Notice2022-17392
Privacy Act of 1974; System of Records
Primary source
Metadata and text below are from the Federal Register, a public-domain U.S. government work. Always verify the official published version before relying on it for any legal matter.
Published
August 12, 2022
Effective
September 16, 2022
Issuing agencies
Personnel Management Office
Abstract
In accordance with the Privacy Act of 1974, the Office of Personnel Management (OPM) proposes to publish a new system of records titled "OPM/Central-27, FEHB Disputed Claims and Complaints Records." This system of records contains information about enrollees or their family members who have submitted a request to OPM for its review of healthcare claim denials made by Federal Employees Health Benefits (FEHB) plans. This system of records also contains records related to complaints received by OPM about the FEHB Program, Carriers, or plans. This newly established system of records will be included in OPM's inventory of record systems.
Full Text
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<title>Federal Register, Volume 87 Issue 155 (Friday, August 12, 2022)</title>
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[Federal Register Volume 87, Number 155 (Friday, August 12, 2022)]
[Notices]
[Pages 49891-49893]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2022-17392]
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OFFICE OF PERSONNEL MANAGEMENT
Privacy Act of 1974; System of Records
AGENCY: Office of Personnel Management, Healthcare and Insurance.
ACTION: Notice of new system of records.
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SUMMARY: In accordance with the Privacy Act of 1974, the Office of
Personnel Management (OPM) proposes to publish a new system of records
titled ``OPM/Central-27, FEHB Disputed Claims and Complaints Records.''
This system of records contains information about enrollees or their
family members who have submitted a request to OPM for its review of
healthcare claim denials made by Federal Employees Health Benefits
(FEHB) plans. This system of records also contains records related to
complaints received by OPM about the FEHB Program, Carriers, or plans.
This newly established system of records will be included in OPM's
inventory of record systems.
DATES: Please submit comments on or before September 12, 2022. This new
system of records is effective upon publication in today's Federal
Register, with the exception of the routine uses, which are effective
September 16, 2022.
ADDRESSES: You may submit written comments through the Federal
Rulemaking Portal: <a href="https://www.regulations.gov">https://www.regulations.gov</a>. Follow the instructions
for submitting comments. All submissions received must include the
agency name and docket number for this Federal Register document. The
general policy for comments and other submissions from members of the
public is to make these submissions available for public viewing at
<a href="https://www.regulations.gov">https://www.regulations.gov</a> as they are received without change,
including any personal identifiers or contact information.
FOR FURTHER INFORMATION CONTACT: For general questions, please contact
Dyan Dyttmer, 202-606-1412. For privacy questions, please contact
Kellie Cosgrove Riley, Chief Privacy Officer, 202-360-6065, or
<a href="/cdn-cgi/l/email-protection#93e3e1fae5f2f0ead3fce3febdf4fce5"><span class="__cf_email__" data-cfemail="cebebca7b8afadb78ea1bea3e0a9a1b8">[email protected]</span></a>.
SUPPLEMENTARY INFORMATION: In accordance with the Privacy Act of 1974,
5 U.S.C 552a, the Office of Personnel Management proposes to establish
a new system of records titled ``OPM/Central-27, FEHB Disputed Claims
and Complaints Records.'' Established in 1960 through the Federal
Employees Health Benefits Act of 1959, 5 U.S.C. 8901 et seq., the FEHB
Program is the largest employer-sponsored group health insurance
program globally, covering over 8 million individuals. Covered
individuals, as defined in 5 CFR 890.101, include employees of the
Federal government, annuitants, members of their families, former
spouses, and miscellaneous groups, enumerated in 5 U.S.C. 8901; United
States Postal Service employees and annuitants, pursuant to 39 U.S.C.
1005; tribal employees, pursuant to 25 U.S.C. 1647b; and separated
employees and former dependents who are eligible for Temporary
Continuation of Coverage under 5 U.S.C. 8905a.
OPM receives, stores, and processes requests from individuals
covered by FEHB plans (or their authorized representatives) to review
healthcare claim denials made by FEHB plans. As part of this review,
OPM gathers records related to the denied claim from the covered
individual (or authorized representatives) and the FEHB Carrier. OPM
may also submit records to an Independent Medical Reviewer to obtain an
advisory opinion from an independent healthcare professional. OPM
issues a written decision regarding the disputed claim; if OPM reverses
the denied healthcare claim, in whole or in part, the FEHB Carrier is
required to comply with OPM's decision. This system of records includes
the request for review, all records related to the review,
correspondence, and OPM's decision.
OPM also receives complaints about the FEHB Program, Carriers, or
plans. These complaints may come from a variety of sources including
FEHB-covered individuals,\1\ health care providers, Congressional and
White House inquiries, tribal entities, the Department of Health and
Human Services and other Federal, State, or local agencies. This system
of records includes the complaints, any records received or developed
by OPM related to investigating the complaints, and OPM's response to
the complaints.
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\1\ Under 5 CFR 890.101(a) a ``covered individual'' means an
enrollee or covered family member. An ``enrollee'' means an
individual in whose name the enrollment is carried. Under 5 CFR
890.105(e), a covered individual is authorized to submit a disputed
claim to OPM.
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The records in this new system of records to date have been
included in the OPM/Central-1 Civil Service Retirement and Insurance
system of records (OPM/Central-1). However, OPM's organizational
structure and its retirement and insurance programs have evolved over
time and OPM has determined that OPM/Central-1 no longer provides the
public with the most informative notice regarding the system of
records, nor adequately facilitates individuals' ability to exercise
their rights under the Privacy Act and OPM's ability to respond
effectively. Accordingly, OPM is in the process of regrouping the
records currently contained in OPM/Central-1 and publishing
corresponding systems of records notices. Additional systems of records
notices related to other record sets currently encompassed in OPM/
Central-1 have been previously published or will be published in the
future.
FEHB disputed claims and complaints records will now be maintained
in the system of records known as OPM/Central-27, FEHB Disputed Claims
and Complaints Records. This newly established system of records will
be included in OPM's inventory of records systems. In accordance with 5
U.S.C. 552a(r), OPM has provided a report of this system of records to
the Office of Management and Budget and to Congress.
Office of Personnel Management.
Stephen Hickman,
Federal Register Liaison.
SYSTEM NAME AND NUMBER:
FEHB Disputed Claims and Complaints Records, OPM/Central-27
SECURITY CLASSIFICATION:
Unclassified.
SYSTEM LOCATION:
Healthcare and Insurance, Office of Personnel Management, 1900 E
Street NW, Suite 3400, Washington, DC 20415 is responsible for this
system of records. The electronic records in this system are maintained
at OPM's data center in Macon, Georgia.
SYSTEM MANAGER(S):
Associate Director, Healthcare and Insurance, Office of Personnel
Management, 1900 E St NW, Washington, DC 20415.
AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
5 U.S.C. Chapter 89, Health Insurance; 5 CFR part 890 (health
insurance generally); 5 CFR 890.105 and Sec. 890.107 (regarding OPM's
review of denied claims and judicial review of OPM's final action); and
5 CFR 890.114 (regarding complaints related to surprise billing).
PURPOSE(S) OF THE SYSTEM:
The purpose of this system of records is to collect, process,
review, maintain, and make decisions concerning disputed healthcare
claims for individuals covered by FEHB plans; collect, process, review,
maintain, and respond to complaints regarding the FEHB Program,
Carriers, and plans;
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track the progress of individual disputed claims and complaints so that
timely decisions and responses are rendered; and create and maintain
the administrative record in the event of judicial review of OPM's
decision related to a disputed healthcare claim. In addition, OPM uses
the records in this system of records to evaluate FEHB Carrier
compliance with the plan brochure and the contract, and to evaluate and
improve FEHB Program benefits and processes.
CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:
a. Enrollees (defined in 5 CFR 890.101) and their family members
who have filed an FEHB disputed claim.
b. Individuals who have submitted a complaint to OPM about the FEHB
Program, Carriers, or plans.
CATEGORIES OF RECORDS IN THE SYSTEM:
a. Name;
b. Date of birth;
c. Home address;
d. Email address;
e. Telephone number;
f. Health plan name and member ID;
g. Dates of service under appeal;
h. All materials submitted by the individual or duly authorized
representative related to the disputed claim, including written
correspondence and emails;
i. Explanation of benefits, including advanced explanation of
benefits;
j. Good Faith Estimate of charges;
k. Notice and Consent Documents related to the No Surprises Act;
l. Reconsideration determination related to the disputed claim from
the FEHB Carrier and any related correspondence;
m. Bills related to the disputed claim;
n. Medical records related to the disputed claim;
o. Response from the FEHB Carrier to OPM regarding the disputed
claim;
p. Advisory opinion from the Independent Medical Reviewer;
q. Copy of OPM's final disposition of the claim and any other
agency correspondence;
r. System-generated reports or documents;
s. All materials submitted to OPM related to a complaint submitted
to OPM about the FEHB Program, Carriers, or plans;
t. All materials generated by OPM in reviewing a complaint
submitted to OPM about the FEHB Program, Carriers, or plans; and
u. Any response generated by OPM to a complaint submitted to OPM
about the FEHB Program, Carriers, or plans.
RECORD SOURCE CATEGORIES:
The records in this system related to disputed claims are obtained
from individuals covered by FEHB plans or their duly authorized
representatives, FEHB Carriers, and Independent Medical Reviewers. The
records in this system related to complaints are obtained from a
variety of sources including FEHB-covered individuals, health care
providers, Congressional and White House inquiries, tribal entities,
the Department of Health and Human Services and other Federal, State,
or local agencies.
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 outside OPM as a
routine use pursuant to 5 U.S.C. 552a(b)(3) as follows:
a. To the Department of Justice, including Offices of the U.S.
Attorneys; another Federal agency conducting litigation or in
proceedings before any court, adjudicative, or administrative body;
another party in litigation before a court, adjudicative, or
administrative body; or to a court, adjudicative, or administrative
body. Such disclosure is permitted only when it is relevant or
necessary to the litigation or proceeding and one of the following is a
party to the litigation or has an interest in such litigation:
(1) OPM, or any component thereof;
(2) Any employee or former employee of OPM in his or her official
capacity;
(3) Any employee or former employee of OPM in his or her individual
capacity where the Department of Justice or OPM has agreed to represent
the employee;
(4) The United States, a Federal agency, or another party in
litigation before a court, adjudicative, or administrative body, upon
the OPM General Counsel's approval, pursuant to 5 CFR part 295 or
otherwise.
b. To the appropriate Federal, State, or local agency responsible
for investigating, prosecuting, enforcing, or implementing a statute,
rule, regulation, or order, when a record, either on its face or in
conjunction with other information, indicates or is relevant to a
violation or potential violation of civil or criminal law or
regulation.
c. To a member of Congress from the record of an individual in
response to an inquiry made at the request of the individual to whom
the record pertains.
d. To the National Archives and Records Administration (NARA) for
records management inspections being conducted under the authority of
44 U.S.C. 2904 and 2906.
e. To appropriate agencies, entities, and persons when (1) OPM
suspects or has confirmed that there has been a breach of the system of
records,[middot] (2) OPM has determined that as a result of the
suspected or confirmed breach there is a risk of harm to individuals,
OPM (including its information systems, programs, and operations), the
Federal Government, or national security; and (3) the disclosure made
to such agencies, entities, and persons is reasonably necessary to
assist in connection with OPM's efforts to respond to the suspected or
confirmed breach or to prevent, minimize, or remedy such harm.
f. To another Federal agency or Federal entity, when OPM determines
that information from this system of records is reasonably necessary to
assist the recipient agency or entity in (1) responding to a suspected
or confirmed breach or (2) preventing, minimizing, or remedying the
risk of harm to individuals, the recipient agency or entity (including
its information systems, programs, and operations), the Federal
Government, or national security, resulting from a suspected or
confirmed breach.
g. To contractors, grantees, experts, consultants, or volunteers
performing or working on a contract, service, grant, cooperative
agreement, or other assignment for OPM when necessary to accomplish an
agency function related to this system of records. Individuals provided
information under this routine use are subject to the same Privacy Act
requirements and limitations on disclosure as are applicable to OPM
employees.
h. To FEHB Carriers for the purpose of obtaining complete records
held by the plan regarding the claim or claims in dispute, obtaining
responsive information relating to a complaint related to the Carrier
or its FEHB plan, or providing OPM's decision regarding the disputed
claim review or OPM's response regarding a complaint.
i. To an Independent Medical Reviewer for the purpose of obtaining
an advisory opinion from the Reviewer regarding the claim or claims in
dispute.
j. To an individual or entity submitting a complaint to OPM about
the FEHB Program, Carriers, or plans, a response or report of outcome
related to the complaint.
POLICIES AND PRACTICES FOR STORAGE OF RECORDS:
The electronic records in this system of records are maintained in
an
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encrypted database. Paper records are kept in lockable metal file
cabinets or in a secured facility. Access to records is limited to
those whose official duties require access.
POLICIES AND PRACTICES FOR RETRIEVAL OF RECORDS:
These records are retrieved primarily by the name of the
individual, FEHB health plan name, date of birth and/or claim number of
the individual to whom they pertain but may be retrieved by any
personal identifier.
POLICIES AND PRACTICES FOR RETENTION AND DISPOSAL OF RECORDS:
The disputed claims and complaints records are subject to the NARA-
approved records schedule NC1-146-77-01 INS 4(b) relating to Healthcare
and Insurance claims correspondence, correspondence with individuals or
carriers' representatives on the interpretation of contracts, and
settlement of Federal employee claims under health benefits and life
insurance plans.
ADMINISTRATIVE, TECHNICAL, AND PHYSICAL SAFEGUARDS:
Records in this system are protected from unauthorized access and
misuse through various administrative, technical, and physical security
measures. OPM security measures are in compliance with the Federal
Information Security Modernization Act of 2014 (Pub. L. 113-203),
associated OMB policies, and applicable standards and guidance from the
National Institute of Standards and Technology (NIST). Transmission of
the data feed from FEHB Carriers and Independent Medical Reviewers to
this system is encrypted in compliance with NIST Federal Information
Processing Standards Publication 197.
RECORD ACCESS PROCEDURES:
Individuals seeking notification of and access to their records in
this system of records may do so by submitting a request in writing to
the Office of Personnel Management, Office of Privacy and Information
Management--FOIA, 1900 E Street NW, Washington, DC 20415-7900 or by
emailing <a href="/cdn-cgi/l/email-protection#90f6fff9f1d0ffe0fdbef7ffe6"><span class="__cf_email__" data-cfemail="1f7970767e5f706f7231787069">[email protected]</span></a>; ATTN: Healthcare and Insurance. Individuals must
furnish the following information for their records to be located:
1. Full name, including any former name.
2. Date of birth.
3. FDC Control Number, if known.
4. Reasonable specification of the requested information.
5. The address to which the information should be sent.
6. Signature.
Individuals requesting access must also comply with OPM's Privacy
Act regulations regarding verification of identity and access to
records (5 CFR 297). Medical or psychological records may also be
subject to 5 CFR 297.205.
Contesting Record Procedures
Individuals wishing to request amendment of their records in this
system of records may do so by writing to the to the Office of
Personnel Management, Office of Privacy and Information Management--
FOIA, 1900 E Street NW, Room 5415, Washington, DC 20415-7900 or by
emailing <a href="/cdn-cgi/l/email-protection#8ee8e1e7efcee1fee3a0e9e1f8"><span class="__cf_email__" data-cfemail="b4d2dbddd5f4dbc4d99ad3dbc2">[email protected]</span></a>; ATTN: Healthcare and Insurance. Requests for
amendment of records should include the words ``PRIVACY ACT AMENDMENT
REQUEST'' in capital letters at the top of the request letter; if
emailed, please include those words in the subject line. Individuals
must furnish the following information for their records to be located:
1. Full name, including any former name.
2. Date of birth.
3. Name and address of employing agency or retirement system.
4. Precise identification of the information to be amended.
5. Signature.
Individuals requesting amendment of their records must also comply
with OPM's Privacy Act regulations regarding verification of identity
and access to records (5 CFR 297). OPM may refer amendment requests to
other entities when those entities are the original source of the
record.
Notification Procedures
See ``Record Access Procedures.''
Exemptions Promulgated for the System
None.
History
OPM/Central-1, Civil Service Retirement and Insurance Records, 73
FR 15013 (March 20, 2008), 80 FR 74815 (November 30, 2015).
[FR Doc. 2022-17392 Filed 8-11-22; 8:45 am]
BILLING CODE 6325-63-P
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This is legal information, not legal advice. Laws vary by jurisdiction and change frequently. Always verify current law with official sources and consult a licensed attorney in your jurisdiction for advice on your specific situation.