Medical/Dental Claim History Files (October 27, 2015, 80 FR 65720)
Records Management, Administration and Management Directorate, 16401 East Centretech Parkway, Aurora, CO 80011-9066, and contractors under contract to the Defense Health Agency.
A listing of Managed Care Support contractors maintaining these records is available from the system manager.
CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:
Eligible beneficiaries and all individuals who seek health care under TRICARE and the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA).
CATEGORIES OF RECORDS IN THE SYSTEM:
File contains claims, billings for services, applications or approval forms, enrollment and disenrollment files, recoupment files, third-party liability files, fraud and abuse files, the name, Social Security Number (SSN) and/or DoD Identification Number (DoD ID Number) of the sponsor and/or beneficiary; beneficiary's relationship to sponsor, case management files, resource sharing files, utilization management/quality assurance files, payment files, medical/dental records, family history files, records of grievances with a medical/dental provider, appeals, hearings, or any other correspondence, memoranda, or reports which are acquired or utilized in the development and processing of TRICARE or CHAMPVA claims.
Records are also maintained on health care demonstration projects, including enrollment and authorization agreements, correspondence, memoranda, forms and reports, which are acquired or utilized during the projects.
AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
10 U.S.C. Chapter 55, Medical and Dental Care; 38 U.S.C. Chapter 17, Hospital, Nursing Home, Domiciliary, and Medical Care; 32 CFR part 199, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); and E.O. 9397 (SSN), as amended.
Defense Health Agency and its contractors and DoD staff (including Military Treatment Facilities, clinics and TRICARE Regional Offices Staff) use the information to control and process health care benefits available under TRICARE and CHAMPVA, including the processing of medical or dental claims, the control and approval of medical or dental treatments, issuance of deductible certificates, and necessary interface with providers of health care. The system also supports audits of contractor-processed claims to determine payment and occurrence accuracy of the contractor's adjudication process.
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 of 1974, as amended, these records may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows:
To the Departments of Health and Human Services and Veterans Affairs consistent with their statutory administrative responsibilities under TRICARE and CHAMPVA pursuant to 10 U.S.C. Chapter 55; and 38 U.S.C. Chapter 17.
Referral to Federal, state, local, or foreign governmental agencies, and to private business entities, including individual providers of care (participating and non-participating), on matters relating to eligibility, claims pricing and payment, fraud, program abuse, utilization review, quality assurance, peer review, program integrity, third-party liability, coordination of benefits, and civil or criminal litigation related to the operation of TRICARE.
Disclosure to the Department of Justice and the United States Attorneys in situations where the matter directly or indirectly involves the TRICARE program.
Disclosure to third-party contacts in situations where the party to be contacted has, or is expected to have, information necessary to establish the validity of evidence or to verify the accuracy of information presented by the individual concerning his or her entitlement, the amount of benefit payments, any review of suspected abuse or fraud, or any concern for program integrity or quality appraisal.
The DoD Blanket Routine Uses set forth at the beginning of the Defense Health Agency compilation of systems of records notices may apply to this system. The complete list of DoD Blanket Routine Uses can be found online at: http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx.
NOTE 1: This system of records contains individually identifiable health information. The DoD Health Information Privacy Regulation (DoD 6025.18-R) or any successor DoD issuances implementing the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and 45 CFR parts 160 and 164, Health and Human Services, General Administrative Requirements and Security & Privacy, respectively, applies to most such health information. DoD 6025.18-R or a successor issuance may place additional procedural requirements on uses and disclosures of such information beyond those found in the Privacy Act of 1974, as amended, or mentioned in this system of records notice.
NOTE 2: Except as provided under 42 U.S.C. 290dd-2, records of identity, diagnosis, prognosis or treatment information of any patient maintained in connection with the performance of any program or activity relating to substance abuse education, prevention, training, treatment, rehabilitation, or research, which is conducted, regulated, or directly or indirectly assisted by a department or agency of the United States will be treated as confidential and disclosed only for the purposes and under the circumstances expressly authorized under 42 U.S.C. 290dd-2.
POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING, AND DISPOSING OF RECORDS IN THE SYSTEM:
Paper records and/or electronic storage media.
Information is retrieved by the name, SSN and/or DoD ID Number of the sponsor or beneficiary; name and SSN and/or Tax Identification Number of the provider; internal control number; classification of medical diagnosis; procedure code; geographical location of care provided; and selected utilization limits.
Electronic media, data and/or electronic records are maintained in a controlled area. Records are maintained in a secure, limited access, or monitored area. The computer system is accessible only to authorized personnel. Entry into these areas is restricted to those personnel with a valid requirement and authorization to enter. Physical entry is restricted by the use of locks, passwords which are changed periodically, and administrative procedures.
The system provides two-factor authentication through user IDs/passwords. Access to personal information is restricted to those who require the data in the performance of their official duties. All personnel whose official duties require access to the information are trained in the proper safeguarding and use of the information.
All of the records must be properly secured for the duration of their life cycle. The safeguards in place for the paper records include placing the documents in locked file cabinets and storage rooms with limited access and electronic security measures. In addition, some of the records are housed in secure facilities monitored by security guards and video surveillance.
RETENTION AND DISPOSAL:
Close out at end of the calendar year in which received. Destroy 10 years after cutoff. When subject to one or more Litigation Holds, preserve records in compliance with the time constraints of the hold(s).
SYSTEM MANAGER(S) AND ADDRESS:
Manager, Records Management, Administration and Management Directorate, 16401 East Centretech Parkway, Aurora, CO 80011-9066.
Individuals seeking to determine whether information about themselves is contained in this system of records should address written inquiries to Chief, Freedom of Information Act (FOIA) Service Center, Defense Health Agency Privacy and Civil Liberties Office, 7700 Arlington Boulevard, Suite 5101, Falls Church, VA 22042-5101.
Requests should contain the full name and signature of the sponsor or beneficiary.
If requesting information about a minor or legally incompetent person, the request must be made by the custodial parent, legal guardian, or party acting in loco parentis of such individual. Written proof of that status may be required before the existence of any information will be confirmed.
RECORD ACCESS PROCEDURES:
Individuals seeking access to records about themselves contained in this system of records should address written inquiries to the Chief, FOIA Service Center, Defense Health Agency Privacy and Civil Liberties Office, 7700 Arlington Boulevard, Suite 5101, Falls Church, VA 22042-5101.
Written requests for information should include the full name and signature of the sponsor or beneficiary.
If requesting records about a minor or legally incompetent person, the requestmust be made by the custodial parent, legal guardian, or party acting in loco parentis of such individual. Written proof of that status may be required before any records will be provided.
CONTESTING RECORD PROCEDURES:
The Office of the Secretary of Defense (OSD) rules for accessing records, for contesting contents and appealing initial agency determinations are published in OSD Administrative Instruction 81, 32 CFR part 311, or may be obtained from the system manager.
RECORD SOURCE CATEGORIES:
Contractors, Beneficiary Counseling and Assistance Coordinators, other Components of the Department of Defense, all branches of the Uniformed Services, Congressional offices, providers of care, consultants, and sponsor and/or beneficiary.
EXEMPTIONS CLAIMED FOR THE SYSTEM:
FEDERAL REGISTER HISTORY:
November 18, 2013, 78 FR 69076; March 29, 2006, 71 FR 15702