[Federal Register Volume 75, Number 179 (Thursday, September 16, 2010)]
[Notices]
[Pages 56601-56603]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2010-23208]


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OFFICE OF PERSONNEL MANAGEMENT


Privacy Act of 1974: New System of Records

AGENCY: U.S. Office of Personnel Management (OPM).

ACTION: Notice of a new system of records.

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SUMMARY: The Patient Protection and Affordable Care Act (the Affordable 
Care Act), Public Law 111-148, was enacted on March 23, 2010; the 
Health Care and Education Reconciliation Act (the Reconciliation Act), 
Public Law 111-152, was enacted on March 30, 2010. The Affordable Care 
Act and implementing regulations (codified in HHS interim final rules 
(IFR) at 45 CFR Part 147) require that non-grandfathered health 
insurance plans and issuers offering group and individual coverage have 
effective internal claims and appeals and external review processes. 
The effective date for these requirements is plan or policy years 
beginning on or after September 23, 2010. Regarding external review, 
the statute requires that health plans and issuers must comply with 
either a state external review process or a process meeting standards 
issued by the Secretary of Health and Human Services (HHS) that is 
``similar to'' a state process meeting requirements in section 2719 (a 
``federal external review process''). The IFR includes a transition 
period prior to July 1, 2011, during which time HHS will work with 
states to assist in making any necessary changes so that the state 
process will meet the minimum consumer protections identified in 45 CFR 
147.136 that must be met in order for the state process to apply. 
During this interim period, health insurance issuers in states with 
external review laws in effect prior to September 23, 2010 will follow 
that state's external review law to the extent applicable. In states 
that have not passed an external review law that is in effect on 
September 23, 2010, a health insurance issuer must follow an interim 
federal external review process that will be administered by the Office 
of Personnel Management (OPM). The system of records will be created as 
OPM assists HHS by providing external reviews of adverse benefit 
determinations and final internal adverse benefit determinations as 
requested by eligible claimants and their authorized representatives 
(``claimants''). The system of records will include any data relevant 
to these external reviews, and OPM proposes to add this new system of 
records to its inventory of records systems subject to the Privacy Act 
of 1974 (5 U.S.C. 552a), as amended. This action is necessary to meet 
the requirements of the Privacy Act to publish in the Federal Register 
notice of the existence and character of records maintained by the 
agency (5 U.S.C. 552a(e)(4)).

DATES: This action will be effective without further notice on October 
18, 2010, unless comments are received that would result in a contrary 
determination.

ADDRESSES: Send written comments to the Office of Personnel Management, 
ATTN: Christopher Layton, Health Claims Disputes External Review 
Services, 1900 E Street, NW., Rm. 3415, Washington, DC 20415.

FOR FURTHER INFORMATION CONTACT: Christopher Layton, 202-606-0004.

SUPPLEMENTARY INFORMATION: The program associated with this system of 
records is part of a broader initiative directed by HHS's Office of 
Consumer Information and Insurance Oversight (OCIIO) to implement 
Section 2719 of the Affordable Care Act. HHS has discretion under the 
Act in the manner in which it implements the external appeals process, 
OPM administers a health insurance appeals program as part of its 
Federal Employees Health Benefits Program, and OPM has offered to 
permit HHS/OCIIO to utilize its existing appeals processes and 
frameworks to administer the interim federal appeals process (as 
modified by an interagency agreement). HHS/OCIIO has accepted that 
offer. Consequently, OPM has authority to administer the program, using 
an arrangement under the Economy Act, 31 U.S.C. 1535.

U.S. Office of Personnel Management.
John Berry,
Director.

SYSTEM NAME:
    Health Claims Disputes External Review Services

SYSTEM LOCATION:
    Office of Personnel Management, 1900 E Street, NW., Washington, DC 
20415.

CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:
    This system will contain records on adverse benefit determinations 
and final internal adverse benefit determinations for claimants who 
qualify for external review according to the IFR and choose to appeal 
to OPM. Individuals may only appeal to OPM (1) if they are in a state 
that did not have an external review law in place on September 23, 
2010, (2) if they purchase a health insurance policy or a group health 
plan from a health insurance issuer, (3) if they are in a non-
grandfathered plan, and (4) if the plan or policy year begins on or 
after September 23, 2010. Health insurance issuers must notify 
claimants upon notice of an adverse benefit determination or final 
internal adverse benefit determination as to how to initiate an 
external review by OPM if they choose to do so. This notice must meet 
the requirements of 45 CFR Part 147(b)(2)(ii)(E).

CATEGORIES OF RECORDS IN THE SYSTEM:
    In order to adjudicate an appeal, OPM requires claimants to submit 
a form with

[[Page 56602]]

their name, insurance ID number, phone number and mailing address as 
well as insurer name and the claim number. In addition, claimants may 
choose to submit the following additional information:
    a. A statement about why the claimant believes their health 
insurance issuer's decision was wrong, based on specific benefit 
provisions in the plan brochure or contract;
    b. Copies of documents that support the claim, such as physicians' 
letters, operative reports, bills, medical records, and explanation of 
benefits (EOB) forms;
    c. Copies of all letters the claimant sent to their insurance plan 
about the claim;
    d. Copies of all letters the health insurance issuer sent to the 
claimant about the claim;
    e. The claimant's daytime phone number and the best time to call; 
and
    f. The claimant's email address if they would like to receive OPM's 
decision via email.
    However, health insurance issuers will provide additional 
information and documentation. Consequently, the records in the system 
may include all of the following information:
    a. Personal Identifying Information (Name, Social Security Number, 
Date of Birth, Gender, Phone number etc).
    b. Address (Current, Mailing).
    c. Dependent Information (Spouse, Dependents and their addresses).
    d. Employment information.
    e. Health care provider information.
    f. Health care coverage information.
    g. Health care procedure information.
    h. Health care diagnosis information.
    i. Provider charges and reimbursement information on coverage, 
procedures and diagnoses.
    j. Any other letters or other documents submitted in connection 
with adverse benefit determinations or final internal adverse benefit 
determinations by claimants, healthcare providers, or health insurance 
issuers.

AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
    HHS has authority to administer the program under Sections 2701 
through 2763, 2791, and 2792 of the Public Health Service Act (42 
U.S.C. 300gg through 300gg-63, 300gg-91, and 300gg-92), as amended. HHS 
has discretion under the Act in the manner in which it implements the 
external appeals process, and it has entered an agreement with OPM 
under the Economy Act, 31 U.S.C. 1535, to provide such services.

PURPOSE:
    The primary purpose of this system of records is to aid in the 
administration of external review of adverse benefit determinations and 
final internal adverse benefit determinations. OPM must have the 
capacity to collect, manage, and access health insurance benefits 
appeals information and documents on an ongoing basis in order for OPM 
to:
    a. Determine eligibility for OPM's review process.
    b. Review the adverse benefit determinations and final internal 
adverse benefit determinations to provide effective external review.
    c. Track the progress of individual appeals and ensure that 
claimants do not submit duplicative appeals.
    d. Make information available for any subsequent litigation related 
to a disputed external review decision.
    e. Monitor whether health insurance issuers are providing benefits 
to which covered individuals are entitled.
    f. Maintain records for parties to the dispute so that the covered 
individual and the insurance issuer can obtain a record of past appeals 
in which they were involved.
    g. Track and report to HHS on the administration of the program.

ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES 
OF USERS AND THE PURPOSES OF SUCH USES:
    In addition to those disclosures generally permitted under 5 U.S.C. 
552a(b) of the Privacy Act, all or a portion of the records or 
information contained in this system may be disclosed to authorized 
entities, as is determined to be relevant and necessary, including 
disclosures outside of OPM as a routine use under 5 U.S.C. 552a(b)(3) 
as follows:
    a. For emergency and specialized claims adjudication--To disclose 
to medical consultants under contract with OPM information needed to 
adjudicate an appeal.
    b. For law enforcement purposes--To disclose pertinent information 
to the appropriate Federal, State, or local agency responsible for 
investigating, prosecuting, enforcing, or implementing a statute, rule, 
regulation, or order, where OPM becomes aware of an indication of a 
violation or potential violation of civil or criminal law or 
regulation.
    c. For congressional inquiries--To provide information to a 
congressional office from the record of an individual in response to an 
inquiry from that congressional office made at the request of that 
individual.
    d. For judicial/administrative proceedings--To disclose information 
to another Federal agency, to a court, or a party in litigation before 
a court or in an administrative proceeding being conducted by a Federal 
agency, when the Government is a party to the judicial or 
administrative proceeding. In those cases where the government is not a 
party to the processing, records may be disclosed if a subpoena has 
been signed by a judge.
    e. For litigation purposes--To disclose to the Department of 
Justice or in a proceeding before a court, adjudicative body, or other 
administrative body before which OPM or HHS is authorized to appear, 
when:
    1. OPM, HHS, or any component thereof; or
    2. Any employee of OPM or HHS in his or her official capacity; or
    3. Any employee of OPM or HHS in his or her individual capacity 
where the Department of Justice or OPM or HHS has agreed to represent 
the employee; or
    4. The United States, when OPM or HHS determines that litigation is 
likely to affect OPM or HHS or any of their components; is a party to 
litigation or has an interest in such litigation, and the use of such 
records by the Department of Justice or OPM of HHS is deemed by OPM to 
be relevant and necessary to the litigation provided, however, that the 
disclosure is compatible with the purpose for which records were 
collected.
    f. In the event of data breach--To conduct investigations of the 
breach and for purposes of mitigation response.
    g. For National Archives and Records Administration or the General 
Services Administration--For use in records management inspections 
conducted pursuant to 44 U.S.C. 2904 and 2906.
    h. Within OPM for statistical/analytical studies by OPM in the 
production of summary descriptive statistics and analytical studies in 
support of the function for which the records are collected and 
maintained, or for related program performance studies.
    i. By program and policy staff at OPM to compile and analyze de-
identified claims utilization data to identify sources of benefit and 
utilization costs and other information and to formulate health care 
program changes and enhancements to reduce cost increases, improve 
outcomes, improve efficiency in program administration and for other 
purposes.
    j. Researchers in and outside the federal government for the 
purpose of conducting research on health care and health insurance 
trends and topical issues. Only de-identified data will be shared.

[[Page 56603]]

POLICIES AND PRACTICES OF STORING, RETRIEVING, SAFEGUARDING, RETAINING, 
AND DISPOSING OF RECORDS IN THE SYSTEM:
Disclosure to consumer Reporting Agencies:
    None

Storage:
    Paper records will be stored in a locked file cabinet within OPM. 
Any electronic records will be maintained in electronic systems and 
will be backed-up according to common convention.

Retrievability:
    Records will primarily be manipulated, managed and summarized using 
a unique number assigned to each appeal. However, information may also 
be accessible by name or social security number.

Safeguards:
    Paper records will be delivered to a locked P.O. Box and kept in a 
locked file cabinet. Electronic records will be maintained on password 
protected computers and systems. All individuals with access to these 
records will receive a background check and privacy training before 
accessing any of the records. OPM also restricts access to the records 
on the databases to employees who have the appropriate clearance.

Retention and Disposal:
    OPM will maintain the records for 6 years. Computer records will be 
destroyed by electronic erasure. Any hard copies of records will be 
destroyed by shredding. A records retention schedule will be 
established with NARA.

System Manager and Address:
    Christopher Layton, U.S. Office of Personnel Management, 1900 E 
Street, NW., Room 3415, Washington, DC 20415.

Notification Procedure:
    Individuals wishing to determine whether this system of records 
contains information about them may do so by writing to the U.S. Office 
of Personnel Management, FOIA Requester Service Center, 1900 E Street, 
NW., Room 5415, Washington, DC 20415-7900 or by emailing foia@opm.gov.
    Individuals must furnish the following information for their 
records to be located:
    a. Full name.
    b. Date and place of birth.
    c. Social Security Number.
    d. Signature.
    e. Available information regarding the type of information 
requested, including the name of the insurance plan involved in any 
appeal and the approximate date of the appeal.
    f. The reason why the individual believes this system contains 
information about him/her.
    g. The address to which the information should be sent.
    Individuals requesting access must also comply with OPM's Privacy 
Act regulations regarding verification of identity and access to 
records (5 CFR part 297).
    In addition, the requester must provide a notarized statement or an 
unsworn declaration made in accordance with 28 U.S.C. 1746, in the 
following format:
     If executed outside the United States: `I declare (or 
certify, verify, or state) under penalty of perjury under the laws of 
the United States of America that the foregoing is true and correct. 
Executed on [date]. [Signature].'
     If executed within the United States, its territories, 
possessions, or commonwealths: `I declare (or certify, verify, or 
state) under penalty of perjury that the foregoing is true and correct. 
Executed on [date]. [Signature].'

Contesting Record Procedure:
    Individuals wishing to obtain a copy of their records or to request 
amendment of records about them should write to the Office of Personnel 
Management, ATTN: Lynelle Frye, Policy Analyst, Planning and Policy 
Analysis, Room 3415, Washington, DC 20415, and furnish the following 
information for their records to be located:
    a. Full name.
    b. Date and place of birth.
    c. Social Security Number.
    d. Signature.
    e. Available information regarding the type of information that the 
individual seeks to have amended, including the name of the insurance 
plan involved in any appeal and the approximate date of the appeal.
    Individuals requesting amendment must also follow OPM's Privacy Act 
regulations regarding verification of identity and amendment to records 
(5 CFR part 297).
    In addition, the requester must provide a notarized statement or an 
unsworn declaration made in accordance with 28 U.S.C. 1746, in the 
following format:
     If executed outside the United States: `I declare (or 
certify, verify, or state) under penalty of perjury under the laws of 
the United States of America that the foregoing is true and correct. 
Executed on [date]. [Signature].'
     If executed within the United States, its territories, 
possessions, or commonwealths: `I declare (or certify, verify, or 
state) under penalty of perjury that the foregoing is true and correct. 
Executed on [date]. [Signature].'

Record Source Categories:
    Information in this system of records is obtained from:
    a. Individuals who request OPM review.
    b. Authorized representatives of covered individuals.
    c. Health care providers.
    d. Health insurance plans.
    e. Medical professionals providing expert medical review under 
contract with OPM.

System Exemptions:
    None.

[FR Doc. 2010-23208 Filed 9-15-10; 8:45 am]
BILLING CODE 6325-39-P