Quality Review Case Files

Effective Date: August 1, 2000

(65 F.R. 46997)

SOCIAL SECURITY ADMINISTRATION NOTICE OF SYSTEM OF RECORDS REQUIRED BY THE PRIVACY ACT OF 1974

System number: 60-0042

System name:

Quality Review Case Files, SSA/DCFAM/OQAPA/OQA.

Security classification:

None.

System location:

Social Security Administration

Office of Quality Assurance and Performance Assessment

Office of Assistance and Insurance Program Quality

6401 Security Boulevard

Baltimore, Maryland 21235

Records also are maintained at Regional offices of Quality Assurance and Performance Assessment Offices (See Appendix C for address information).

Categories of individuals covered by the system:

Randomly selected applicants for and/or beneficiaries of:

a. Supplemental Security Income (SSI) payments under title XVI of the Social Security Act. Records of some SSI beneficiaries may have been transferred from State welfare rolls for aid to the aged, blind and disabled.

b. Retirement, Survivors Disability Insurance (RSDI) benefits under title II of the Social Security Act.

Categories of records in the system:

Quality review case files contain information from SSA records and information obtained by Quality Review Specialists from RSI and SSI applicants and/or beneficiaries and from third party sources. These case files may contain information relating to any combination of these three programs.

Authority for maintenance of the system:

Sections 205(a), 1631(d)(1) and 1631(e)(1)(B) of the Social Security Act.

Purpose(s):

Both title II (Disability Insurance) and title XVI (Supplemental Security Income) quality review case files are used for accumulating data concerning the eligibility or entitlement of applicants/beneficiaries and of benefit amounts paid under the RSI programs and the SSI program. Case files also provide data necessary to complete the Quality Review Data Base and to provide information to SSA's regional offices to review cases in order to obtain information on the general level of accuracy of the entire beneficiary rolls in the programs noted previously.

Routine uses of records maintained in the system, including categories of users and the purposes of such uses:

With respect to SSI data, disclosure may be made as indicated below. However, disclosure of any information constituting “returns or return information” within the scope of the Internal Revenue Code will not be disclosed unless disclosure is authorized by that statute.

1. To the appropriate Federal agency charged with the responsibility for investigating or prosecuting 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, if this system of records indicates that a violation may have occurred.

2. To the Internal Revenue Service (IRS), as necessary, for the purpose of auditing SSA’s compliance with safeguard provisions of the Internal Revenue Code (IRC) of 1986, as amended.

3. To a contractor for the purpose of collating, evaluating, analyzing, aggregating or otherwise refining records in this system when SSA contracts with a private firm. (The contractor shall be required to maintain Privacy Act (PA) safeguards with respect to such records.)

4. To third party contacts in situations where the party to be contacted has, or is expected to have, information relating to the individual’s capability to manage his/her affairs or his/her eligibility for or entitlement to benefits under the Social Security program when:

a) The individual is unable to provide information being sought. An individual is considered to be unable to provide certain types of information when:

i) he/she is incapable or of questionable mental capability;

ii) he/she cannot read or write;

iii) he/she cannot afford the cost of obtaining the information;

iv) he/she has a hearing impairment, and is contacting SSA by telephone through a telecommunications relay system operator;

v) a language barrier exists; or

vi) the custodian of the information will not, as a matter of policy, provide it to the individual; or

b) The data are needed to establish the validity of evidence or to verify the accuracy of information presented by the individual, and it concerns one or more of the following:

i) his/her eligibility for benefits under the Social Security program;

ii) the amount of his/her benefit payment; or

iii) any case in which the evidence is being reviewed as a result of suspected abuse or fraud, concern for program integrity, or for quality appraisal, or evaluation and measurement activities.

5. To third party contacts where necessary to establish or verify information provided by representative payees or payee applicants.

6. To State Welfare Departments pursuant to agreements with SSA for the Federal administration of State supplementation payments.

7. State agencies for administration of the Medicaid Quality Control System.

8. To a congressional office in response to an inquiry from that office made at the request of the subject of a record.

9. To a Federal agency having the power to subpoena records, for example the Internal Revenue Service (IRS) or the Civil Rights Commission, in response to a subpoena for information contained in this system of records.

10. Information may be disclosed to contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the efficient administration of its programs. We contemplate disclosing information under this routine use only in situations in which SSA may enter into a contractual or similar agreement with a third party to assist in accomplishing an agency function relating to this system of records.

11. Non-tax return information which is not restricted from disclosure by Federal law may be disclosed to the General Services Administration (GSA) and the National Archive and Records Administration (NARA) for the purpose of conducting records management studies with respect to their duties and responsibilities under 44 U.S.C. § 2904 and § 2906, as amended by NARA Act of 1984.

12. To the Department of Justice (DOJ), a court or other tribunal, or another party before such tribunal when:

(a) SSA, or any component thereof; or

(b) any SSA employee in his/her official capacity; or

(c) any SSA employee in his/her individual capacity where DOJ (or SSA where it is authorized to do so) has agreed to represent the employee; or

(d) the United States or any agency thereof where SSA determines that the litigation is likely to affect the operations of SSA or any of its components,

is party to litigation or has an interest in such litigation, and SSA determines that the use of such records by DOJ, the court or other tribunal is relevant and necessary to the litigation, provided, however, that in each case, SSA determines that such disclosure is compatible with the purpose for which the records were collected.

Wage and other information which are subject to the disclosure provisions of the IRC (26 U.S.C. § 6103) will not be disclosed under this routine use unless disclosure is expressly permitted by the IRC.

With respect to title II data, routine disclosure is made only as indicated in items 1, 2, 3, 4, 5, 8, 9, 10 and 11.

13. To student volunteers and other workers, who technically do not have the status of Federal employees, when they are performing work for SSA as authorized by law, and they need access to personally identifiable information in SSA records in order to perform their assigned Agency functions.

14. We may disclose information to appropriate Federal, State, and local agencies, entities, and persons when (1) we suspect or confirm that the security or confidentiality of information in this system of records has been compromised; (2) we determine that as a result of the suspected or confirmed compromise there is a risk of harm to economic or property interests, identity theft or fraud, or harm to the security or integrity of this system or other systems or programs of SSA that rely upon the compromised information; and (3) we determine that disclosing the information to such agencies, entities, and persons is necessary to assist in our efforts to respond to the suspected or confirmed compromise and prevent, minimize, or remedy such harm. SSA will use this routine use to respond only to those incidents involving an unintentional release of its records.

Policies and practices for storing, retrieving, accessing, retaining and disposing of records in the system:

Storage:

Records are maintained in paper form (e.g., paper forms in manila folders).

Retrievability:

Quality review case files are retrieved by use of the SSN. Retrieval will be speedier if the individual's State of residence, program under which benefits were received and/or applied for and sample selection month are supplied.

Safeguards:

Quality review case files are stored in SSA's regional offices that have jurisdictional responsibility for review of the selected sample cases. All quality review case files are stored either in locked cabinets and/or locked rooms in space serviced by GSA guards.

Access is limited to SSA employees with responsibility for reviewing and maintaining such case files and, in the case of SSI quality review case files, to State Medicaid Quality Control employees pursuant to item 7 above. (See Appendix G to this publication for additional information relating to safeguards SSA employs to protect personal records.)

Retention and disposal:

a. Title XVI quality review case files are retained for 18 months after the close of the fiscal year for which the cases were selected for quality review.

b. Title II quality review case files are retained for 18 months after the close of the fiscal year period for which the cases were selected for review.

System manager(s) and address:

Director

Office of Assistance and Insurance Program Quality

Office of Quality Assurance and Performance Assessment

Social Security Administration

6401 Security Boulevard

Baltimore, Maryland 21235

Notification procedure:

An individual can determine if this system contains a record about him/her by writing to the appropriate address in Appendix C. When requesting notification, the individual should provide his/her name, Social Security number (SSN), State of residence and type of claim filed (e.g., RSI). (Furnishing the SSN is voluntary, but it will make searching for an individual's record easier and avoid delay.)

An individual can determine if this system contains a record about him/her by writing to the systems manager(s) at the above address and providing his/her name, SSN or other information that may be in the system of records that will identify him/her. An individual requesting notification of records in person should provide the same information, as well as provide an identity document, preferably with a photograph, such as a driver’s license or some other means of identification, such as a voter registration card, credit card, etc. If an individual does not have any identification documents sufficient to establish his/her identity, the individual must certify in writing that he/she is the person claimed to be and that he/she understands that the knowing and willful request for, or acquisition of, a record pertaining to another individual under false pretenses is a criminal offense.

If notification is requested by telephone, an individual must verify his/her identity by providing identifying information that parallels the record to which notification is being requested. If it is determined that the identifying information provided by telephone is insufficient, the individual will be required to submit a request in writing or in person. If an individual is requesting information by telephone on behalf of another individual, the subject individual must be connected with SSA and the requesting individual in the same phone call. SSA will establish the subject individual’s identity (his/her name, SSN, address, date of birth and place of birth along with one other piece of information such as mother’s maiden name) and ask for his/her consent in providing information to the requesting individual.

If a request for notification is submitted by mail, an individual must include a notarized statement to SSA to verify his/her identity or must certify in the request that he/she is the person claimed to be and that he/she understands that the knowing and willful request for, or acquisition of, a record pertaining to another individual under false pretenses is a criminal offense. These procedures are in accordance with SSA Regulations (20 CFR § 401.40).

An individual who requests access to his or her medical records shall be given direct access to those records unless SSA determines that it is likely that direct access would adversely affect the individual. If SSA determines that direct access to the medical record(s) would like adversely affect the individual, he or she must designate a responsible representative who is capable of explaining the contents of the medical record(s) to him or her and who would be willing to provide the entire record(s) to the individual. These procedures are in accordance with SSA Regulations (20 CFR 401.55).

A parent or guardian who requests notification of or access to a minor's medical record shall at the time he or she makes the request designate a physician or other health professional (other than a family member) who is capable of explaining the contents of the medical record(s) to them and who would be willing to provide the entire record(s) to the individual. These procedures are in accordance with SSA Regulations (20 CFR 401.55(c)(2)(ii)).

Record access procedures:

Same as notification procedures. Requesters should also reasonably specify the record contents being sought.

Contesting record procedures:

Same as notification procedures. Requesters should also reasonably identify the record, specify the information they are contesting and state the corrective action sought and the reasons for the correction with supporting justification showing how the record is incomplete, untimely, inaccurate or irrelevant. These procedures are in accordance with SSA Regulations (20 CFR 401.65(a)).

Record source categories:

Information in the quality review case file is furnished by applicants/beneficiaries under the RSI program, the SSI program, representatives of such individuals (where appropriate), SSA offices, and other Federal, State, and local agencies and from private sources.

Systems exempted from certain provisions of the Privacy Act:

None.