Privacy Act of 1974; System of Records

87 FR 49891Privacy Act of 1974; System of Records

87 FR 49891Office of Personnel Management, Healthcare and Insurance.

87 FR 49891Notice of new system of records.

87 FR 49891In 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.

87 FR 49891Please 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.

87 FR 49891You may submit written comments through the Federal Rulemaking Portal: https://www.regulations.gov. 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 https://www.regulations.gov as they are received without change, including any personal identifiers or contact information.

87 FR 49891For general questions, please contact Dyan Dyttmer, 202-606-1412. For privacy questions, please contact Kellie Cosgrove Riley, Chief Privacy Officer, 202-360-6065, or privacy@opm.gov.

87 FR 49891In 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.

87 FR 49891OPM 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. 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. 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.

87 FR 49891FEHB 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.

87 FR 49891FEHB Disputed Claims and Complaints Records, OPM/Central-27

87 FR 49891Healthcare 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.

87 FR 49891Associate Director, Healthcare and Insurance, Office of Personnel Management, 1900 E St NW, Washington, DC 20415.

87 FR 498915 U.S.C. Chapter 89, Health Insurance; 5 CFR part 890 (health insurance generally); 5 CFR 890.105 and § 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).

87 FR 49891The 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; 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.

87 FR 49892a. 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.

87 FR 49892a. 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.

87 FR 49892The 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.

87 FR 49892In 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.

87 FR 49892d. 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,· (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.

87 FR 49892h. 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.

87 FR 49892The electronic records in this system of records are maintained in an 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.

87 FR 49893These 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.

87 FR 49893The 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.

87 FR 49893Records 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.

87 FR 49893Individuals 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 foia@opm.gov; 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.

87 FR 49893Individuals 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 foia@opm.gov; 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.

87 FR 49893See “Record Access Procedures.”

87 FR 49893OPM/Central-1, Civil Service Retirement and Insurance Records, 73 FR 15013 (March 20, 2008), 80 FR 74815 (November 30, 2015).