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SORN 09-90-0048

System Name:  Medicare Appeals Council Records.

Security Classification:  None.

Categories of individuals covered by the system:  All individuals who appeal an action of an Administrative Law Judge (ALJ) concerning a claim for payment under Title XVIII or XI of the Social Security Act or concerning entitlement to Medicare benefits. Also individuals those cases are referred to the Medicare Appeals Council (MAC) by the Centers for Medicare & Medicaid Services (CMS) pursuant to the MAC's discretionary review authority.

Categories of records in the system:  The system contains information concerning Medicare beneficiaries; physicians, providers, suppliers, and other persons or entities involved in furnishing healthcare items or services to Medicare beneficiaries; and third-party appellants such as State Medicaid agencies. Information on beneficiaries may include: name, address, health insurance claim number, medical records, items or services for which Medicare reimbursement is requested, and material used to determine the amount of benefits allowable under Medicare. Information on physicians, providers, suppliers and other persons may include: name, address, specialty, identification number, items or services for which Medicare reimbursement is requested, and material used to determine the amount of benefits allowable under Medicare. This system contains some information that is about entities, rather than individuals, and that information is not covered by the Privacy Act.

Authority for maintenance of the system:  Sections 1852(g), 1869, 1876(c)(5), and 1155 of the Social Security Act, as amended.

Purpose(s):  The records contain information used in processing an appellant's request for review of an ALJ decision or dismissal (or for other MAC action) or information used in considering a CMS referral; information used in tracking and ascertaining the status of the request or referral; information used to reply to correspondence; and information the MAC used to reach a decision on the request or referral.

Routine uses of records maintained in the system, including categories of users and the purposes of such uses:

 Disclosures may be made to:

1. Student volunteers, individuals working under a personal services contract, and other individuals performing functions for HHS but technically not having the status of agency employees, if they need access to the records to perform their assigned agency functions.

2. A congressional office from the record of an individual or entity whose case is pending, in response to an inquiry from the congressional office at the request of that individual or entity.

3. Components of the Social Security Administration and authorized hearing offices that provide information/inquiry services to individuals or entities pursuing appeals or provide hearings on request of individuals or entities.

4. The Department of Justice, a court or other tribunal, or another party before such tribunal, when:

a. HHS, or any component thereof; or

b. Any HHS employee in his or her official capacity; or

c. Any HHS employee in his or her individual capacity where the Department of Justice (or HHS, where it is authorized to do so) has agreed to represent the employee; or

d. The United States or any agency thereof where HHS determines that the litigation is likely to affect HHS or any of its components, is a party to litigation or has an interest in such litigation, and HHS determines that the use of such records by the Department of Justice, the tribunal or the other party is relevant and necessary to the litigation and would help in the effective representation of the governmental party, provided, however, that in each case, HHS determines that such disclosure is compatible with the purpose for which the records were collected.

5. HHS contractors who have been engaged by HHS to assist in the performance of a service related to this system of records and who have a need to access the records in order to perform the activity.

Policies and Practices for storing, retrieving, accessing, retaining and disposing of records in the system:

Storage: These records are maintained in file folders, computer disks, and on password-protected computers or servers.

Retrievability:  Records are normally retrieved numerically by the “M Number,'' a number assigned by the MOD when it receives a record. Records will be cross-referenced by the beneficiary's health insurance claim number; beneficiary's, physician's, provider's, suppliers, or other appellant's name; or ALJ appeal number.


a. Authorized Users: Only agency employees and contractor personnel whose duties require the use of information in the system. In addition, such agency employees and contractor personnel are advised that the information is confidential and of criminal sanctions for unauthorized disclosure of information.

b. Physical Safeguards: Paper records are maintained in file cabinets, offices, and other secure areas to which only authorized individuals have access. Computer terminals are in secured areas that only authorized individuals may use.

c. Procedural Safeguards: Employees who maintain records in the system are instructed to grant regular access only to authorized users.  Data stored in computers or on servers are accessed through the use of passwords known only to authorized personnel. Contractors who maintain records in this system are instructed to make no further disclosure of the records except as authorized by the system manager and permitted by the Privacy Act. Privacy Act language is included in contracts related to this system.

Retention and Disposal:  The period of retention of the paper case file depends upon the final action taken by the MAC. If the final action requires the CMS contractor to effectuate a decision, the case file is sent to the contractor immediately after the MAC has entered its final decision.

When a case is remanded to an ALJ, the case file is forwarded with the order of remand to the appropriate hearing office. If the MAC enters an unfavorable decision or a denial of review of an ALJ decision, the case file is stored and maintained in the MAC file room for 6 months. If the

MAC enters an order of dismissal or a denial of review of an ALJ dismissal, the case file is stored and maintained for 3 months. At the end of the applicable period, the case file is sent to the designated CMS contractor or SSA. If a case is appealed to Federal District Court, the case file is stored and maintained for 3 months after the certified copy of the record has been furnished to the Court and at that point is sent to the contractor or SSA.

Workpaper documents created by the MAC or MOD are not included in the case file and are destroyed at the time the MAC final action is released. Electronic versions of case disposition documents are saved on the computer database for four years and then deleted. Electronic case tracking records are maintained indefinitely on the computer database, with daily updating to the storage area network.

System Manager and Address: Chief, Medicare Operations Division, Departmental Appeals Board,

Department of Health and Human Services, Office of the Secretary, MS 6127, 330 Independence Avenue, SW., Cohen Building, Room G-644, Washington, DC 20201.

Notification Procedure:  Individuals inquiring whether this system of records contains information about them should contact the System Manager indicated above. The requester must specify the appellant's name, social security number, health insurance claim number, or docket number.

Record Access Procedure:  Same as notification procedures. Requesters should also reasonably specify the record contents being sought.

Contesting Record Procedure(s):  Contact the System Manager at the address specified above, reasonably identify the record, and specify the information to be contested and corrective action sought with the supporting justification.

Record Source Categories:  The DAB obtains the identifying information in this system from the request for review or referral. Claim file records are obtained from Medicare contractors and ALJ hearing offices.

Systems exempted from certain provisions of the Act:  None.

Content created by Freedom of Information Act (FOIA) Division