[Federal Register: September 6, 2002 (Volume 67, Number 173)]
[Notices]               
[Page 57020-57024]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr06se02-74]                         

-----------------------------------------------------------------------

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

 
Privacy Act of 1974; Report of New System

AGENCY: Department of Health and Human Services (HHS), Centers for 
Medicare & Medicaid Services (CMS).

ACTION: Notice of new system of records (SOR).

-----------------------------------------------------------------------

SUMMARY: In accordance with the requirements of the Privacy Act of 
1974, we are proposing to establish a new system of records, called the 
``Correspondence Tracking Management System (CTMS),'' HHS/CMS/OSORA No. 
09-70-3005. The CMTS replaces the Correspondence and Assignment 
Tracking and Control System (CATCS), System No. 09-70-9001 that was 
deleted from CMS' database inventory through a published notice in the 
Federal Register. The primary purpose of the system of records is to 
aid CMS in tracking incoming correspondence about CMS programs from the 
Office of the Secretary, Medicare beneficiaries and Medicaid 
recipients. In addition, it will track all correspondence from the 
public, other government agencies, contractors, and members of the 
Congress. Information retrieved from this system of records will be 
used to support regulatory, reimbursement, and policy functions 
performed within the agency or by a contractor or consultant; support 
constituent requests made to a Congressional representative; and 
support litigation involving the agency.
    We have provided background information about the proposed system 
in the ``Supplementary Information'' section, below. Although the 
Privacy Act requires only that the ``routine use'' portion of the 
system be published for comment, CMS invites comments on all portions 
of this notice. See ``Effective Dates'' section for comment period.

EFFECTIVE DATES: CMS filed a new system report with the Chair of the 
House Committee on Government

[[Page 57021]]

Reform and Oversight, the Chair of the Senate Committee on Governmental 
Affairs, and the Administrator, Office of Information and Regulatory 
Affairs, Office of Management and Budget (OMB) on August 20, 2002. In 
any event, we will not disclose any information under a routine use 
until forty (40) calendar days after publication. We may defer 
implementation of this system of records or one or more of the routine 
use statements listed below if we receive comments that persuade us to 
defer implementation.

ADDRESSES: The public should address comments to: Director, Division of 
Data Liaison and Distribution (DDLD), CMS, Room N2-04-27, 7500 Security 
Boulevard, Baltimore, Maryland 21244-1850. Comments received will be 
available for review at this location, by appointment, during regular 
business hours, Monday through Friday from 9 a.m.-3 p.m., eastern time 
zone.

FOR FURTHER INFORMATION CONTACT: Chris Worrall, Division of 
Correspondence Control, Office of Communications and Operations 
Support, CMS, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

SUPPLEMENTARY INFORMATION: 

I. Description of the New System of Records

A. Statutory and Regulatory Basis for System of Records

    42 CFR 401.101-401.148 and 1106(a) of the Social Security Act, 42 
U.S.C. 1306(a).

B. Background

    The CMTS is being established to replace the Correspondence and 
Assignment Tracking and Control System (CATCS), System No. 09-70-9001 
that was deleted from CMS' database inventory through a published 
notice in the Federal Register.

II. Collection and Maintenance of Data in the System

A. Scope of the Data Collected

    The CMTS includes the following information: name and address of 
correspondent(s); subject of request; Centers/Office to which case is 
assigned, correspondence control number, date of initial entry and any 
subsequent updating, location of case, due date, type(s) of information 
requested, any cross reference, incoming correspondence, response and 
if provided in the correspondence, information about a beneficiary 
(e.g., name, address, Social Security Number.

B. Agency Policies, Procedures, and Restrictions on the Routine Use

    The Privacy Act permits 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 disclosure of data is known as a ``routine use.'' 
The government will only release CMTS information that can be 
associated with an individual as provided for under ``Section III. 
Entities Who May Receive Disclosures Under Routine Use.'' Both 
identifiable and non-identifiable data may be disclosed under a routine 
use. Identifiable data includes individual records with CMTS 
information and identifiers. Non-identifiable data includes individual 
records with CMTS information and masked identifiers or CMTS 
information with identifiers stripped out of the file.
    CMS will only disclose the minimum personal data necessary to 
achieve the purpose of the CMTS. CMS has the following policies and 
procedures concerning disclosures of information that will be 
maintained in the system. In general, disclosure of information from 
the SOR will be approved only for the minimum information necessary to 
accomplish the purpose of the disclosure after CMS:

    1. Determines that the use or disclosure is consistent with the 
reason that the data are being collected; e.g., track, control, and 
respond to correspondence from the public, other government agencies, 
contractors, and members of the Congress.
    2. Determines that:
    a. The purpose for which the disclosure is to be made can only be 
accomplished if the record is provided in individually identifiable 
form;
    b. The purpose for which the disclosure is to be made is of 
sufficient importance to warrant the effect and/or risk on the privacy 
of the individual that additional exposure of the record might bring; 
and
    c. There is a strong probability that the proposed use of the data 
would, in fact, accomplish the stated purpose(s).
    3. Requires the information recipient to:
    a. Establish administrative, technical, and physical safeguards to 
prevent unauthorized use of disclosure of the record;
    b. Remove or destroy at the earliest time all individually, 
identifiable information; and
    c. Agree to not use or disclose the information for any purpose 
other than the stated purpose under which the information was 
disclosed.
    4. Determines that the data are valid and reliable.

III. Proposed Routine Use Disclosures of Data in the System

A. Entities That 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 CMTS 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. CMS proposes to 
establish the following routine use disclosures of information 
maintained in the system:
    1. To agency contractors, or consultants that have been contracted 
by the agency to assist in the performance of a service related to this 
system of records and that need to have access to the records in order 
to perform the activity.
    CMS contemplates disclosing information under this routine use only 
in situations in which CMS may enter into a contractual or similar 
agreement with a third party to assist in accomplishing agency business 
functions relating to purposes for this system of records.
    CMS occasionally contracts out certain of its functions when doing 
so would contribute to effective and efficient operations. CMS must be 
able to give a contractor whatever information is necessary for the 
contractor to fulfill its duties. In these situations, safeguards are 
provided in the contract prohibiting the contractor from using or 
disclosing the information for any purpose other than that described in 
the contract and requires the contractor to return or destroy all 
information at the completion of the contract.
    2. To a Member of Congress or to a Congressional staff member in 
response to an inquiry of the Congressional Office made at the written 
request of the constituent about whom the record is maintained.
    Individuals sometimes request the help of a Member of Congress in 
resolving some issue relating to a matter before CMS. The Member of 
Congress then writes CMS, and CMS must be able to give sufficient 
information to be responsive to the inquiry.

[[Page 57022]]

    3. To 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.

    Whenever CMS is involved in litigation, or occasionally when 
another party is involved in litigation and CMS's policies or 
operations could be affected by the outcome of the litigation, CMS 
would be able to disclose information to the DOJ, court or adjudicatory 
body involved. A determination would be made in each instance that, 
under the circumstances involved, the purposes served by the use of the 
information in the particular litigation is compatible with a purpose 
for which CMS collects the information.

B. Additional Provisions Affecting Routine Use Disclosures

    In addition, CMS policy will be to prohibit release even of non-
identifiable data, except pursuant to one of the routine uses, if 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).
    This System of Records contains Protected Health Information as 
defined by the Department of Health and Human Services' regulation 
``Standards for Privacy of Individually Identifiable Health 
Information'' (45 CFR parts 160 and 164, 65 FR 82462 as amended by 66 
FR 12434). Disclosures of Protected Health Information 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.''

IV. Safeguards

    The CMTS system will conform to applicable law and policy governing 
the privacy and security of Federal automated information systems. 
These include but are not limited to: the Privacy Act of 1974, Computer 
Security Act of 1987, the Paperwork Reduction Act of 1995, the Clinger-
Cohen Act of 1996, and OMB Circular A-130, Appendix III, ``Security of 
Federal Automated Information Resources.'' CMS has prepared a 
comprehensive system security plan as required by OMB Circular A-130, 
Appendix III. This plan conforms fully to guidance issued by the 
National Institute for Standards and Technology (NIST) in NIST Special 
Publication 800-18, ``Guide for Developing Security Plans for 
Information Technology Systems.'' Paragraphs A-C of this section 
highlight some of the specific methods that CMS is using to ensure the 
security of this system and the information within it.

A. Authorized Users

    Personnel having access to the system have been trained in Privacy 
Act and systems security requirements. Employees who maintain records 
in the system are instructed not to release any data until the intended 
recipient agrees to implement appropriate administrative, technical, 
procedural, and physical safeguards sufficient to protect the 
confidentiality of the data and to prevent unauthorized access to the 
data. Records are used in a designated work area and system location is 
attended at all times during working hours.
    To ensure security of the data, the proper level of class user is 
assigned for each individual user level. This prevents unauthorized 
users from accessing and modifying critical data. The system database 
configuration includes five classes of database users:
    [sbull] Database Administrator class owns the database objects 
(e.g., tables, triggers, indexes, stored procedures, packages) and has 
database administration privileges to these objects.
    [sbull] Quality Control Administrator class has read and write 
access to key fields in the database;
    [sbull] Quality Index Report Generator class has read-only access 
to all fields and tables;
    [sbull] Policy Research class has query access to tables, but are 
not allowed to access confidential patient identification information; 
and
    [sbull] Submitter class has read and write access to database 
objects, but no database administration privileges.

B. Physical Safeguards

    All server sites will implement the following minimum requirements 
to assist in reducing the exposure of computer equipment and thus 
achieve an optimum level of protection and security for the CMS system:
    Access to all servers is to be controlled, with access limited to 
only those support personnel with a demonstrated need for access. 
Servers are to be kept in a locked room accessible only by specified 
management and system support personnel. Each server is to require a 
specific log-on process. All entrance doors are identified and marked. 
A log is kept of all personnel who were issued a security card, key 
and/or combination, which grants access to the room housing the server, 
and all visitors are escorted while in this room. All servers are 
housed in an area where appropriate environmental security controls are 
implemented, which include measures implemented to mitigate damage to 
Automated Information Systems (AIS) resources caused by fire, 
electricity, water and inadequate climate controls.
    Protection applied to the workstations, servers and databases 
include:
    [sbull] User Log-on--Authentication is to be performed by the 
Primary Domain Controller/Backup Domain Controller of the log-on 
domain.
    [sbull] Workstation Names--Workstation naming conventions may be 
defined and implemented at the agency level.
    [sbull] Hours of Operation--May be restricted by Windows NT. When 
activated all applicable processes will automatically shut down at a 
specific time and not be permitted to resume until the predetermined 
time. The appropriate hours of operation are to be determined and 
implemented at the agency level.
    [sbull] Inactivity Lockout--Access to the NT workstation is to be 
automatically locked after a specified period of inactivity.
    [sbull] Warnings--Legal notices and security warnings are to be 
displayed on all servers and workstations.
    [sbull] Remote Access Security--Windows NT Remote Access Service 
(RAS) security handles resource access control. Access to NT resources 
is to be controlled for remote users in the same manner as local users, 
by utilizing Windows NT file and sharing permissions. Dial-in access 
can be granted or restricted on a user-by-user basis through the 
Windows NT RAS administration tool.

C. Procedural Safeguards

    All automated systems must comply with Federal laws, guidance, and 
policies for information systems security. These include, but are not 
limited to: the Privacy Act of 1974; the Computer Security Act of 1987; 
OMB Circular A-130, revised; Information Resource Management Circular 
10; HHS AIS Security Program; the CMS Information Systems 
Security Policy, Standards, and Guidelines Handbook;

[[Page 57023]]

and other CMS systems security policies. Each automated information 
system should ensure a level of security commensurate with the level of 
sensitivity of the data, risk, and magnitude of the harm that may 
result from the loss, misuse, disclosure, or modification of the 
information contained in the system.

V. Effects of the New System on Individual Rights

    CMS proposes to establish this system in accordance with the 
principles and requirements of the Privacy Act and will collect, use, 
and disseminate information only as prescribed therein. Data in this 
system will be subject to the authorized releases in accordance with 
the routine uses identified in this system of records.
    CMS will monitor the collection and reporting of CMTS data. CMTS 
information is submitted to CMS through standard systems. CMS will use 
a variety of onsite and offsite edits and audits to increase the 
accuracy of CMTS data.
    CMS will take precautionary measures (see item IV., above) to 
minimize the risks of unauthorized access to the records and the 
potential harm to individual privacy or other personal or property 
rights of patients whose data are maintained in the system. CMS will 
collect only that information necessary to perform the system's 
functions. In addition, CMS will make disclosure from the proposed 
system only with consent of the subject individual, or his/her legal 
representative, or in accordance with an applicable exception provision 
of the Privacy Act.
    CMS, therefore, does not anticipate an unfavorable effect on 
individual privacy as a result of maintaining this system of records.

Thomas A. Scully,
Administrator, Centers for Medicare & Medicaid Services.
09-70-3005

System Name:
    Correspondence Tracking Management System, (CMTS).

Security Classification:
    Level 3, Privacy Act Sensitive.

System Location:
    HCFA Data Center, 7500 Security Boulevard, North Building, First 
Floor, Baltimore, Maryland 21244-1850. CMS contractors and agents at 
various locations.

Categories of Individuals Covered by the System:
    The system of records will contain data on any correspondent whose 
letter is sent to CMS and on individuals referenced in such 
correspondence (e.g., beneficiaries, the public, other government 
agencies, contractors, and members of the Congress.

Categories of Records in the System:
    The system contains incoming correspondence, responses to 
correspondence and information CMS uses to track correspondence, and 
e.g. CMTS control number.

Authority for Maintenance of the System:
    42 CFR 401.101-401.148 and sec 1106(a) of the Social Security Act, 
42 U.S.C. 1306(a).

Purpose(s):
    The primary purpose of the system of records is to aid CMS in 
tracking incoming correspondence about CMS programs from the Office of 
the Secretary, Medicare beneficiaries and Medicaid recipients. In 
addition, it will track all correspondence from the public, other 
government agencies, contractors, and members of the Congress. 
Information retrieved from this system of records will be used to 
support regulatory, reimbursement, and policy functions performed 
within the agency or by a contractor or consultant; support constituent 
requests made to a Congressional representative; and support litigation 
involving the agency.

Routine uses of Records Maintained in the System, Including Categories 
or Users and the Purposes of Such Uses:
    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 CMTS 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. In addition, CMS 
policy will be to prohibit release even of non-identifiable data, 
except pursuant to one of the routine uses, if 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). Be advised, this System of Records contains Protected 
Health Information as defined by the Department of Health and Human 
Services' (HHS) regulation ``Standards for Privacy of Individually 
Identifiable Health Information'' (45 CFR parts 160 and 164, 65 FR 8462 
as amended by 66 FR 12434). Disclosures of Protected Health Information 
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.''
    1. To agency contractors, or consultants that have been contracted 
by the agency to assist in the performance of a service related to this 
system of records and that need to have access to the records in order 
to perform the activity.
    2. To a Member of Congress or to a Congressional staff member in 
response to an inquiry of the Congressional Office made at the written 
request of the constituent about whom the record is maintained.
    3. To 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.

Policies and Practices for Storing, Retrieving, Accessing, Retaining, 
and Disposing of Records in the System:
STORAGE:
    All records are stored on magnetic media.

RETRIEVABILITY:
    Name of correspondent, name of individual referenced in the 
correspondence, or correspondence control number retrieves the records.

SAFEGUARDS:
    CMS has safeguards 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 systems security 
requirements. Employees who maintain records in the system are 
instructed not to release any data until the intended recipient agrees 
to implement appropriate administrative, technical, procedural, and 
physical safeguards sufficient to

[[Page 57024]]

protect the confidentiality of the data and to prevent unauthorized 
access to the data.
    In addition, CMS has physical safeguards in place to reduce the 
exposure of computer equipment and thus achieve an optimum level of 
protection and security for the CMS system. For computerized records, 
safeguards have been established in accordance with HHS standards and 
National Institute of Standards and Technology guidelines; e.g., 
security codes will be used, limiting access to authorized personnel. 
System securities are established in accordance with HHS, Information 
Resource Management Circular 10, Automated Information Systems 
Security Program; CMS Information Systems Security, Standards 
Guidelines Handbook and OMB Circular No. A-130 (revised) Appendix III.

RETENTION AND DISPOSAL:
    The records are maintained on-line in the system for 2 years. After 
a 2-year period, records are transferred to an archive file and 
destroyed three years later.
    Due to a freeze imposed by the Department of Justice in 1992, 
correspondence documenting/supporting a specific claim, 
reconsideration, appeal or similar case will be maintained until 
further notice. Once the freeze is lifted, destroy 6 years and 3 months 
after final payment/resolution.

SYSTEM MANAGER(S) AND ADDRESS:
    Director, Division of Correspondence Control, Office of 
Communications and Operations Support, Health Care Financing 
Administration, 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, 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 
correspondence.

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:
    Incoming correspondence and responses to such correspondence.

SYSTEMS EXEMPTED FROM CERTAIN PROVISIONS OF THE ACT:
    None.
[FR Doc. 02-22742 Filed 9-5-02; 8:45 am]
BILLING CODE 4120-03-P