System Name: "Medicare Multi-Carrier Claims System (MCS)," 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. See Appendix A for various remote sites where this system is also maintained.
Categories of Individuals Covered by the System: The system contains information on Medicare beneficiaries who have submitted claims for Supplemental Medical Insurance (SMI) benefit (Medicare Part B), or individuals whose enrollment in an employer group health benefits plan covers the beneficiary.
Categories of Records in the System: Information contained in this system consist of request(s) for payment, provider billing for patient services, prepayment plan for group Medicare practice dealing through a carrier, health insurance claim form, request(s) for medical payment, explanation of benefits, request for claim number verification, payment record transmittal, statement of person regarding Medicare payment for medical services furnished deceased patient, report of prior period of entitlement, itemized bills and other similar documents required to support payments to beneficiaries and to physicians and other suppliers of Part B services, and Medicare secondary payer records containing other party liability insurance information necessary for appropriate Medicare claims payment.
Authority for Maintenance of the System: Authority for the collection and maintenance of this system is given under the provisions of sections 1842, 1862 (b) and 1874 of Title XVIII of the Social Security Act (The Act) (42 United States Code (U.S.C.) 1395u, 1395y (b), and 1395kk).
Purpose(s): The primary purpose of the SOR is to
(1) properly pay medical insurance benefits to or on behalf of entitled beneficiaries. Information in this system will also be released to: (1) support regulatory 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;
(4) support providers and suppliers of services dealing through fiscal intermediaries or carriers;
(5) support Quality Improvement Organizations (QIO);
(6) assist insurance companies and other groups providing protection for their enrollees, insurers and other groups providing protection against medical expenses who are primary payers to Medicare in accordance with 42 U.S.C 1395y(b)
(7) support an individual or organization for a research, evaluation, or epidemiological project;
(8) support litigation involving the Agency related to this SOR; and
(9) combat fraud, waste, and abuse in certain Federally-funded health care programs.
Routine Uses of Records Maintained in the System, Including Categories of Users and the Purposes of such Uses:
A. Entities Who May Receive Disclosures Under Routine Use
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 contractor, consultant or grantee who have been engaged by the agency to assist in the accomplishment of a CMS function relating to the purposes for this system and who need to have access to the records in order to assist CMS.
2. To assist another Federal and/or state agency, agency of a state government, an agency established by state law, or its fiscal agent:
a. Contribute to the accuracy of CMS' 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
c. Assist Federal/state Medicaid programs within the state.
3. To assist third party contacts (without the consent of the individuals to whom the information pertains) 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 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; and the amount of reimbursement; any case in which the evidence is being reviewed as a result of suspected fraud, waste, and abuse, program integrity, quality appraisal, or evaluation and measurement of program activities.
4. To assist providers and suppliers of services dealing through fiscal intermediaries or carriers for the administration of Title XVIII of the Act.
5. To Quality Improvement Organizations (QIO) in connection with review of claims, or in connection with studies or other review activities, conducted pursuant to Part B of Title XI of the Act and in performing affirmative outreach activities to individuals for the purpose of establishing and maintaining their entitlement to Medicare benefits or health insurance plans.
6. To assist insurance companies, third party administrators (TPA), employers, self-insurers, managed care organizations, other supplemental insurers, non-coordinating insurers, multiple employer trusts, group health plans (i.e., health maintenance organizations (HMO) or a competitive medical plan (CMP) with a Medicare contract, or a Medicare-approved health care prepayment plan (HCPP)), directly or through a contractor, and other groups providing protection for their enrollees. Information to be disclosed shall be limited to Medicare entitlement data. In order to receive the information, they must agree to:
a. Certify that the individual about whom the information is being provided is one of its insured or employees, or is insured and/or employed by another entity for whom the serve as a TPA;
b. Utilize the information solely for the purpose of processing the identified individual's insurance claims; and
c. Safeguard the confidentiality of the data a prevent unauthorized access.
7. To support an individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease or disability, the restoration or maintenance of health, or payment-related projects.
8. To support 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.
9. To support a CMS contractor (including, but not limited to fiscal intermediaries and carriers) that assists in the administration of a CMS-administered health benefits program, or to a grantee of the 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.
10. 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 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, waste, or abuse in such programs.
11. To disclose to health plans, defined for this purpose as plans or programs that provide health benefits, whether directly, through insurance, or otherwise, and includes—(1) a policy of health insurance; (2) a contract of a service benefit organization; and (3) a membership agreement with a health maintenance organization or other prepaid health plan 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. Disclosures may include provider and beneficiary-identifiable data.
12. To appropriate agencies, entities, and persons when (a) HHS suspects or has confirmed that there has been a breach of the system of records; (b) HHS has determined that as a result of the suspected or confirmed breach there is a risk of harm to individuals, HHS (including its information systems, programs, and operations), the federal government, or national security; and (c) the disclosure made to such agencies, entities, and persons is reasonably necessary to assist in connection with HHS' efforts to respond to the suspected or confirmed breach or to prevent, minimize, or remedy such harm.
13. To another federal agency or federal entity, when HHS determines that information from this system of records is reasonably necessary to assist the recipient agency or entity in (a) responding to a suspected or confirmed breach or (b) preventing, minimizing, or remedying the risk of harm to individuals, the recipient agency or entity (including its information systems, programs, and operations), the federal government, or national security, resulting from a suspected or confirmed breach.
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: Records are maintained on paper, computer diskette and on magnetic storage media.
Retrievability: Information can be retrieved by the beneficiary's name, HIC, and assigned unique physician identification number.
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 include 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: Records are maintained in a secure storage area with identifiers. Records are closed at the end of the fiscal year, in which paid, and destroyed after 6 years and 3 months. 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 Systems Operations, Business Applications Management Group, Office of Information Services, CMS, 7500 Security Boulevard, Room N2-07-27, 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, HIC, address, date of birth, and sex, and for verification purposes, the subject individual's name (woman's maiden name, if applicable), 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: Sources of information contained in this records system is obtained from third party agencies, Social Security Administration's Master Beneficiary Record, and CMS's Enrollment Database.
System Exempted from Certain Provisions of the Act: None.
Appendix A.--Health Insurance Claims
Medicare records are maintained at the CMS Central Office (see section 1 below for the address). Health Insurance Records of the Medicare program can also be accessed through a representative of the CMS Regional Office (see section 2 below for addresses). Medicare claims records are also maintained by private insurance organizations that share in administering provisions of the health insurance programs. These private insurance organizations, referred to as carriers and intermediaries, are under contract to the Centers for Medicare & Medicaid Services and the Social Security Administration to perform specific task in the Medicare program (see section three below for addresses for intermediaries, section four addresses the carriers, and section five addresses the Payment Safeguard Contractors.
I. Central Office Address
CMS Data Center, 7500 Security Boulevard, North Building, First Floor, Baltimore, Maryland 21244-1850.
II. CMS Regional Offices
Boston Region--Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont. John F. Kennedy Federal Building, Room 1211, Boston, Massachusetts 02203. Office Hours: 8:30 a.m.-5 p.m.
New York Region--New Jersey, New York, Puerto Rico, Virgin Islands. 26 Federal Plaza, Room 715, New York, New York 10007, Office Hours: 8:30 a.m.-5 p.m.
Philadelphia Region--Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia. Post Office Box 8460, Philadelphia, Pennsylvania 19101. Office Hours: 8:30 a.m.-5 p.m.
Atlanta Region--Alabama, North Carolina, South Carolina, Florida, Georgia, Kentucky, Mississippi, Tennessee. 101 Marietta Street, Suite 702, Atlanta, Georgia 30223, Office Hours: 8:30 a.m.-4:30 p.m.
Chicago Region--Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin. Suite A-824, Chicago, Illinois 60604. Office Hours: 8 a.m.-4:45 p.m.
Dallas Region--Arkansas, Louisiana, New Mexico, Oklahoma, Texas, 1200 Main Tower Building, Dallas, Texas. Office Hours: 8 a.m.- 4:30 p.m.
Kansas City Region--Iowa, Kansas, Missouri, Nebraska. New Federal Office Building, 601 East 12th Street-Room 436, Kansas City, Missouri 64106. Office Hours: 8 a.m.-4:45 p.m.
Denver Region--Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming. Federal Office Building, 1961 Stout St-Room 1185, Denver, Colorado 80294. Office Hours: 8 a.m.-4:30 p.m.
San Francisco Region--American Samoa, Arizona, California, Guam, Hawaii, Nevada. Federal Office Building, 10 Van Ness Avenue, 20th Floor, San Francisco, California 94102. Office Hours: 8 a.m.-4:30 p.m.
Seattle Region--Alaska, Idaho, Oregon, Washington. 1321 Second Avenue, Room 615, Mail Stop 211, Seattle, Washington 98101. Office Hours 8 a.m.-4:30 p.m.
III. Intermediary Addresses (Hospital Insurance)
Medicare Coordinator, Assoc. Hospital Serv. Maine (ME BC), 2 Gannett Drive, South Portland, ME 04106-6911.
Medicare Coordinator, Anthem New Hampshire, 300 Goffs Falls Road, Manchester, NH 03111-0001.
Medicare Coordinator, BC/BS Rhode Island (RI BC), 444 Westminster Street, Providence, RI 02903-3279.
Medicare Coordinator, Empire Medicare Services, 400 S. Salina Street, Syracuse, NY 13202.
Medicare Coordinator, Cooperativa, P.O. Box 363428, San Juan, PR 00936-3428.
Medicare Coordinator, Maryland B/C, P.O. Box 4368, 1946 Greenspring Ave., Timonium, MD 21093.
Medicare Coordinator, Highmark, P5103, 120 Fifth Avenue Place, Pittsburgh, PA 15222-3099.
Medicare Coordinator, United Government Services, 1515 N. Rivercenter Dr., Milwaukee, WI 53212.
Medicare Coordinator, Alabama B/C, 450 Riverchase Parkway East, Birmingham, AL 35298.
Medicare Coordinator, Florida B/C, 532 Riverside Ave., Jacksonville, FL 32202-4918.
Medicare Coordinator, Georgia B/C, P.O. Box 9048, 2357 Warm Springs Road, Columbus, GA 31908.
Medicare Coordinator, Mississippi B/C B MS, P.O. Box 23035, 3545 Lakeland Drive, Jackson, MI 39225-3035.
Medicare Coordinator, North Carolina B/C, P.O. Box 2291, Durham, NC 27702-2291.
Medicare Coordinator, Palmetto GBA A/RHHI, 17 Technology Circle, Columbia, SC 29203-0001.
Medicare Coordinator, Tennessee B/C, 801 Pine Street, Chattanooga, TN 37402-2555.
Medicare Coordinator, Anthem Insurance Co. (Anthem In), P.O. Box 50451, 8115 Knue Road, Indianapolis, IN 46250-1936.
Medicare Coordinator, Arkansas B/C, 601 Gaines Street, Little Rock, AR 72203.
Medicare Coordinator, Group Health Of Oklahoma, 1215 South Boulder, Tulsa, OK 74119-2827.
Medicare Coordinator, TrailBlazer, P.O. Box 660156, Dallas, TX 75266-0156.
Medicare Coordinator, Cahaba GBA, Station 7, 636 Grand Avenue, Des Moines, IA 50309-2551.
Medicare Coordinator, Kansas B/C, P.O. Box 239, 1133 Topeka Ave., Topeka, KS 66629-0001.
Medicare Coordinator, Nebraska B/C, P.O. Box 3248, Main Po Station, Omaha, NE 68180-0001.
Medicare Coordinator, Mutual Of Omaha, P.O. Box 1602, Omaha, NE 68101.
Medicare Coordinator, Montana B/C, P.O. Box 5017, Great Falls Div., Great Falls, MT 59403-5017.
Medicare Coordinator, Noridian, 4510 13th Avenue S.W., Fargo, ND 58121-0001.
Medicare Coordinator, Utah B/C, P.O. Box 30270, 2455 Parleys Way, Salt Lake City, UT 84130-0270.
Medicare Coordinator, Wyoming B/C, 4000 House Avenue, Cheyenne, WY 82003.
Medicare Coordinator, Arizona B/C, P.O. Box 37700, Phoenix, AZ 85069.
Medicare Coordinator, UGS, P.O. Box 70000, Van Nuys, CA 91470-0000.
Medicare Coordinator, Regents BC, P.O. Box 8110 M/S D-4A, Portland, OR 97207-8110.
Medicare Coordinator, Premera BC, P.O. Box 2847, Seattle, WA 98111-2847.
IV. Medicare Carriers
Medicare Coordinator, NHIC, 75 Sargent William Terry Drive, Hingham, MA 02044.
Medicare Coordinator, B/S Rhode Island (RI BS), 444 Westminster Street, Providence, RI 02903-2790.
Medicare Coordinator, Trailblazer Health Enterprises, Meriden Park, 538 Preston Ave., Meriden, CT 06450.
Medicare Coordinator, Upstate Medicare Division, 11 Lewis Road, Binghamton, NY 13902.
Medicare Coordinator, Empire Medicare Services, 2651 Strang Blvd., Yorktown Heights, NY 10598.
Medicare Coordinator, Empire Medicare Services, NJ, 300 East Park Drive, Harrisburg, PA 17106.
Medicare Coordinator, Triple S, #1441 F.D., Roosvelt Ave., Guaynabo, PR 00968.
Medicare Coordinator, Group Health Inc., 4th Floor, 88 West End Avenue, New York, NY 10023.
Medicare Coordinator, Highmark, P.O. Box 89065, 1800 Center Street, Camp Hill, PA 17089-9065.
Medicare Coordinator, Trailblazers Part B, 11150 McCormick Drive, Executive Plaza 3 Suite 200, Hunt Valley, MD 21031.
Medicare Coordinator, Trailblazer Health Enterprises, Virginia, P.O. Box 26463, Richmond, VA 23261-6463. United Medicare Coordinator, Tricenturion, 1 Tower Square, Hartford, CT 06183.
Medicare Coordinator, Alabama B/S, 450 Riverchase Parkway East, Birmingham, AL 35298.
Medicare Coordinator, Cahaba GBA, 12052 Middleground Road, Suite A, Savannah, GA 31419.
Medicare Coordinator, Florida B/S, 532 Riverside Ave, Jacksonville, FL 32202-4918.
Medicare Coordinator, Administar Federal, 9901 Linnstation Road, Louisville, KY 40223.
Medicare Coordinator, Palmetto GBA, 17 Technology Circle, Columbia, SC 29203-0001.
Medicare Coordinator, CIGNA, 2 Vantage Way, Nashville, TN 37228.
Medicare Coordinator, Railroad Retirement Board, 2743 Perimeter Parkway, Building 250, Augusta, GA 30999.
Medicare Coordinator, Cahaba GBA, Jackson Miss, P.O. Box 22545, Jackson, MI 39225-2545.
Medicare Coordinator, Adminastar Federal (IN), 8115 Knue Road, Indianapolis, IN 46250-1936.
Medicare Coordinator, Wisconsin Physicians Service, P.O. Box 8190, Madison, WI 53708-8190.
Medicare Coordinator, Nationwide Mutual Insurance Co., P.O. Box 16788, 1 Nationwide Plaza, Columbus, OH 43216-6788.
Medicare Coordinator, Arkansas B/S, 601 Gaines Street, Little Rock, AR 72203.
Medicare Coordinator, Arkansas-New Mexico, 601 Gaines Street, Little Rock, AR 72203.
Medicare Coordinator, Palmetto GBA-DMERC, 17 Technology Circle, Columbia, SC 29203-0001.
Medicare Coordinator, Trailblazer Health Enterprises, 901 South Central Expressway, Richardson, TX 75080.
Medicare Coordinator, Nordian, 636 Grand Avenue, Des Moines, IA 50309-2551.
Medicare Coordinator, Kansas B/S, P.O. Box 239, 1133 Topeka Ave., Topeka, KS 66629-0001.
Medicare Coordinator, Kansas B/S-NE, P.O. Box 239, 1133 Topeka Ave., Topeka, KS 66629-0239.
Medicare Coordinator, Montana B/S, P.O. Box 4309, Helena, MT 59601.
Medicare Coordinator, Nordian, 4305 13th Avenue South, Fargo, ND 58103-3373.
Medicare Coordinator, Noridian Backbend (C0), 730 N. Simms #100, Golden, CO 80401-4730.
Medicare Coordinator, Noridian BCBSND (WY), 4305 13th Avenue South, Fargo, ND 58103-3373.
Medicare Coordinator, Utah B/S, P.O. Box 30270, 2455 Parleys Way, Salt Lake City, UT 84130-0270.
Medicare Coordinator, Transamerica Occidental, P.O. Box 54905, Los Angeles, CA 90054-4905.
Medicare Coordinator, NHIC-California, 450 W. East Avenue, Chico, CA 95926.
Medicare Coordinator, Cigna, Suite 254, 3150 Lake Harbor, Boise, ID 83703.
Medicare Coordinator, Cigna, Suite 506, 2 Vantage Way, Nashville, TN 37228.
V. Payment Safeguard Contractors
Medicare Coordinator, Aspen Systems Corporation, 2277 Research Blvd., Rockville, MD 20850.
Medicare Coordinator, DynCorp Electronic Data Systems (EDS), 11710 Plaza America Drive, 5400 Legacy Drive, Reston, VA 20190-6017.
Medicare Coordinator, Lifecare Management Partners Mutual of Omaha Insurance Co., 6601 Little River Turnpike, Suite 300, Mutual of Omaha Plaza, Omaha, NE 68175.
Medicare Coordinator, Reliance Safeguard Solutions, Inc., P.O. Box 30207, 400 South Salina Street, 2890 East Cottonwood Pkwy., Syracuse, NY 13202.
Medicare Coordinator, Science Applications International, Inc., 6565 Arlington Blvd. P.O. Box 100282, Falls Church, VA.
Medicare Coordinator, California Medical Review, Inc., Integriguard Division Federal Sector Civil Group, One Sansome Street, San Francisco, CA 94104-4448.
Medicare Coordinator, Computer Sciences Corporation, Suite 600, 3120 Timanus Lane, Baltimore, MD 21244.
Medicare Coordinator, Electronic Data Systems (EDS), 11710 Plaza America Drive, 5400 Legacy Drive, Plano, TX 75204.
Medicare Coordinator, TriCenturion, L.L.C., P.O. Box 100282, Columbia, SC 29202.