Privacy Act of 1974; Report of a Modified or Altered System of Records

AGENCY:

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

ACTION:

Notice of a Modified or Altered System of Records (SOR).

SUMMARY:

In accordance with the requirements of the Privacy Act of 1974, CMS is proposing to modify or alter existing system of records titled “National Provider System,” System No. 09-70-0008. Under the authority of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Public Law (Pub. L.) 104-191, this system was established and published in the Federal Register (FR) at 63 FR 40297 (July 28, 1998). The system name “National Provider System” describes the original system designed to enumerate individual health care providers and maintain the information submitted in their application, the National Provider Identifier (NPI) Application/Update Form (Form CMS-10114). Expectation of the adoption of a standard unique health identifier for health plans would broaden the function of the system to enable it to assign health plan identifiers to health plans; as a result, the name of the system is proposed to read: the “National Plan and Provider Enumeration System (NPPES).” Although the Federal Register Notice (July 28, 1998) stated that both organizational providers and providers who are individuals are included in the NPS database, and the system may be expanded in the future to include enumerated health plans, this system of records will be applicable only to the collection and maintenance of information about enumerated health care providers who are individuals (e.g., physicians and non-physician practitioners), containing the information they submitted on their NPI applications and their assigned NPI.

We propose to assign a new CMS identification number to this system to simplify the obsolete and confusing numbering system originally designed to identify the Bureau, Office, or Center that maintained information in the Health Care Financing Administration systems of records. The new assigned identifying number for this system should read: System No. 09-70-0555.

We propose to delete published routine use number 1 authorizing disclosure to Federal and Medicaid health plans that are enumerators and their agents. Published routine use number 1 will be deleted because the proposal to have Federal and Medicaid health plans serving as enumerators was not implemented.

We propose to delete published routine use number 2 authorizing disclosures to entities implementing or maintaining systems and data files necessary for compliance with Title XI, Part C of the Social Security Act because the information necessary for this use is available in accordance with the NPS Data Dissemination Notice (CMS-6060-N) published in the Federal Register on May 30, 2007.

We propose to delete routine use number 3 authorizing disclosure to support constituent requests made to a congressional representative. If an authorization for the disclosure has been obtained from the data subject, then no routine use is needed. The Privacy Act allows for disclosures with the “prior written consent” of the data subject.

We propose to delete published routine use number 4 authorizing disclosures to another Federal agency for use in processing research and statistical data related to the administration of its programs because the information from NPPES that would be used for this purpose is available in accordance with the Notice published in the Federal Register on May 30, 2007 (CMS-6060-N).

We propose to delete published routine use number 6 authorizing disclosures to an individual or organization for a research, demonstration, evaluation, or epidemiological project because the information in NPPES that would be used for this purpose is available in accordance with the Notice published in the Federal Register on May 30, 2007 (CMS-6060-N).

We propose to delete published routine use number 7 authorizing disclosures to contractors for the purpose of refining ADP or telecommunication systems or supporting records in the system. Disclosures allowed by published routine use number 7 will be covered by a new routine use for contractors, consultants, or grantees who have been contracted by the Agency to assist with a CMS assigned task and who need access to the records in order to complete that task. The new routine use will be numbered as routine use number 1.

We propose to delete routine use number 8 authorizing disclosures to an agency of the State government for purposes of determining effectiveness of health care services provided in the State because the information in NPPES that would be used for this purpose is available in accordance with the Notice published in the Federal Register on May 30, 2007 (CMS-6060-N).

We propose to delete in part routine use number 9 authorizing disclosures to another Federal or State agency to fulfill a Federal or State statute or regulation that implements a program funded in whole or in part with Federal funds because the information in NPPES that would be used for this purpose is available in accordance with the Notice published in the Federal Register on May 30, 2007 (CMS-6060-N). We retain routine use number 9 for purposes of identifying health care providers for Debt Collection Information Act of 1996 and the Balanced Budget Act of 1997 and include this as routine use number 2.

Routine use number 5 authorizing disclosures to the Department of Justice, to a court or other tribunal, or to another party before such tribunal, is revised for clarity and is renumbered as routine use number 3.

We have added two new routine uses for the purposes of combating fraud, waste, and abuse in CMS-administered health benefits programs and to support other Federal agencies, States, and local government agencies in combating fraud, waste, and abuse in programs funded in whole or in part by Federal funds. These two routine uses are routine use numbers 4 and 5.

In addition, we propose to add a new routine use to disclose information maintained in this system to respond to a suspected or confirmed breach of the security or confidentiality of information maintained in the system. This new routine use will be numbered as routine use 6.

The security classification previously reported as “None” will be modified to reflect that data in this system are considered to be “Level Three Privacy Act Sensitive.” We are modifying the language in the remaining routine uses to provide a proper explanation as to the need for the routine use and to provide clarity to CMS's intention to disclose individual-specific information contained in this system. We will also take the opportunity to update any sections of the System of Records Notice that were affected by the reorganization of CMS or to update language in the administrative sections to correspond with language used in other CMS SORs where appropriate.

The purpose of the NPPES is to collect and maintain, on behalf of the Secretary, information needed to uniquely identify an individual physician or non-physician practitioner, assign a National Provider Identifier (NPI) to that physician or non-physician practitioner, and maintain and update the information in that health care provider's record in NPPES. Information maintained in this system will also be disclosed to: (1) Support the NPI Enumerator and other agency contractors who need NPPES data to perform their contractual requirements; (2) to assist Federal and State agencies to identify health care providers for debt collection under Federal statutes; (3) to assist the Department of Justice in litigation; (4) to support CMS contractors in combating fraud, waste, and abuse in CMS-administered health benefits programs; (5) to support other Federal agencies or States in combating fraud, waste, and abuse in federally-funded programs; and (6) to assist Federal agencies in responding to security breaches of information contained in NPPES. We have provided background information about the system in the SUPPLEMENTARY INFORMATION section below. Although the Privacy Act requires only that CMS provide an opportunity for interested persons to comment on the proposed routine uses, CMS invites comments on all portions of this notice. See “Effective Dates” section for comment period.

DATES:

Effective Dates: CMS filed a modified or altered system report with the Chair of the House Committee on Government Reform and Oversight, the Chair of the Senate Committee on Homeland Security & Governmental Affairs, and the Administrator, Office of Information and Regulatory Affairs, Office of Management and Budget (OMB) on May 25, 2010. To ensure that all parties have adequate time in which to comment, the modified system, including routine uses, will become effective 30 days from the publication of the notice, or 40 days from the date it was submitted to OMB and Congress, whichever is later, unless CMS receives comments that require alterations to this notice.

ADDRESSES:

The public should address comments to: CMS Privacy Officer, Division of Information Security and Privacy Management, Enterprise Architecture and Strategy Group, Office of Information Services, CMS, Room N2-24-08, 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:

Patricia Peyton, Office of Financial Management, Program Integrity Staff, Division of Provider/Supplier Enrollment, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Mail Stop C3-02-16, Baltimore, Maryland 21244-1850. The telephone number is 410-786-1812 or contact Patricia.Peyton@cms.hhs.gov.

SUPPLEMENTARY INFORMATION:

I. Description of the Modified or Altered System of Records

A. Statutory and Regulatory Basis for this SOR

Authority for maintenance of this system is given under §§ 1173 and 1175 of the Act; as amended by Public Law 104-191, authorize the assignment of a unique identifier to all health care providers and the maintenance of a data base containing the information they furnished in their application for an NPI.

B. Collection and Maintenance of Data in the System

For purposes of this SOR, the system contains information related to health care providers who are individuals who have applied for and have been assigned a NPI. The definition of a health care provider is limited to those entities that furnish or bill and are paid for, health care services in the normal course of business. The statutory definition of a health care provider is found at 45 CFR 160.103.

The system contains name(s), demographic information, (gender, date of birth), provider taxonomy information, address data, contact information, practice location information, and certain optional information such as social security numbers and provider identifiers assigned to these health care providers by health plans.

II. Agency Policies, Procedures, and Restrictions on Routine Use

A. 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 NPPES information that can be associated with an individual as provided for under “Section III. Proposed Routine Use Disclosures of Data in the System.” Both individually identifiable and non-individually-identifiable data may be disclosed under a routine use.

We will only disclose the minimum personal data necessary to achieve the purpose of NPPES. CMS has the following policies and procedures concerning disclosures of information that is maintained in the system. Disclosure of information from the system will be approved only to the extent necessary to accomplish the purpose of the disclosure and only after CMS:

1. Determines that the use or disclosure is consistent with the reason that the data is being collected; e.g., maintain information to uniquely identify an individual physician or non-physician practitioner, assign a National Provider Identifier (NPI) to that physician or non-physician practitioner, and maintain and update information about that physician or non-physician.

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 or 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. 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 contractors (such as the NPI Enumerator contractor), consultants, or 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.

We contemplate 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 a CMS function relating to purposes for this system.

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, consultant, or grantee whatever information is necessary for the contractor, consultant, or grantee to fulfill its duties. In these situations, safeguards are provided in the contract prohibiting the contractor, consultant, or grantee from using or disclosing the information for any purpose other than that described in the contract and requires the contractor or consultant to return or destroy all information at the completion of the contract.

2. To assist another Federal or State agency, agency of a State government, agency established by State law, or its fiscal agent to identify health care providers for debt collection under the provisions of the Debt Collection Information Act of 1996 and the Balanced Budget Act of 1997.

3. Federal or State agencies, agencies of State governments, agencies established by State law, or their fiscal agents may need NPPES data to assist them in collecting debts from health care providers as authorized by the Debt Collection Information Act of 1996 and the Balanced Budget Act of 1997. 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 of 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.

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.

4. 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.

5. We contemplate disclosing information under this routine use only in situations in which CMS may enter into a contract or grant with a third party to assist in accomplishing CMS functions relating to the purpose of combating fraud, waste, or abuse.

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 or grantee whatever information is necessary for the contractor or grantee to fulfill its duties. In these situations, safeguards are provided in the contract prohibiting the contractor or grantee from using or disclosing the information for any purpose other than that described in the contract and requiring the contractor or grantee to return or destroy all information.

6. To support another Federal agency or 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.

Other agencies may require NPPES information for the purpose of combating fraud, waste, or abuse in such Federally-funded programs.

7. To assist appropriate Federal agencies and Department contractors that have a need to know the information for the purpose of assisting the Department's efforts to respond to a suspected or confirmed breach of the security or confidentiality of information maintained in this system of records, and the information disclosed is relevant and unnecessary for the assistance.

Other Federal agencies and contractors may require NPPES information for the purpose of assisting in a response to a suspected or confirmed breach of the security or confidentiality of information.

IV. 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 to maintain the confidentiality of protected information.

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.

V. Effects of the Modified System of Records on Individual Rights

CMS proposes to modify 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 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 physicians and non-physician practitioners 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, 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 information relating to individuals.

SYSTEM NUMBER: 09-70-0555

SYSTEM NAME:

“National Plan and Provider Enumeration System” (NPPES), HHS/CMS/OFM”.

SECURITY CLASSIFICATION:

Level Three Privacy Act Sensitive Data.

SYSTEM LOCATION:

The Centers for Medicare & Medicaid Services (CMS) Data Center, 7500 Security Boulevard, North Building, First Floor, Baltimore, Maryland 21244-1850.

CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:

For purposes of this SOR, the system contains information related to health care providers who are individuals who have applied for and have been assigned a NPI. The definition of a health care provider is limited to those entities that furnish or bill and are paid for, health care services in the normal course of business. The statutory definition of a health care provider is found at 45 CFR 160.103.

CATEGORIES OF RECORDS IN THE SYSTEM:

The system contains name(s), demographic information, (gender, date of birth), provider taxonomy information, address data, contact information, practice location information, and certain optional information such as social security numbers and provider identifiers assigned to these health care providers by health plans.

AUTHORITY FOR MAINTENANCE OF THE SYSTEM:

Authority for maintenance of this system is given under §§ 1173 and 1175 of the Act; as amended by Public Law 104-191, authorize the assignment of a unique identifier to all health care providers and the maintenance of a data base on containing the information they furnished in their application for an NPI.

PURPOSE(S) OF THE SYSTEM:

The purpose of the NPPES is to collect and maintain, on behalf of the Secretary, information needed to uniquely identify an individual physician or non-physician practitioner, assign a National Provider Identifier (NPI) to that physician or non-physician practitioner, and maintain and update the information in that health care provider's record in NPPES. Information maintained in this system will also be disclosed to: (1) Support the NPI Enumerator and other agency contractors who need NPPES data to perform their contractual requirements; (2) to assist Federal and State agencies to identify health care providers for debt collection under Federal statutes; (3) to assist the Department of Justice in litigation; (4) to support CMS contractors in combating fraud, waste, and abuse in CMS-administered health benefits programs; (5) to support other Federal agencies or States in combating fraud, waste, and abuse in federally-funded programs; and (6) to assist Federal agencies in responding to security breaches of information contained in NPPES.

ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES OR USERS AND THE PURPOSES OF SUCH USES:

A. 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 contractors (such as the NPI Enumerator contractor), consultants, or 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.

2. To assist another Federal or State agency, agency of a State government, agency established by State law, or its fiscal agent to identify health care providers for debt collection under the provisions of the Debt Collection Information Act of 1996 and the Balanced Budget Act of 1997.

3. 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.

4. 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.

5. 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.

6. To assist appropriate Federal agencies and Department contractors that have a need to know the information for the purpose of assisting the Department's efforts to respond to a suspected or confirmed breach of the security or confidentiality of information maintained in this system of records, and the information disclosed is relevant and unnecessary for the assistance.

POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING, AND DISPOSING OF RECORDS IN THE SYSTEM:

STORAGE:

All records are stored on paper and magnetic disk.

RETRIEVABILITY:

Magnetic media records are retrieved by the name of the health care provider or the NPI. Paper records are retrieved alphabetically by name of health care provider or the NPI.

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 to maintain the confidentiality of protected information.

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 will retain identifiable data indefinitely in accordance with 69 FR 3434.

SYSTEM MANAGERS AND ADDRESS:

Director, Division of Provider/Supplier Enrollment, Office of Financial Management, CMS, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

NOTIFICATION PROCEDURE:

For purpose of access by a subject individual, the subject individual may access to view or update his or her own record in NPPES by using his or her NPPES User ID and password or the subject individual should write to the system manager who will require the system name, the subject individual's SSN, and, for verification purposes, the subject individual's name (woman's maiden name, if applicable). NPPES data that are publicly available may be found in the NPI Registry at https://nppes.cms.gov/NPPES/NPIRegistryHome.do and in the downloadable monthly NPPES File at http://nppesdata.cms.gov/CMS_NPI_files.html.

RECORD ACCESS PROCEDURE:

For purpose of access, the same procedures outlined in Notification Procedures above are applicable to subject individuals. Other requestors must write to the system manager and 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:

Information contained in this system is received from the Form(s) CMS-10114, “National Provider Identifier Application/Update Form.”

SYSTEMS EXEMPTED FROM CERTAIN PROVISIONS OF THE ACT:

None.