Social Security Justification Memo

OFFICE OF THE ASSISTANT SECRETARY OF DEFENSE

HEALTH AFFAIRS

7700 ARLINGTON BOULEVARD, SUITE 5]0 1
FALLS CHURCH, VA 22042-5101

TR ICARE
MANAGEMENT
ACTIV ITY

MEMORANDUM FOR THE RECORD
SUBJECT: Justification for the Use of the Social Security Number (SSN) on DD Form 2527,
"Statement of Personal Injury - Possible Third Party Liability, TRICARE Management Activity
This memorandum is written to satisfy the requirement established in the Office of the
Under Secretary of Defense (OUSD) Personnel and Readiness (P&R) Directive-Type
Memorandum 07-015-USD (P&R), "DoD Social Security Number (SSN) Reduction Plan," that
requires justification ofthe collection and use of the SSN on the proposed revision to DD Form
2527 "Statement of Personal Injury - Possible Third Party Liability, TRICARE Management
Activity." The System of Records Notice applicable to DD Form 2527 is DTMA 04
Medical/Dental Claim History Files (March 29, 2006, 71 FR 15702) (Attachment 1). The OMB
Control Number for DD Form 2527 is 0720-0003 and is being renewed (Attachment 2).
DD Form 2527 collects data, including the SSN, on beneficiaries who suffer personal
injuries that may result in third party liability (TPL) in favor of the US Government. At the
present time, the SSN is the primary personal identifier used to identify the beneficiary's medical
and claims records in Military Health System (MHS) databases and records systems. Upgrades
to, or replacement of, MHS legacy systems databases to replace an individual's SSN with the
individual's internal Electronic Data Interchange/Personal Number (EDIIPN) for use in internal
DoD/MHS business processes will not eliminate the need to collect an individual's SSN through
DD Form 2527.
Health plans, liability insurers, and other sources of third party liability for healthcare
provided by the MHS to an individual do not recognize or use, as an identifier, EDIIPNs or other
internal DoD/MHS unique personal identifiers. Rather, actual and potential sources of third
party reimbursement to the MHS, including government agencies such as the Department of
Health and Human Services, the Department of Veterans Affairs, and the Social Security
Administration, will require DoD to provide an individual's SSN as part of the agency
determining the extent, if any, to which it may be liable for MHS healthcare provided to the
individual. The same need for an SSN will arise in identifying an individual to a private
insurance company or health plan against which third party liability may be claimed. Without
collection of an individual's SSN on DD Form 2527, DoD's ability to identify potential TPL
claims, and to collect those claims from third parties, under the Federal Medical Care Recovery
Act (FMCRA) would be severely limited. Without the use of the SSN, the government would
risk losing millions of dollars in potential FMCRA claims it would not be able to identify.
Based on the forgoing, and in accordance with DTM 07-015, continued use of the SSN is,
for current internal DoD and MHS business processes, justified under "Legacy System

Interface," paragraph 2.c.(lI), so long as there are plans in place for the migration away from
SSNs in the future. Currently our systems have been designed to recognize SSNs as unique
personal identifiers for these internal business processes. At the present time, the Defense
Manpower Data Center (DMDC) is working with TRICARE Management Activity on a suitable
alternate personal identifier. The SSN is required on this form until a suitable alternate personal
identifier can be developed and fielded in the personnel and health care databases.
To the extent that TPL claims are identified and asserted against non-DoD entities
(including both federal, state and local government agencies, as well as private health plans and
liability insurers) in accordance with FMCRA, continued collection and use of SSNs through DD
Form 2527 is further justified under DTM 07-015 Acceptable Uses cases 2.c(6); Administration
of Federal Worker's Compensation, 2.c(9); Computer Matching (e.g., with the Social Security
Administration regarding disability benefits and/or with the Department of Veterans Affairs);
and 2.c(12), Other Cases (identifying and asserting TPL claims against other health plans and
insurance companies identified as being potentially liable and who cannot be compelled by
DoDIMHS not to use SSNs as a personal identifier).
If you have any questions, my point of contact is Michael Bibbo, who can be reached at
(303) 676-3462 or [email protected].

utte , SES
General Counsel
TRICARE Management Activity
Enclosures:
As stated

2

STATEMENT OF PERSONAL INJURY - POSSIBLE THIRD PARTY LIABILITY
TRICARE MANAGEMENT ACTIVITY

OMB No. 0720-0003
OMB approval expires
Oct 31, 2010

IF A PREADDRESSED ENVELOPE IS NOT ENCLOSED WITH THIS IFORM, PLEASE RETURN YOUR
COMPLETED FORM TO ,EITHER OF THESE LOCATIONS:
(1) THE TRICARE (TMA) PROCESSOR WHO SENT YOU THE FORM; OR
(2) THE TRICARE (TMA) CLAIMS PROCESSOR FOR THE STATE/COUNTRY IN WHICH YOU RECEIVED THE
MEDICAL CARE (the Health Benefits Advisor at your nearest military installation can provide you with this
address).
The public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing
instructions. searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden,
to the Department of Defense. Washington Headquarters Services. Executive Services Directorate. Information Management Division. 1155
Defense Pentagon. Washington. DC 20301-1155 (0720-0003). Respondents should be aware that notwithstanding any other provision of law. no
person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION.

PRIVACY ACT STATEMENT
AUTHORITY: 42 U.S.C. 2651 - 2653; 10 U.S.C. 1079, 1085, 1086 and 1092; and E.O. 9397.
PRINCIPAL PURPOSE(S): To assist in determining possible third party liability for medical supplies and services
claims under THICARE (previously known as CHAMPUS). Information requested is used in reviewing claims to obtain
additional information to determine proper liability of third parties for claims and to facilitate possible recovery by the
United States for improperly paid claims.
ROUTINE USE(S): Information may be given to the Department of Health and Human Services and/or the
Department of Homeland Security consistent with their statutory administrative responsibilities under TRICARE
(formerly known as CHAMPUS) ; to the Department of Justice for representation of the Secretary of Defense in civil
actions; to the Internal Revenue Service and private collection agencies in connection with recoupment claims; and to
members of Congress with the consent of the individual involved . Appropriate disclosures may be made to other
Federal, state, local and/or foreign law enforcement agencies, private business entities, and individual providers of
care, on matters relating to entitlement, claims adjudication, fraud, program abuse, utilization review, quality
assurance, peer review, program integrity, third-party lJiability, coordination of benefits, and civil and criminal litigation
related to the operation of TRICARE (formerly CHAMPUS).
DISCLOSURE: Voluntary; however, failure to provide information will result in a claims processing delay and may
result in denial of the claim.

INSTRUCTIONS
We recently received a claim from you or your medical care provider for medical services required by (you/your family
member) that indicate that the patient may have had an illness or injury related to an accident.
Payment of your claims has been suspended until we receive more information. Your claims, and any related
claims that are subsequently received, will be denied if this form is not completed and returned within 35 days
from the date of this letter.
This information is requested solely for the purpose of processing your TRICARE claim. It has no bearing on any legal
action you may pursue as a result of your injury. All questions you may have concerning possible legal actions should
be referred to an attorney. Do not execute a release or settle any personal injury claim you may have without notice to
a military claims officer.

DO FORM 2527, JAN 2008

PREVIOUS EDITION IS OBSOLETE.

Page 1 of 2 Pages
Adobe Professional 7.0

STATEMENT OF PERSONAL INJURY - POSSIBLE THIRD PARTY LIABILITY

TRICARE MANAGEMENT ACTIVITY

Please fill out this form to permit the United States to recover medical expenses from whoever caused your injury.
Processing of your TRICARE claim will be suspended until you complete and return this form in the attached self-addressed
envelope . Address questions to any Judge Advocate office or call toll free telephone number 1-800- __ - ___.
SECTION I - GENERAL INFORMATION
1. SPONSOR'S SOCIAL SECURITY NUMBER:

I ARMY
I COAST GUARD

I
I

LNAVY
I USPHS

I

I AIR FORCE

I

I NOAA

2.a. INJURED PATIENT'S NAME:
c. TELEPHONE NUMBER :

b. INJURED PATIENT'S ADDRESS:

3. DATE INJURY OCCURRED (YYYYMMDD):

l

APPROXIMATE TIME OF INJURY:

4. LOCALITY AND STATE WHERE INJURY OCCURRED:
SECTION II - TYPE AND CAUSE OF INJURY
5. TRAFFIC ACCIDENT. (Gi ve name of at-fault driver and insurance company name. If you were a passenger in the accident

W

vehicle, give name of driver and driver's insurance company.)

W

6. SLiPIFALL, DOG BITE, MISHAP. (Give name of employer, business, municipality, or homeowner where injury occurred.)

W

7. EXPLOSION. (Specify type of explosive, name and address of place where injury occurred.)

W

8. ASSAULT. (Give name(s) of person(s) who assaulted you, and responding police department.)

~ 9. TOXIC SUBSTANCE. (Specify substance or drug name, and place where the incident occurred.)

~ 10. ON-THE-JOB INJURY. (Give name and address of employer, and cause of injury.)

~ 11 . PRODUCT MALFUNCTION. (Give product name and place where the injury occurred.)

W 12. MEDICAL MALPRACTICE.

(Give date you first knew of the malpractice, doctor's name, and place where the malpractice occurred.)

~ 13. OTHER TYPE AND CAUSE OF INJURY . (Specify.)

SECTION III - MISCELLANEOUS
14. LIST OF MILITARY MEDICAL FACILITIES THAT PROVIDED CARE FOR THIS INJURY, AND DATES OF TREATMENT:

15. HAVE YOU HIRED A LAWYER TO REPRESENT YOU REGARDING THIS INJURY?
a. LAWYER'S NAME AND ADDRESS :

I NO
I YES
I
b. LAWYER'S TELEPHONE NUMBER:

16. DO YOU HAVE INSURANCE?
a. NAME OF INSURANCE PROVIDER(S):

INO
I YES
I
b. INSURANCE TELEPHONE NUMBER(S):

17. YOUR SIGNATURE

DO FORM 2527, JAN 2008

18. DATE SIGNED (YYYYMMDD)

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SYSTEM OF RECORDS NOTICES (SORNs)
DOD COMPONENT NOTICES
Office of the Secretary, 0001 Joint Staff
DTMA 04
SYSTEM NAME:

Medical/Dental Claim History Files (March 29, 2006, 71 FR 15702) .

SYSTEM LOCATION:

TRICARE Management Activity, Department of Defense, 16401 East Centretech Parkway, Aurora, CO 80011-9066,

and contractors under contract to TRICARE. A listing of TRICARE 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 (medical and dental) under TRICARE/CHAMPUS and

CHAMPVA .

CATEGORIES OF RECORDS IN THE SYSTEM:

File contains claims, billings for services, applications or approval forms, enrollment files, recoupment files, third­

party liability files, fraud and abuse files, 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/CHAMPUS 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:

41 CFR 101-11 .000; chapter 55,10 U.S .c. 613, chapter 17, 38 U.S.c.; 32 CFR part 199; and E.O. 9397 (SSN).

PURPOSE(S):

TRICARE Management Activity and its contractors , DoD staff (including Military Treatment Facilities, clinics and

Lead Agent Staff) use the information to control and process health care benefits available under

TRICARE/CHAMPUS and CHAMPVA including the processing of medical/dental claims , the control and approval of

medical/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 contracto(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, these records or

information contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.c.

552a(b)(3) as follows:

To the Department of Health and Human Services and/or the Department of Veterans Affairs consistent with their

statutory administrative responsibilities under TRICARE/CHAMPUS and CHAMPVA pursuant to chapter 55, 10 U.S .c.

and section 613, chapter 17,38 U.S.c.

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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/CHAMPUS .
Disclosure to the Department of Justice and the United States Attorneys in situations where the United States is an
interested party.
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 OS D's compilation of systems of records notices apply
to this system.

NOTE; This system of records contains individually identifiable health information. The 000 Health Information
Privacy Regulation (000 6025. 18-R) issued pursuant to the Health Insurance Portability and AccountabWty Act of
1996, applies to most such health Information. 0006025. 18-R may place additional procedural requirements

on

the uses and disclosures of such information beyond those found in the Privacy Act of 1974 or mentioned in this
system of records notice.

DISCLOSURE TO CONSUMER REPORTING AGENCIES:
Disclosures pursuant to 5 U.S.c. 552a(b)(12) may be made from this system to consumer reporting agencies as
defined in the Fair Credit Reporting act of 1966 (15 U.S .c. 1681a(f» or the Federal Claims Collections Act of 1966
(31 U.S.c. 3701 (a)(3» . The purpose of the disclosure is to aid in the collection of outstanding debts owed to the
Federal Government; typically, to provide an incentive for debtors to repay delinquent Federal Government debts
by making these debts part of thei r credit records.
The disclosure is limited to information necessary to establish the identity of the individual , including name,
address, and taxpayer identification number (Social Security Number); the amount, status, and history of the
claim; and the agency or program under which the claim arose for the sole purpose of allowing the consumer
reporting agency to prepare a commercial credit report .

POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING, AND
DISPOSING OF RECORDS IN THE SYSTEM:
STORAGE:
Records are maintained on paper, electronic, microfilm , imaging, or optical formats .

RETRIEVABILlTY:
Information is retrieved by sponsor's name; sponsor's Social Security Number; beneficiary's name; beneficiary's
Social Security Number; provider's name; provider's number (Tax Identification Number or Social Security Number) ;
internal control number; classification of medical diagnosis; procedure code; geographical location of care
provided ; and selected utilization limits.

SAFEGUARDS:
Records are maintained in areas accessible only to authorized personnel who are properly screened, cleared and
trained. Decentralized automated segments within contractor's operations are accessible on-line only to authorized
persons possessing user identification codes. The automated portion of the Primary System is accessible only

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through TRICARE Management Activity on -line data systems. Security systems and/or security guards protect
buildings where records are maintained .

RETENTION AND DISPOSAL:
Paper records are closed out at the end of the calendar year in which finalized and held six additional years and
then destroyed. Where hard copy records (except Claims History Files) have been converted to electronic,
microfilm, imaging, or optical formats, the hard copy record is destroyed and the electronic , microfilm , imaging,
or optical format is kept by the contractor for six years after claim is processed to completion and then destroyed.
Claims History Files maintained in electronic format are kept for ten years and are then destroyed or deleted.

SYSTEM MANAGER(S) AND ADDRESS:
TRICARE Management Activity, Department of Defense, Administration and Evaluation Directorate, 16401 East
Centretech Parkway, Aurora, CO 80011-9066 .

NOTIFICATION PROCEDURE:
Individuals seeking to determine whether information about themselves is contained in this system should address
written inquiries to the TRICARE Management Activity, Department of Defense, ATTN: Privacy Act Officer, 16401
Centretech Parkway, Aurora, CO 80011-9066; or TRICARE Management Activity Privacy Office, Skyline 5, Suite 810,
5111 Leesburg Pike, Falls Church, VA 22041-3201.

RECORD ACCESS PROCEDURES:
Individuals seeking access to information about themselves contained in this system should address written
inquiries to the TRICARE Management Activity, Department of Defense, ATTN: Privacy Act Officer, 16401
Centretech Parkway, Aurora , CO 80011-9066; or TRICARE Management Activity Privacy Office, Skyline 5, Suite 810,
5111 Leesburg Pike, Falls Church, VA 22041-3201 .
Written request for information should include the full name of the beneficiary, the full name of the sponsor and
sponsor's Social Security Number, current address and telephone number.
For personal visits to examine records, the individual should provide some acceptable identification such as a
driver's license or other form of picture identification .
If it is determined that the release of medical information to the requester could have an adverse effect upon the
individual's physical or mental health, the requester should be prepared to provide the name and address of a
physician who would be willing to receive the medical record, and at the physician's discretion, inform the
individual covered by the system of the contents of that record. In the event the physician does not agree to
convey the information contained within the record to the individual, TRICARE Management Activity will take
positive measures to ensure the individual is provided the requested information.

CONTESTING RECORD PROCEDURES:
The 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, Health Benefit Advisors; other Components of the Department of Defense; all branches of the
Uniformed Services; Congressional offices; providers of care; consultants; and individuals.

EXEMPTIONS CLAIMED FOR THE SYSTEM:
None.

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