System Name: "Medicare Exclusion Database (MED)," HHS/CMS/OFM.
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, and at various other remote locations.
Categories of Individuals Covered by the System: For purposes of this SOR, the system contains information related to individual health care providers who have been excluded from participation in Medicare and other Federal and State health care programs.
Categories of Records in the System: The system contains information such as other provider identifiers used by those individuals, names, demographic information, including, but not limited to gender and date of birth, provider taxonomy information, address data, contact information, and taxpayers identifying number.
Authority for Maintenance of the System: Authority for maintenance of this system is given under §§ 1128 A and B, and 1156 of the Social Security Act.
Purpose(s): The primary purpose of this system of records is to collect and maintain information on individuals that have been excluded from receiving Medicare payments for any item or service furnished during the period when excluded from participation in the Medicare program. Information maintained in this system will also be disclosed to: (1) Support regulatory, reimbursement, and policy functions performed within the Agency or by a contractor, consultant or CMS grantee; (2) assist another Federal 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 epidemiological projects; (4) support litigation involving the Agency; and (5) 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: 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:
To support Agency contractors, consultants, or CMS grantees that have been contracted by the Agency to assist in accomplishment of a CMS function relating to the purposes for this system and who need access to the records in order to assist CMS.
To assist another Federal or State agency, agency of a State government, an agency established by State law, or its fiscal agent to: Contribute to the accuracy of CMS's proper payment of Medicare benefits, 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 assist Federal/State Medicaid programs within the State.
To support an individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease or disability or the restoration or maintenance of health.
To assist the Department of Justice (DOJ), court or adjudicatory body when:
The Agency or any component thereof, or any employee of the Agency in his or her official capacity, or any employee of the Agency in his or her individual capacity where the DOJ has agreed to represent the employee, or 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.
To support a CMS contractor 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 programs.
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 or abuse in a 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.
Policies and Practices for Storing, Retrieving, Accessing, Retaining, and Disposing of Records in the System—
Storage: All records are stored on magnetic media.
Retrievability: All records are accessible by UPIN/NPI or alpha (name) search. This system supports both on-line and batch access.
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 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: Records are maintained for a period of 15 years. 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, Program Integrity Group, Office of Financial Management, CMS, Mail Stop C3-02-16, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
Notification Procedure: For purpose of access, the subject individual health care provider should write to the system manager who will require the system name, National Provider Identifier, address, date of birth, and gender, and for verification purposes, the subject individual health care provider's name (woman's maiden name, if applicable), and 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 health care provider should contact the systems manager named above, 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: The Office of the Inspector General Exclusion file, Online Survey Certification and Reporting System file, National Supplier Clearing House file, Unique Physician Identification Number Registry, Medicare Contractor Provider Files, and Social Security Administration records to assist in a determination of the excluded individual's employers.
System Exempted from Certain Provisions of the Act: None.