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Authentication, Credential and Controlled Enterprise Security System at CMS

Date signed: 9/18/2026

PIA information for the Authentication, Credential and Controlled Enterprise Security System at CMS system
PIA QuestionsPIA Answers
OPDIV:CMS
PIA Unique Identifier:P-2705412-960145
Name:Authentication, Credential and Controlled Enterprise Security System at CMS
The subject of this PIA is which of the following?Major Application
Identify the Enterprise Performance Lifecycle Phase of the system.Operate
Is this a FISMA-Reportable system?Yes
Does the system include a Website or online application available to and for the use of the general public?No
Identify the operator:Contractor
Is this a new or existing system?New
Does the system have Security Authorization (SA)?No
Planned Date of Authorization9/1/2026
Describe the purpose of the systemThe Authentication, Credential and Controlled Enterprise Security System at CMS, known as AccessCMS, is classified as a Moderate level system and is hosted within the CMS Amazon Web Services (AWS) environment. AccessCMS plays a pivotal role as the Agency’s digital identity, credential, and access management (ICAM) program. This system functions as a comprehensive framework, integrating the policies, processes, and technologies required to manage and regulate access to CMS information resources. As the primary application used for the provisioning, management, and certification of credentials for all CMS employees and contractors it ensures secure and controlled access throughout the organization.
Describe the type of information the system will collect, maintain (store), or share. (Subsequent questions will identify if this information is PII and ask about the specific data elements)The information that may be collected and stored are Social Security Number, Passport Number, name, date of birth, Employment status, Legal Documents, Email Address, Mailing Address, Phone number, Birth place, Company name and address, Alien Registration number, Visa Number, Work Permit Number, Sex, Citizenship information, Contact Information, Resume, Federal Agency affiliation, and CMS/HHS/Harp ID information. This system also contains internal administration information, system access history, workflows, and approvals necessary to grant various types of access.
Provide an overview of the system and describe the information it will collect, maintain (store), or share, either permanently or temporarily.

AccessCMS is an enterprise Identity, Credential, and Access Management (ICAM) platform that serves as the secure entry point for managing digital identities and access across the CMS environment. It supports identity lifecycle management by providing services for user registration, authentication, credentialing, vetting, and access approval for CMS employees, contractors, and other authorized users. The system is designed to ensure that only properly authorized and vetted individuals and systems can access CMS resources, while improving security, compliance, and operational efficiency.

To perform these functions, AccessCMS collects, stores, maintains, and shares information necessary to establish, verify, and manage user identities and access privileges. This information is used to identify and authenticate users, support credentialing and vetting processes, manage access throughout the user lifecycle, and enable secure access to CMS systems. The information may be stored permanently or temporarily, as appropriate, to support identity management, security, auditing, and compliance requirements.

Indicate the type of PII that the system will collect or maintain.
  • Social Security Number
  • Passport Number
  • Name
  • Date of Birth
  • Employment Status
  • Legal Documents
  • E-Mail Address
  • Mailing Address
  • Phone Numbers
  • Other - Birth place, Company name and address, Alien Registration number, Visa Number, Work Permit Number, Sex, Citizenship information, Contact Information, Resume, Federal Agency affiliation, CMS/HHS/Harp ID information, and internal administration information, system access history, workflows, and approvals necessary to grant various types of access.
Indicate the categories of individuals about whom PII is collected, maintained or shared.
  • Employees
  • Business Partners/Contacts (Federal, state, local agencies)
How many individuals' PII in the system?10,000-49,999
For what primary purpose is the PII used?The PII is used to assign, control, track, and report authorized access to and use of CMS information systems and applications.
None
Describe the secondary uses for which the PII will be used (e.g. testing, training or research)
Describe the function of the SSN.The SSN is used to uniquely identify the system users. SSN is used during the background investigation process. 
Cite the legal authority to use the SSN.
  • Executive Order 9397
Identify legal authorities​ governing information use and disclosure specific to the system and program.
  • Title 5 U.S.C 301 Departmental Regulations
Are records on the system retrieved by one or more PII data elements?Yes
Identify the number and title of the Privacy Act System of Records (SORN) that is being used to cover the system or identify if a SORN is being developed.Individuals Authorized Access to CMS Computer Services (IACS), published 7/26/2002 as 09-70-0064 and updated on 11/13/2007 to 09-70-0538 and updated as part of a CMS enterprise update on 2/14/18.
Identify the sources of PII in the system: Directly from an individual about whom the information pertains
  • Online
Identify the sources of PII in the system: Government Sources
  • Within the OPDIV
  • Other HHS OPDIV
  • State/Local/Tribal
  • Foreign
  • Other Federal Entities
Identify the sources of PII in the system: Non-Government Sources 
Identify the OMB information collection approval number and expiration dateNot applicable
Is the PII shared with other organizations?Yes
Identify with whom the PII is shared or disclosed and for what purpose.
  • Within HHS: PII is used to uniquely identify CMS information system users.
Describe any agreements in place that authorizes the information sharing or disclosure (e.g. Computer Matching Agreement, Memorandum of Understanding (MOU), or Information Sharing Agreement (ISA)).Enterprise Systems Solutions Group (ESSG), establishes and maintains ISAs, and related documents to ensure information sharing and disclosure agreements adequately address information security concerns. At launch the AccessCMS system will have signed ISAs for sharing information to the Foreign National Management System (FNMS) and will add the required MOUs/ISAs as connections are added to the system in the future. 
Describe the procedures for accounting for disclosuresThe information stored within the AccessCMS system is only disclosed to authorized AccessCMS users with a legitimate business need, including authorized CMS administrators, Roster Owners, Federal Approvers/Contracting Officer Representatives (CORs), and Foreign National Reviewers (when applicable). Users will have access to their own information only if they are are not also assigned one of the roles above. All requests for disclosures are tracked in a separate system, the CMS Issue Tracking System. Any inappropriate disclosures are handled as information security PII incidents which are reported to the CMS IT service desk and tracked in the CMS Issue Tracking system. Inappropriate disclosures are handled by the CMS Information Security and Privacy Group and reported on in accordance with CMS and HHS requirements.
Describe the process in place to notify individuals that their personal information will be collected. If no prior notice is given, explain the reason.Individuals are advised that their personal information is being collected when they apply for access to CMS systems. There is a Privacy Act notice that informs individuals that their personal information is being collected.
Is the submission of the PII by individuals voluntary or mandatory?Voluntary
Describe the method for individuals to opt-out of the collection or use of their PII. If there is no option to object to the information collection, provide a reason.Because an individual's PII (user ID and password) is required for access to and use of the AccessCMS system, there is no 'opt out' method.
Describe the process to notify and obtain consent from the individuals whose PII is in the system when major changes occur to the system (e.g., disclosure and/or data uses have changes since the notice at the time of original collection). Alternatively, describe why they cannot be notified or have their consent obtained.If there was a major change to the AccessCMS system that affected the use and/or disclosure of system users' PII, the individuals would be notified by normal CMS methods: user-wide email alerts and notification within the AccessCMS system landing page. However, obtaining 'consent' isn't part of the process, because PII is required to access the AccessCMS system.
Describe the process in place to resolve an individual's concerns when they believe their PII has been inappropriately obtained, used, or disclosed, or that the PII is inaccurate. If no process exists, explain why not.If an individual has concerns about their PII in the system, then the person would contact the CMS IT Service Desk, by telephone or email, and explain the concerns. The CMS IT Service Desk creates a service/investigation ticket and routes it to the CMS Incident Management Team (IMT), who would investigate and determine if any additional action by the user or CMS is required. If a user believes their PII is inaccurate they can either correct it in their account or the AccessCMS administrators would update PII, as approved by the AccessCMS Government Technical Lead (GTL)
Describe the process in place for periodic reviews of PII contained in the system to ensure the data's integrity, availability, accuracy and relevancy. If no processes are in place, explain why not.To maintain the accuracy and relevancy of the PII, AccessCMS users may review and update their own accounts (at will). System administrators review access and are authorized to delete or de-activate accounts. Data integrity and availability is ensured by reviewing accounts quarterly and deactivating dormant accounts. In addition, the access to user information is limited to a specified group of privileged users. AccessCMS also implements various access and system logs that monitor user activity and alerts system administrators of anomalies.  
Identify who will have access to the PII in the system and the reason why they require access.
  • Users: Users will only have access to their own PII unless they are given one of the other roles listed below. 
  • Administrators: Database administrators, system administrators, who are either CMS employees or direct contractors, will have various access levels to PII to perform system functions or manage other  user AccessCMS accounts. 
  • Developers: Developers have access to PII for database migration and reporting activities. This access window is monitored to ensure data integrity.
  • Others - Federal Approvers/COR, FNMS team, and Roster Owners: While not full administrators on the systems, the Federal approvers/CORs, FNMS team, and Roster owners all require access to the PII of the Users that they are managing or approver. The information is used to verify who the users is who they say they are. 
Describe the procedures in place to determine which system users (administrators, developers, contractors, etc.) may access PII.AccessCMS uses role-based assignments to allow access to PII. The access is limited by a 'need to know and need to access' basis. The AccessCMS Procedures documents the level of access.
Describe the methods in place to allow those with access to PII to only access the minimum amount of information necessary to perform their job.Access to PII is limited by the principle of least privilege, where most system users can only access their own PII and can only access a limited view of the system. Privileged users, such as administrators or developers, have access to PII to perform their job functions and maintain the system. For those users, information is redacted and only certain aspects of the system are accessible.
Identify training and awareness provided to personnel (system owners, managers, operators, contractors and/or program managers) using the system to make them aware of their responsibilities for protecting the information being collected and maintained.

The CMS Information Security and Privacy Awareness Training is required to be completed by all users on an annual basis. This training is mandatory for continued access to CMS systems.

In addition, the direct contractor organizations require their staff to take company-sponsored annual security and privacy training. In both scenarios, users acknowledge successful training after passing a test at the end of training and the system verifies completion.

Describe training system users receive (above and beyond general security and privacy awareness training)Administrators and those with privileged access to the system receive additional training regarding the appropriate and ethical use of privileged accounts. Additionally, rules of behavior for privileged users and acceptable use policies are acknowledged by privileged users.
Do contracts include Federal Acquisition Regulation and other appropriate clauses ensuring adherence to privacy provisions and practices?Yes
Describe the process and guidelines in place with regard to the retention and destruction of PII. Cite specific records retention schedules.

AccessCMS follows the CMS Records Control Schedules located on the cms.gov website and the National Archives and Records Administration (NARA) website. 

For CMS and the information systems that support its missions, NARA Transmittal 29 includes the General Records Schedules (GRS) that are followed. GRS 3.2 provides the requirements for the retention and destruction of PII handled by AccessCMS. For System Access Records (GRS 3.2 Item 030), EUA retains records for up to six (6) years to enable the recreation of computer related access to both the operation system and the application wherever PII is stored. 

AccessCMS follows the guidance of National Institute of Standards and Technology (NIST) Special Publication 800-88 Rev. 1 as part of the implementation of the Media Protection Security controls. AccessCMS will disintegrate, pulverize, melt, incinerate, and/or shred PII data once it is no longer necessary to retain. Certificates of destruction are completed and retained whenever PII data is destroyed.

Describe, briefly but with specificity, how the PII will be secured in the system using administrative, technical, and physical controls.

Administrative: The administrative controls in place to secure PII include role-based access and permissions, periodic review of users and deletion or revoking of user accounts. Only authorized administrators can approve requests and there is a multi-tier process to authorize access. 

Technical: The technical controls in place are firewalls that prevent unauthorized access, encrypted access at log on, security scans, penetration testing, and intrusion detection and prevention systems (IDS/IPS) and computer system controls that prevent users without administrative or developer access too long into a test environment and the test environment and usable application are not joined together. 

Physical: AccessCMS is hosted in a secure data center (CDM AWS) that employs physical controls and monitoring to restrict physical access and ensure the security of doors with the use of security cards and pass codes; environmental controls that ensure the efficacy of heating, ventilation and air conditioning; smoke and fire alarms, and fire suppression systems; and by employing cameras, fencing and security guards.

Privacy Impact Assessment (PIA) published by CMS as an Operating Division of the U.S. Department of Health and Human Services