Data Use Agreement (State) {CMS-R-0255ST} | Pdf Fpdf Doc Docx | Official Federal Forms

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Data Use Agreement (State) {CMS-R-0255ST} | Pdf Fpdf Doc Docx | Official Federal Forms

Data Use Agreement (State) {CMS-R-0255ST}

This is a Official Federal Forms form that can be used for Centers For Medicare And Medicaid Services.

Alternate TextLast updated: 5/23/2006

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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0734 DATA USE AGREEMENT BETWEEN CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) AND THE STATE OF_____________________________________ AGREEMENT FOR USE OF CMS DATA CONTAINING INDIVIDUAL-SPECIFIC INFORMATION In order to secure data that resides in a CMS Privacy Act System of Records, and in order to ensure the integrity, security, and confidentiality of information maintained by CMS, and to permit appropriate disclosure and use of such data as permitted by law, CMS and _______________________________, enter into this agreement to comply with the following specific paragraphs. 1. This Agreement is by and between CMS, a component of the U.S. Department of Health and Human Services (DHHS), and ___________________________, hereinafter termed "User." 2. This Agreement addresses the conditions under which CMS will disclose and the User will obtain and use the CMS Enrollment Database (EDB) Customized State File specified in section 5. This Agreement supersedes any and all agreements between the parties with respect to the use of the EDB Customized State File, and preempts and overrides any instructions, directions, agreements, or other understanding in or pertaining to any grant award or other prior communication from the Department of Health and Human Services or any of its components with respect to the data specified herein. Further, the terms of this Agreement can be changed only by a written modification to this Agreement, or by the parties adopting a new agreement. The parties agree further that instructions or interpretations issued to the User concerning this Agreement or the data specified herein, shall not be valid unless issued in writing by the CMS point-of-contact specified in section 18, or the CMS signatory to this Agreement shown in section 18. 3. The parties mutually agree that CMS retains all ownership rights to the data file(s) referred to in this Agreement, and that the User does not obtain any right, title, or interest in any of the data furnished by CMS. 4. The User represents, and in furnishing the EDB Customized State File, CMS relies upon such representation, that this file(s) will be used solely for the purpose(s) outlined below. The EDB Customized State File is used for the following: A. To enable the User to identify Medicare individuals who are potentially eligible for inclusion in a State Buy-In account, including Qualified Medicare Beneficiaries (QMBs), and B. To identify Medicare/Medicaid dually eligible individuals for whom Medicaid has secondary payer liability by: (1) Obtaining a beneficiary's correct health insurance claim number (HICN), (2) Verifying a beneficiary's name, date of birth and address, social security number, State buy-in indicator code, Railroad Board indicator code, (3) Avoiding duplicate claims payments by screening pre-payment of Medicaid claims, and (4) Enabling recoupment of payments by reviewing post payment of Medicaid claims. C. To support the development of risk adjustment factors which are a necessary element in establishing capitation rates or prospective payment levels, and which contribute to sound fiscal planning and the evaluation of future program initiatives. The User represents further that, except as specified in an Enclosure to this Agreement or except as CMS shall authorize in writing, the User shall not disclose, release, reveal, show, sell, rent, lease, loan, or otherwise grant Form CMS-R-0235ST (03/06) EF 03/2006 American LegalNet, Inc. www.USCourtForms.com 1 access to the data covered by this Agreement to any person(s). The User agrees that, within the User organization, access to the data covered by this Agreement shall be limited to the minimum number of individuals necessary to achieve the purpose stated in this section and to those individuals on a need-to-know basis only. Disclosure of this data is made pursuant to: · Freedom of Information Act (5 U.S.C. Section 552) · Privacy Act (5 U.S.C. Section 552a) · Section 1106 of the Social Security Act (42 U.S.C. Section 1306) · Computer Matching and Privacy Protection Act of 1988 (P.L. 100-503) · Section 1843 of the Social Security Act (42 U.S.C. Section 1395v) 5. CMS will provide the User with the EDB Customized State File, which is an extract from the Health Insurance Master Record (HIMR), System Number 09-07-0502. CMS warrants that the file is accurate to the extent possible. Beneficiaries included in the EDB Customized State File will vary from State to State depending on the number of Medicare beneficiaries residing in the State, present or past and on the size of the finder file submitted for the given month. The following files are covered under this Agreement: File Year(s) EDB Customized State File Current 6. The parties mutually agree that the aforesaid file(s) (and/or any derivative file(s) [includes any file that maintains or continues identification of individuals]) may be retained by the User only for the period of time required for any processing related to matching under this Agreement. The User agrees to notify CMS within 30 days of the completion of the purpose specified above in section 4. Upon such notice, CMS will notify the User either to return all data files to CMS at the User's expense, or to destroy such data. If CMS elects to have the User destroy the data, the User agrees to certify the destruction of the files in writing within 30 days of CMS's instruction. A statement certifying this action must be sent to CMS. If CMS elects to have the data returned, the User agrees to return all files to CMS within 30 days of receiving notice to that effect. The User agrees that no data from CMS records, or any parts thereof, shall be retained when the aforementioned file(s) are returned or destroyed unless authorization in writing for the retention of such file(s) has been received from the appropriate Systems Manager or the person designated in section 20 of this Agreement. The User acknowledges that stringent adherence to the aforementioned information outlined in this paragraph is required. The User further acknowledges that the EDB Customized State File received for any previous periods, and all copies thereof, must be destroyed upon receipt of an updated version, and verification made to CMS. Certification of the destruction of these files is required in writing within 30 days of such destruction. 7. The User agrees to establish appropr

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