System Name: "Unique Physician/Practitioner Identification Number" (UPIN), HHS/CMS/OFM.
Security Classification: Level Three Privacy Act Sensitive.
System Location(s): CMS Data Center, 7500 Security Boulevard, North Building, First Floor, Baltimore, Maryland 21244-1850. The system is also located at CMS contractors and agents at various locations (see Appendix A).
Categories of Individuals Covered by the System: All physicians, non-practitioners and medical groups practices, defined by §§ 1124(A), 1861(r), 1842(b)(I)(ii)(iii)(iv) (v)(r), and 1877(h)(4) of the Social Security Act who request or receive Medicare reimbursement for medical services.
Categories of Records in the System: The system contains an UPIN, tax identification, and social security number (SSN) for each physician, non-physician practitioner and medical group. Also, the system contains information concerning a provider's birth, residence, medical education, and eligibility information for Medicare reimbursement.
Authority for Maintenance of the System: Authority for the collection and maintenance of this system is given under the provisions of §§ 1842(r)-(42 U.S.C. 1395u) of Pub. L. 101-508; 1861(s)(1)-(42 U.S.C. 1395x); §§ 1833(q)(1)-(42 U.S.C. 1395l); 1842(b)(18) -(42 U.S.C. 1395u); § 1842(h)(4) & (5)-(42 U.S.C. 1395u); and 4164 of Omnibus Budget Reconciliation Act of 1990 (OBRA).
Purpose(s): The primary purpose of the SOR is to: (1) Collect and maintain an unique identification of each physician, non-physician practitioner, or medical group practice requesting or receiving Medicare payment, and (2) provide beneficiaries and other interested entities with the identification of each physician or non-physician practitioner assigned an UPIN and who are participating in the Medicare program. Information retrieved from this SOR will be used to: (1) Support regulatory, reimbursement, and policy functions performed within the Agency or by a contractor or consultant, or CMS grantee; (2) assist another Federal and/or State agency, agency of a State government, an agency established by State law, or its fiscal agent; (3) facilitate research on the quality and effectiveness of care provided, as well as payment related projects; (4) assist Quality Improvement Organizations; (5) provide the American Medical Association with information needed for them to assist us in identifying physicians; (6) support litigation involving the Agency; and (7) combat fraud, waste, and abuse in certain health benefits 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
These routine uses specify circumstances, in addition to those provided by statute in the Privacy Act of 1974, under which CMS may release information from the UPIN without the consent of the individual to whom such information pertains. Each proposed disclosure of information under these routine uses will be evaluated to ensure that the disclosure is legally permissible, including but not limited to ensuring that the purpose of the disclosure is compatible with the purpose for which the information was collected. We propose to establish or modify the following routine use disclosures of information maintained in the system:
1. To support Agency contractors, consultants, or grantees who have been engaged by the Agency to assist in accomplishment of a CMS function relating to the purposes for this SOR and who need to have access to the records in order to assist CMS.
2. To assist another Federal or State agency, agency of a State government, an agency established by State law, or its fiscal agent pursuant to agreements with CMS to:
a. Contribute to the accuracy of CMS's 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 may require UPIN information for purposes related to this system.
3. To assist 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.
4. To support 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.
5. To support the American Medical Association (AMA), for the purpose of assisting CMS to identify medical doctors when CMS is unable to establish an identity, provided the AMA agrees to:
a. Use the information provided by CMS solely to identify a medical doctor;
b. Make no copies of the information it receives from the CMS, except for one back-up copy;
c. Return such information to CMS upon completion of its matching operation, and erase the back-up copy;
d. Establish appropriate administrative, technical, and physical safeguards to prevent unauthorized use or disclosure of the records; and,
e. Sign a written statement attesting to its understanding of, and willingness to abide by these provisions.
6. To assist 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.
7. To assist 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 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, waste or abuse in such program.
8. To assist 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.
9. 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.
B. Additional Circumstances 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 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 records are retrieved alphabetically by the provider name, social security number or by their assigned UPIN.
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 and the repository of the National Archive and Records Administration will retain identifiable UPIN assessment data for a total period not to exceed fifteen (15) years.
System Manager(s) and Address(es): Director, Program Integrity Group, Office of Financial Management, CMS, 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, health insurance claim number, 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), address, date of birth, and sex.
Record Access Procedures: For purpose of access, use the same procedures outlined in Notification Procedures above. Requestors should also 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 records 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 obtains the identifying information in this system from carriers. Information in these records concerning the eligibility of physicians, practitioners, and medical groups for Medicare reimbursement is obtained either directly from such entities through Medicare Regional Offices, contractors, PRO, Department of Justice, State or local judicial systems, medical licensing and certification agencies or organizations, medical societies and medical associations.
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 tasks 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.
1. Central Office Address
CMS Data Center, 7500 Security Boulevard, North Building, First Floor, Baltimore, Maryland 21244-1850.
2. 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
3. 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 MS, P.O. Box 23035, 3545 Lakeland Drive, Jackson, MS 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. (ANTHM 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 SW., 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.
4. 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., Roosevelt 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, MS 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 Bcbsnd (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 Lakeharbor, Boise, ID 83703.
Medicare Coordinator, Cigna, Suite 506, 2 Vantage Way, Nashville, TN 37228.
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.