, Eligibility, and Entitlement)
 Authorize release of information about his/her title XVIII Medicare claim;  Designate to whom the release is authorized;   Show that the release authorized is for complementary insurance purposes (this may be implied by the  designation in the second bullet above);   Indicate whether the authorization is for a one -time or ongoing release of data (i.e., for the duration of the claims and appeals process, but not to exceed 2 years); and   Bear the signature of the beneficiary, the  beneficiary's legal guardian, or the beneficiary's authorized representative.   Where the bill contains a beneficiary signature or indicates that the beneficiary's signature authorizing release of information is contained in the provider's records, the bil l must contain the name of the complementary insurer unless a dated statement as outlined above is already on file.   Where the contractor has a dated statement on file, information may not be released for individual claims when the beneficiary indicated that they do not want disclosure on that claim.  This may be indicated on certain claims forms by the beneficiary checking an appropriate block, or by attaching a separate statement.   If someone other than the beneficiary, legal guardian, or authorized repre sentative has authorized disclosure to a third party by filling out the appropriate item on the billing form, the contractor may not release the information unless an authorization from the beneficiary is on file.  Instead, where feasible, the contractor w ill inform the beneficiary (or legal guardian or authorized representative) that the signature on the claims form does not constitute a proper authorization for disclosure and that, if the beneficiary desires information to be disclosed to a third party, t he beneficiary should send to either the contractor or the third party, a statement authorizing release.  (The contractor will indicate the necessary contents of a proper authorization or enclose an appropriate form or statement for use by the proper party  in authorizing release.)   If invalid authorizations are a frequent problem, the contractor advises third party payers to obtain appropriate ongoing consent statements from enrollees.   C. Methods of Handling Requests   Where the complementary insurers desir e title XVIII information for certain claims only, either the complementary insurer or the beneficiary may request its release.
(Medicare General Information, Eligibility, and Entitlement)
C. Methods of Handling Requests   Where the complementary insurers desir e title XVIII information for certain claims only, either the complementary insurer or the beneficiary may request its release.   The complementary insurer must furnish the required authorization(s) for release and must pay any charges.  (The Medicare progr am will absorb charges for supplying duplicate MSN's or billing forms to beneficiaries, their authorized representatives, and to social security offices.)  In the absence of a standing arrangement, the mere presence of an "authorization' to release and the  identification of a complementary insurer on a title XVIII billing form does not constitute a request for the "release" of information.  There must be a specific request for the information.   The contractor may enter into a standing arrangement with a com plementary insurer to provide and charge for title XVIII information, such as MSNs or deductible non- met letters, in every case in which the contractor receives a title XVIII claim which contains the necessary authorizations and identifies the complementar y insurer.   D. Release of Title XVIII Claims Information for Complementary Insurance Purposes by Providers   Contractors should be aware that, subject to specific written beneficiary authorization, providers are permitted to furnish certain limited informat ion about Medicare eligibility status and related claims information to third party payers for complementary insurance purposes.  ( See 170. )  90 - Matching MAC Health Insurance  (Rev. 1, 09- 11-02)  In using an integrated claims processing system, it is permissible to match a currently updated subscriber file against a run of currently processed Medicare claims to extract information required to pay the complementary claim provided:    When routinely securing beneficiary authorization for an ongoing release of information safeguards are maintained to ensure that, where a beneficiary revokes the authorization on the billing form or by a separate statement, there will be no release of informati on;   When a statement is not routinely secured for the ongoing release of information, controls ensure that there is an authorization per 80.1  of this chapter from each Medicare beneficiary  with complementary insurance before information is released; and    Controls ensure that no information will be released in the matching process for any Medicare beneficiary who does not have complementary insurance.
(Medicare General Information, Eligibility, and Entitlement)
 Controls ensure that no information will be released in the matching process for any Medicare beneficiary who does not have complementary insurance.   Contractors must update the subscriber  file to incorporate all terminations before each match with the Medicare claims file so that information will not be passed to the private business sector for beneficiaries who are not entitled to the complementary insurance plan.  The contractor may not permit the private business sector to have access to the Medicare claims history file.  The private business sector may use only information concerning the current claim from the current run of processed claims.   100 - Disclosure to State Agencies or to Contractors Acting for State Agencies Administering Programs Receiving Grants in Aid (Contractors)  (Rev. 1, 09- 11-02)  100.1 - Information That May Be Disclosed and Authorization Required (Rev. 1, 09- 11-02)  The contractor may disclose information on such ma tters as entitlement, benefit payment, or benefit utilization relating to an individual who has applied for benefits administered by the State welfare departments.  It may make such disclosure without the authorization of the individual or the individual's  legal representative (i.e., legal guardian appointed by a court or a parent or a minor) to any duly authorized officer or employee of a State agency administration of grants -in-aid programs under titles IV, V, or XIX or in the case of Puerto Rico, Guam, or the Virgin Islands, titles I, X, or XVI of the Social Security Act with the authorization of the individual or their authorized representative.  Medical information beyond that shown on billing forms relating to an individual (and obtained in the adminis tration of the Medicare program) may be disclosed to a State agency administering the grants -in-aid program if the State agency shows a special need for the information, and the file contains a written authorization by the beneficiary specifically consenti ng to disclosure of medical information.   Title XVIII, billing forms and completion instructions, provide for authorization by the beneficiary for the release of information to State agencies or their agents.  Where the contractor, or a third party organiz ation, is administering the medical payment program under a contract or underwriting arrangement with the State, it may release information to itself or to the third party organization on the same basis as it may release information to a State agency.   100.2 - Procedures for Supplying Title XVIII Information to State Agencies  (Rev. 1, 09- 11-02)
(Medicare General Information, Eligibility, and Entitlement)
100.2 - Procedures for Supplying Title XVIII Information to State Agencies  (Rev. 1, 09- 11-02)  Contractors may provide State Medicaid agencies with Medicare claims information.  See Pub 100- 04, Chapter 28 for more information.   100.3 - Disclosure to Title V and Title XIX Agencies of Information Indicating Unprofessional or Unethical Practices by Physicians and Other Practitioners  (Rev. 1, 09- 11-02)  The release of information obtained in the administration of title XVIII indicating a course of unprofessional conduct or unethical practices by a physician or other practitioner will assist in the investigation of such conduct under titles V and XIX.  The  information to be released must have previously been released by a contractor in the administration of title XVIII to an official of a State licensing board (see 100.4  of this chapter), or to any 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 a Federal tax law (see 120  of this chapter).   100.4 - Disclosure to Title XIX Agencies of Physician Charge Information  (Rev. 1, 09- 11-02)  The CMS, which administers title XIX, requires a correlation between payments under that title and the fee schedule or the 75th percentile of the range of customary charges, if applicable, as determined for treatment rendered under Part B of title XVIII.  This requirement assumes that title XVIII fee schedule and medical charge experience,  where applicable, will be available to title XIX agencies.   Therefore, it is necessary that agencies administering title XIX be furnished with physician, other practitioner, and supplier identification numbers; and fee schedules and/or charges of physicia ns or other practitioners, or suppliers for services furnished to beneficiaries, to enable them to determine the amount of benefits payable for medical services furnished under Title XVIII and XIX.   As the individual title XIX programs of the several State s may differ, some variation in the type of information required can be expected.  Therefore, in order to obtain the information it needs, each State agency should consult with the title XVIII contractor(s) serving the various areas in each State concernin g the availability and format of the necessary information.  (CMS advises the appropriate State agencies of this arrangement.)
(Medicare General Information, Eligibility, and Entitlement)
Contractor Involvement -   The contractor will normally receive the request of the State title XIX agency through the RO.   The con tractor will determine the amount of information it can furnish in accordance with the particular request. (See 10 ff of this chapter.)   The contractor will determine the charge and discuss it with the State agency. (See Medicare Carrier Manual, Part 1, 4602.6.)   If consultation or clarification of the data requested is needed, the contractor should make contact with the State agency through the RO or directly, as advised by the RO.   When all det ails are completed, the contractor should submit the requested information in final form to the RO for furnishing to the State agency.   100.5 - Electronic Reporting of Crossover Claims (Rev. 1, 09- 11-02)  Contractors may provide State Medicaid agencies wit h Medicare claims information.  See Pub 100- 04, Chapter 28 for more information.   110 - Disclosure to Peer Review Organizations (PROs)  (Rev. 1, 09- 11-02)  The CMS and/or A/B MACs (A) may furnish PROs information on claims specified by CMS for PRO review.   120 - Disclosure to the Internal Revenue Service (Contractors)  (Rev. 1, 09- 11-02)  The contractor may disclose information to the Internal Revenue Service when requested for investigation of a possible violation of the F.I.C.A., S.E.C.A., F.U.T.A., or any Federal income tax law.  The contractor will bring to the attention of the RO any problem in complying with the IRS request (e.g., machine capability, cost, etc.).   130 - Disclosure to the Office for the Civilian Health and Medical Program of the Uniformed  Services (TriCare) by Contractors  (Rev. 1, 09- 11-02)  130.1  General  (Rev. 1, 09- 11-02)  The CMS may disclose certain information to TriCare for use in administering the TriCare program.  The type of information to be made available parallels that made available to non- complementary title V and XIX State agencies and contractors.  (See 100  of this chapter.)   130.2 - Type of Information  (Rev. 1, 09- 11-02)
(Medicare General Information, Eligibility, and Entitlement)
130.2 - Type of Information  (Rev. 1, 09- 11-02)  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)