Privacy Act of 1974; System of Records

AGENCY:

Department of Veterans Affairs (VA).

ACTION:

Amendment of system of records notice “veteran's spouse or dependent civilian health and medical care records-VA”.

SUMMARY:

As required by the Privacy Act of 1974, 5 U.S.C. 552a(e), notice is hereby given that the Department of Veterans Affairs (VA) is amending the system of records currently known as “Veteran's Spouse or Dependent Civilian Health and Medical Care Records-VA (54VA136)” as set forth in the Federal Register 88 FR 14242 (6/24/88). VA is amending the system by revising the paragraphs for System Name; System Location; Categories of individuals covered by the system; Categories of records in the system; Routine uses or records maintained in the system, including categories of users and the purposes of such uses; Policies and practices for storing, retrieving, accessing, retaining and disposing of records in the system; the location of the records and revising routine use statements; Safeguards; System manager(s) and address; Notification procedure; Record access procedures; Record source categories. VA is republishing the system notice in its entirety at this time.

DATES:

Comments on the amendment of this system of records must be received no later than January 25, 2001. If no public comment is received, the new system will become effective January 25, 2001.

ADDRESSES:

Written comments concerning the proposed new system of records may be submitted to the Office of Regulations Management (02D), Department of Veterans Affairs, 810 Vermont Avenue NW., Washington, DC 20420. Comments will be available for public inspection at the above address in the Office of Regulations Management, Room 1158, between the hours of 8:00 a.m. and 4:30 p.m., Monday through Friday (except holidays).

FOR FURTHER INFORMATION CONTACT:

VHA Privacy Act Officer, Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC 20420, telephone (727) 320-1839.

SUPPLEMENTARY INFORMATION:

The name and number of the system is changed from “Veteran's Spouse or Dependent Civilian Health and Medical Care Records-VA” (54VA136) to “Health Administration Center Civilian Health and Medical program Records-VA” (54VA17) to reflect organizational changes. The system location has been amended to reflect the current address of the Health Administration Center in this system. The Authority Section has been amended to reflect the current legal authority to maintain these records. Wording has been revised in this system to reflect that Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) has been renamed by the Department of Defense as TRICARE. The categories of individuals covered by the system has been amended to include the health care providers who treat CHAMPVA beneficiaries. The categories of records in the system has been amended to include other health insurance information collected and the type of medical services provided in order to process claims for payment.

Title 38, United States Code, section 1713 requires VA to administer health care benefits for the dependents of certain veterans. This program is known as the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA). VHA established the CHAMPVA Center in 1988 as the organization responsible for management of the CHAMPVA program. The CHAMPVA Center was recently renamed the Health Administration Center (HAC). The HAC administers all activities of the CHAMPVA program, including claims processing and an automated call center. In the process of daily activities, HAC is required to obtain and disclose certain information to make determinations of eligibility, issue authorization for medical services and provide payment and benefit data. This information is disclosed to health care providers, trading partners and contractors, CHAMPVA sponsors, beneficiaries and their representatives.

The following terms used in this System of Records are defined as follows:

• Trading Partners and Contractors—A trading partner or contractor is a third party organization that submits claims to CHAMPVA for payment consideration under either a formal Memorandum of Understanding or contractual agreement with HAC.
• CHAMPVA Sponsors, Beneficiaries and their Representatives—A CHAMPVA sponsor is the veteran whose dependents are eligible for CHAMPVA benefits. A CHAMPVA beneficiary refers to the eligible children and spouse of a CHAMPVA sponsor. A representative is an individual designated by a CHAMPVA beneficiary to act in their behalf or in the case of a minor, his or her parent or guardian.

Several routine use disclosures have been amended, as described below, to enable efficient administration of the program and granting of medical benefits to eligible beneficiaries.

• Routine use one (1) has been revised and amended to enable disclosure of claimant information in this system of records to health care providers, trading partners, contractors, and CHAMPVA beneficiaries contacting the HAC. Generally, the purpose of these contacts is to verify eligibility for benefits, obtain benefit information, obtain benefit assistance, resolve claim issues, verify payment for services, obtain authorization for medical services, and obtain financial and billing information for accounting purposes.
• Routine use 23 has been added to enable the exchange of certain information in this system of records to validate CHAMPVA beneficiary social security numbers and Medicare eligibility. Medicare information is required by Statute to determine beneficiary eligibility for CHAMPVA benefit. In order to obtain Medicare information, the beneficiary's social security number must be valid.
• Federal regulation (38 CFR part 17, §§ 17.270 through 17.278) requires health care providers who deliver medical services to CHAMPVA beneficiaries to accept the CHAMPVA determined allowable reimbursement rate as payment in full for rendered services. Since implementation of this regulation on October 9, 1998, some health care providers have elected not to provide medical services to CHAMPVA beneficiaries. Thus, routine use 24 has been added to enable VA to disclose the name and address of health care providers who provide medical services to CHAMPVA beneficiaries.
• Routine uses 11 and 12 have been revised to eliminate disclosure of information in this system as a result of Federal, State and municipal subpoenas.

The paragraph “Policies and Practices for Storing, Retrieving, Accessing, Retaining and Disposing of Records” has been amended to reflect that some paper documents and those received electronically are maintained electronically. The wording in the paragraph “Safeguards” has been revised to reflect current practices. The paragraph “Retention and Disposal” has been amended to reflect that those paper documents that are scanned onto optical disk for electronic storage are destroyed after scanning.

The purpose of this system of records is to establish and monitor eligibility and process medical claims for payment for certain beneficiaries of eligible veterans. Information submitted by health care providers that is included in this System of Records is used to process claims and may be used as a provider referral source to CHAMPVA beneficiaries.

The notice of intent to publish and an advance copy of the system notice have been sent to the appropriate Congressional committees and to the Director of the Office of Management and Budget (OMB) as required by 5 U.S.C. 522a(r) (Privacy Act) and guidelines issued by OMB (61 FR 6428), February 20, 1996.

54VA17

SYSTEM NAME:

Health Administration Center Civilian Health and Medical Program Records-VA.

SYSTEM LOCATION:

Records are maintained at the Health Administration Center, 300 South Jackson Street, Denver, Colorado 80209.

CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:

1. Individuals who seek health care under Title 38, United States Code, section 1713, including:

a. The spouse or child of a veteran who has a total disability, permanent in nature, resulting from a service-connected disability;

b. The surviving spouse or child of a veteran who died as a result of a service-connected disability or who at the time of death had a total disability, permanent in nature, resulting from a service-connected disability;

c. The surviving spouse or child of a person who died in the active military, naval, or air service in the line of duty and not due to such person's own misconduct; and who are not eligible for medical care under TRICARE or Medicare.

2. The veteran sponsor of the spouse or child.

3. Health care providers treating individuals who receive care under Title 38, United States Code, section 1713.

CATEGORIES OF RECORDS IN THE SYSTEM:

Records maintained in the system include medical benefit application and eligibility information concerning the spouse and/or dependent(s) and the veteran sponsor, other health insurance information correspondence concerning individuals and documents pertaining to claims for medical services, information related to claims processing and third party liability recovery actions taken by VA and/or TRICARE. The record may include the name, address and other identifying information concerning health care providers, services provided, amounts claimed and paid for health care services, medical records, and treatment and payment dates. Additional information may include veteran, spouse and/or dependent identifying information (e.g., name, address, social security number, VA claims file number, date of birth), and military service information concerning the veteran sponsor (e.g., dates, branch and character of service, medical information).

AUTHORITY FOR MAINTENANCE OF THE SYSTEM:

Title 38, United States Code, Chapter 5, section 501(a) and 501(b), and Chapter 17, section 1713.

PURPOSE:

Records may be used for purposes of establishing and monitoring eligibility to receive CHAMPVA benefits; and process medical claims for payment for eligible beneficiaries of certain veterans.

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

1. Eligibility and claim information from this system of records may be disclosed as a useful purpose in response to an inquiry made by the claimant, claimant's guardian, health care provider or trading partner or contractor. Purposes of these disclosures are to assist the provider or claimant in obtaining reimbursement for claimed medical services, facilitate billing processes, to verify beneficiary eligibility for requested services and to provide payment information regarding claimed services. Eligibility or entitlement information disclosed may include the name, CHAMPVA authorization number (social security number), effective dates of eligibility, the reasons for any period of ineligibility and other health insurance information of the named individual. Claim information disclosed may include payment information such as payment identification number, date of payment, date of service, amount billed, amount paid, name and address of payee or reasons for non-payment.

2. Transfer of statistical and other data to Federal, State, and local government agencies and national health organizations to assist in the development of programs that will be beneficial to health care recipients, to protect their rights under the law, and to assure that they are receiving all health benefits to which they are entitled.

3. In the event that a system of records maintained by this agency to carry out its functions indicates a violation or potential violation of law, whether civil, criminal or regulatory in nature, and whether arising by general statute or particular program statute, or by regulation, rule or order issued pursuant thereto, the relevant records in the system of records may be referred, as a routine use, to the appropriate agency, whether Federal, State, local or foreign, charged with the responsibility of investigating or prosecuting such violation or charged with enforcing or implementing the statute, or rule, regulation or order issued pursuant thereto.

4. A record from this system of records may be disclosed to a Federal agency, in the issuance of a security clearance, the reporting of an investigation of an employee, the letting of a contract, or the issuance of a license, grant or other benefit by the requesting agency, to the extent that the information is relevant and necessary to the requesting agency's decision on the matter.

5. A record from this system of records may be disclosed as a “routine use” to a Federal, State or local agency maintaining civil, criminal or other relevant information, such as current licenses, if necessary to obtain information relevant to an agency decision concerning the hiring or retention of an employee, the issuance of a security clearance, the letting of a contract, or the issuance of a license, grant or other health, educational or welfare benefit.

6. Relevant information from this system of records, including the nature and amount of a financial obligation, may be disclosed as a routine use, in order to assist VA in the collection of unpaid financial obligations owed to the VA, to a debtor's employing agency or commanding officer so that the debtor-employee may be counseled by his or her Federal employer or commanding officer. This purpose is consistent with 5 U.S.C. 5514, 4 CFR 102.5, and section 206 of Executive Order 11222 of May 8, 1965 (30 FR 6469).

7. Disclosure may be made to a congressional office from the record of an individual in response to an inquiry from the congressional office made at the request of that individual.

8. Disclosure may be made to National Archives and Records Administration (NARA), General Services Administration (GSA) in records management inspections conducted under authority of 44 United States Code.

9. Any relevant information in this system of records may be disclosed to attorneys, insurance companies, employers, and to courts, boards, or commissions; such disclosures may be made only to the extent necessary to aid VA in preparation, presentation, and prosecution of claims authorized under Federal, State, or local laws, and regulations promulgated thereunder.

10. Any information in this system of records may be disclosed to the United States Department of Justice or United States Attorneys in order for the foregoing parties to prosecute or defend litigation involving or pertaining to the United States.

11. Any information in this system of records may be disclosed to a Federal grand jury, a Federal court or a party in litigation, or a Federal agency or party to an administrative proceeding being conducted by a Federal agency, in order for VA to respond to and comply with the issuance of a Federal court order.

12. Any information in this system of records may be disclosed to a State or municipal grand jury, a State or municipal court or a party in litigation, or to a State or municipal administrative agency functioning in a quasi-judicial capacity or a party to a proceeding being conducted by such agency, in order for VA to respond to and comply with issuance of a State court order; provided that any disclosure of claimant information made under this routine use must comply with the provisions of 38 CFR 1.511.

13. Any information concerning the claimant's indebtedness to the United States by virtue of a person's participation in a benefits program administered by VA, including personal information obtained from other Federal agencies through computer matching programs, may be disclosed to any third party, except consumer reporting agencies, in connection with any proceeding for the collection of any amount owed to the United States. Purposes of these disclosures may be to assist VA in collection of costs of services provided individuals not entitled to such services and to initiate legal actions for prosecuting individuals who willfully or fraudulently obtain Title 38 benefits without entitlement. This disclosure is consistent with 38 U.S.C. 5701(b)(6).

14. Any relevant information from this system of records may be disclosed to TRICARE, Department of Defense and the Defense Eligibility Enrollment Reporting System (DEERS) to the extent necessary to determine eligibility for CHAMPVA or TRICARE benefits, to develop and process CHAMPVA or TRICARE claims, and to develop cost recovery actions for claims involving individuals not eligible for the services or claims involving potential third party liability.

15. The name and address of a veteran or dependent, and other information as is reasonably necessary to identify such individual, may be disclosed to a consumer reporting agency for the purpose of locating the individual or obtaining a consumer report to determine the ability of the individual to repay an indebtedness to the United States by virtue of the individual's participation in a benefits program administered by VA, provided that the requirements of 38 U.S.C. 5701(g)(2) have been met.

16. the name and address of a veteran or dependent, and other information as is reasonably necessary to identify such individual, including personal information obtained from other Federal agencies through computer matching programs, and any information concerning the individual's indebtedness to the United States by virtue of the individual's participation in a benefits program administered by VA, may be disclosed to a consumer reporting agency for purposes of assisting in the collection of such indebtedness, provided that the requirements of 38 U.S.C. 5701(g)(4) have been met.

17. In response to an inquiry about a named individual from a member of the general public, disclosure of information may be made from this system of records to report the amount of VA monetary benefits being received by the individual. This disclosure is consistent with 38 U.S.C. 5701(c)(1).

18. The name and address of a veteran or dependent may be disclosed to another Federal agency or to a contractor of that agency, at the written request of the head of that agency or designee of the head of that agency for the purpose of conducting government research necessary to accomplish a statutory purpose of that agency.

19. Any information in this system of records relevant to a claim of a veteran or dependent, such as the name, address, the basis and nature of a claim, amount of benefit payment information, medical information and military service and active duty separation information may be disclosed at the request of the claimant to accredited service organizations, VA-approved claim agents and attorneys acting under a declaration of representation so that these individuals can aid claimants in the preparation, presentation and prosecution of claims under the laws administered by VA. The name and address of a claimant will not, however, be disclosed to these individuals under this routine use if the claimant has not requested the assistance of an accredited service organization, claims agent or an attorney.

20. Any information in this system including medical information, the basis and nature of claim, the amount of benefits and personal information may be disclosed to a VA Federal fiduciary or a guardian ad litem in relation to his or her representation of a claimant only to the extent necessary to fulfill the duties of the VA Federal fiduciary or the guardian ad litem.

21. The individual's name, address, social security number and the amount (excluding interest) of any indebtedness which is waived under 38 U.S.C. 3102, compromised under 4 CFR Part 103, otherwise forgiven, or for which the applicable statute of limitations for enforcing collection has expired, may be disclosed to the Treasury Department, Internal Revenue Service, as a report of income under 26 U.S.C. 61(a)(12).

22.The name of a veteran or dependent, other information as is reasonably necessary to identify such individual, and any other information concerning the individual's indebtedness by virtue of a person's participation in a benefits program administered by VA, may be disclosed to the Treasury Department, Internal Revenue Service, for the collection of Title 38, U.S.C. benefit overpayments, overdue indebtedness, and/or costs of services provided to an individual not entitled to such services, by the withholding of all or a portion of the person's Federal income tax refund.

23. The name, date of birth and social security number of a veteran, spouse or dependent, and other identifying information as is reasonably necessary may be disclosed to Social Security Administration and Health Care Financing Administration, Department of Health and Human Services, for the purpose of validating social security numbers and Medicare information.

24. The name and address of any health care provider in this system of records who has received payment for claimed services in behalf of a CHAMPVA beneficiary may be disclosed in response to an inquiry from a member of the general public.

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

STORAGE:

Records are stored electronically, in paper folders, magnetic discs, and magnetic tape. Paper documents may be scanned/digitized and stored for viewing electronically.

RETRIEVABILITY:

Paper records are retrieved by name or VA claims file number or social security number of the veteran sponsor. Computer records are retrieved by name or social security number of the veteran sponsor, spouse, and/or dependent, or VA claims file number of the veteran sponsor.

SAFEGUARDS:

Working spaces and record storage areas at HAC are secured during all business and non-business hours. All entrance doors require an electronic passcard for entry. The HAC Security Officer issues electronic passcards. HAC staff control visitor entry by door release and escort. The building is equipped with an intrusion alarm system monitored by HAC security staff during business hours and by a security service vendor during non-business hours. Records are stored in an electronic controlled storage filing area. Records in work areas are stored in locked file cabinets or locked rooms. Access to record storage areas is restricted to VA employees on a “need-to-know” basis. Access to the computer room is generally limited by appropriate locking devices and restricted to authorized VA employees and vendor personnel. ADP peripheral devices are generally placed in secure areas or are otherwise protected. Authorized VA employees may access information in the computer system by a series of individually unique passwords/codes.

RETENTION AND DISPOSAL:

Records are maintained and disposed of in accordance with record disposition authority approved by the Archivist of the United States. Paper records that are scanned/digitized for viewing electronically are destroyed after they have been scanned onto optical disks.

SYSTEM MANAGER(S) AND ADDRESS:

Chief Financial Officer (17), Department of Veterans Affairs, Veterans Health Administration, VA Central Office, 810 Vermont Avenue, NW, Washington, DC 20420.

Official maintaining the system:

Director, Department of Veterans Affairs, Health Administration Center, PO Box 65020, Denver, CO 80206-9020.

NOTIFICATION PROCEDURE:

Any individual who wishes to determine whether a record is being maintained in this system under his or her name or other personal identifier, or wants to determine the contents of such record, should submit a written request to Director, VA Health Administration Center, PO Box 65020, Denver, Colorado 80206-9020, or apply in person to the Director, VA Health Administration Center, 300 South Jackson Street, Denver, Colorado 80209. Inquiries should include the veteran sponsor's full name and social security and VA claims file numbers, and the spouse or department's name, social security number and return address.

RECORD ACCESS PROCEDURES:

An individual who seeks access to records maintained under his or her name in this system may write or visit the Director, VA Health Administration Center.

CONTESTING RECORD PROCEDURES:

(See Record Access Procedures above.)

RECORD SOURCE CATEGORIES:

The veteran sponsor, spouse and/or dependent, military service departments, private medical facilities and health care professionals, electronic trading partners, contractors, Department of Defense (DoD), TRICARE, DoD Defense Eligibility Enrollment Reporting System (DEERS), other Federal agencies, VA regional offices, Veterans Benefits Administration automated record systems.