Strategic Work Information Folder Transfer System
Privacy Impact Assessment (PIA) published by CMS as an Operating Division of the U.S. Department of Health and Human Services
Date signed: 9/29/2022
PIA Questions | PIA Answers | |||
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OPDIV: | CMS | |||
PIA Unique Identifier: | P-9970293-422480 | |||
Name: | Strategic Work Information Folder Transfer System | |||
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? | Existing | |||
Does the system have Security Authorization (SA)? | Yes | |||
Date of Security Authorization | 3/20/2023 | |||
Indicate the following reason(s) for updating this PIA. Choose from the following options. |
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Describe in further detail any changes to the system that have occurred since the last PIA. | The Strategic Work Information Folder Transfer System (SWIFT) has recently integrated a Freedom of Information Act (FOIA) Public Portal to seamlessly route Medicare beneficiary records requests from the public to CMS’ existing FOIA management application (SWIFT) for tracking and processing. SWIFT has built a connection between SWIFT and the Department of Justice (DOJ) National FOIA Portal to seamlessly route non-beneficiary related requests to CMS’ existing FOIA management application (SWIFT) for tracking and processing. These enhancements will ensure confidentiality, integrity, availability, and reliability of the FOIA requests and will comply with applicable security regulations, policies, standards and controls. There is a new SWIFT application, Regulations Management System (RMS), which facilitates regulations planning, development and clearance across the agency. There is a new SWIFT application, Digital Mail, which digitizes and distributes the incoming paper mail in a digital format within CMS. The SWIFT servers are in the process of being migrated from the Leidos Managed Data Center – East (LMDC-E) datacenter to the Kent, WA datacenter. No new privacy risks are created by the changes above. SWIFT is a Federal Information Security Management Act (FISMA) moderate system and already contains sensitive Personal Identifiable Information (PII).
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Describe the purpose of the system | SWIFT is divided into five applications and a portal: SWIFT Correspondence, SWIFT FOIA, SWIFT Digital Mail, SWIFT Litigation Holds, SWIFT Regulations and FOIA Contractor Portal. SWIFT is a CMS administrative system that tracks and reports on executive correspondence, memos, regulations, Reports to Congress, Freedom of Information Act (FOIA) requests, Medicare beneficiary records request, and digital mail. This workflow application is used by approximately 1400 CMS employees. SWIFT Correspondence, correspondence is received in CMS, a folder is created in SWIFT and the correspondence item is scanned or uploaded to the folder. The folder is then referred to other components for response, clearance or signature. The components can attach various documents (response, clearance, supporting, records) to the folder. The users can perform customized searches that will find folders in their own component or throughout CMS. The system also stores all information describing the document and the kind of action that is required. The SWIFT Correspondence application includes SWIFT Executive Correspondence. SWIFT FOIA, Freedom of Information Act (FOIA) requests are logged, tracked and reported, whether it originates in the Regions or Central Office. The public can check on the status of their request by using the FOIA Public web application on the cms.gov website. The SWIFT FOIA Public Portal enables the public to request Medicare beneficiary records from CMS. The SWIFT Digital Mail solution automates the incoming mail within CMS's correspondence process. Mail items received at CMS are scanned and converted into a digital image that is securely delivered to the component’s designated No new privacy risks are created by the changes above. SWIFT is a FISMA moderate system and already contains sensitive PII. Points of Contact (POCs). Leveraging automation of the classification and distribution of received mail, eliminates the need to manually consolidate, organize and disperse the incoming mail. The SWIFT Litigation Holds solution is based upon the Memorandum module of the SWIFT Correspondence application. Executives wanted to have the same convenience and efficiency when approving Litigation Holds Memorandums. The paperless approval features in the SWIFT Correspondence application were leveraged to create a paperless approval process for Litigation Holds. The SWIFT Regulations solution, RMS, facilitates regulation planning, development and clearance across the agency. It provides comment tracking and management, document repository, reports the progress of regulations under development in the agency, manages the workflow of the clearance process and facilitates collaboration during clearance. The FOIA Contractor Portal is designed to capture information and documentation on all CMS Freedom of Information Act (FOIA) requests that are handled by the Medicare Administrative Contractors (MACs). The portal provides the ability to maintain FOIA requester information, processing dates, closure reasons, fees, invoices, and related documentation such as the FOIA request, determination letter, and release letter. The data captured allows CMS to generate the monthly and annual statistics as designated by the FOIA. The portal resides on the same servers (database and web) as the SWIFT application. This allows CMS to use the portal data for generating reports. The portal is web based on the CMS intranet and uses a SQL Server database to store all the FOIA data. It can only be accessed by users with CMS issued user ids. | |||
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 SWIFT Correspondence application contains data and documents related to incoming letters from external parties or correspondents, such as individuals in Congress or from citizens. The system collects and maintains Personally Identifiable Information (PII) such as names, addresses, email addresses, phone numbers, Organizations, HICN (Health Insurance Claim Number), and MBI (Medicare Beneficiary Identifier) in requests when voluntarily provided by correspondents. HICN and MBI are only available on the beneficiary Inquiry document type where the business need exists for those data elements. Due to the sensitive nature of the attribute, the HICN cannot be exported to reports to protect it from inadvertent disclosure. Documents and/or letters voluntarily provided by the requestor may contain other PII including Social Security Numbers (SSN). However, PII in documents is not captured or displayed on any web pages available to the user (i.e. PII in documents is not captured in structured data elements). The FOIA application contains data and documents related to incoming FOIA requests. The system also contains the response records to incoming requests and includes information requested under the Freedom of Information Act. The system collects and maintains PII such as names, addresses, email addresses, and phone numbers voluntarily provided by requestors. Documents and/or letters voluntarily provided by the requestor may contain other PII including Social Security Numbers (SSN). However, PII in documents is not captured or displayed on any web pages available to the user (i.e. PII in documents is not captured in structured data elements). All FOIA records in SWIFT are removed in accordance with the Agency’s records management schedule then forwarded to the National Archives and Records Administration (NARA).
The FOIA Public Portal collects data and documents supplied by the public needed to fulfill a request for the Medicare beneficiary records for the requestor or on behalf of the requestor. The requests are routed to the SWIFT FOIA application where they are managed. No data or documents are stored on the FOIA Public Portal server. The data collected includes PII such as first name, last name, MBI, address, From Organization, email address, phone number, and fax number. Documents and/or letters voluntarily provided by the requestor may contain other PII including Social Security Numbers (SSN). However, PII in documents is not captured or displayed on any web pages available to the user (i.e. PII in documents is not captured in structured data elements).
The information in Litigation Holds is collected to assist Executives in approving Litigation Holds Memorandums. Litigation Holds does not collect or maintain any PII.
The RMS application contains data and documents pertaining to regulations that are being authored and cleared by CMS. RMS does not collect or maintain any PII.
The Digital Mail application contains digitized mail addressed to CMS in PDF format. The system collects and maintains PII such as the sender’s name and address. The scanned images of the mail as well as any documents and/or letters voluntarily provided by the sender may contain other PII including Social Security Numbers (SSN). However, PII in scanned mail and documents is not captured or displayed on any web pages available to the user (i.e. PII in documents is not captured in structured data elements). All digitized mail items in SWIFT are considered temporary records because SWIFT is not the system of record for Digital Mail. The information is kept in SWIFT for three (3) years, then destroyed after review and signature by the business owner.
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Provide an overview of the system and describe the information it will collect, maintain (store), or share, either permanently or temporarily. | The information in the SWIFT Correspondence application is collected to route and process correspondence/requests and to respond to the submitter. The HICN and MBI are needed to enable CMS employees to search on these numbers to identify the correspondent. Records can be retrieved by the correspondent’s name, address, email address, phone number, organization, HICN, and MBI.
The information in the FOIA application is collected to identify the person making the FOIA request so that the requestor’s response records can be provided. Records can be retrieved by the requestor’s name, address, email address, organization, or phone number.
The information collected by the FOIA Public Portal is used to transmit into SWIFT FOIA a request for the Medicare beneficiary records for the requestor or on behalf of the requestor. No information is stored or maintained within the portal. All information is transmitted into the existing SWIFT FOIA system as a new case with the same data elements as any other case created by other methods.
The information in Litigation Holds is collected to assist Executives in approving Litigation Holds Memorandums. Litigation Holds does not collect or maintain any PII.
The information in the RMS application is collected to author and clear regulations for CMS. RMS does not collect or maintain any PII.
The information in the Digital Mail application is collected to record who sent the mail and to distribute the mail to the correct recipient(s). Mail is only delivered through SWIFT; no mail is responded to through SWIFT. Records can be retrieved by the sender’s name, address, or organization. | |||
Does the system collect, maintain, use or share PII? | Yes | |||
Indicate the type of PII that the system will collect or maintain. |
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Indicate the categories of individuals about whom PII is collected, maintained or shared. |
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How many individuals' PII in the system? | 50,000-99,999 | |||
For what primary purpose is the PII used? | The primary purpose of collecting PII in SWIFT is to identify individuals corresponding to HHS / CMS and to identify Freedom of Information Act (FOIA) details used to properly respond back to those individuals. PII is collected when it is voluntarily provided by individuals and it is used to accurately respond. | |||
Describe the secondary uses for which the PII will be used (e.g. testing, training or research) | Secondary uses of the PII are to identify requests from the same requester or that seek records about the same individual(s) to reduce duplicative records. | |||
Describe the function of the SSN. | SWIFT collects the HICN (Health Insurance Claim Number) which is based on the requestor’s SSN. The HICN is used to uniquely identify a Medicare beneficiary submitting an inquiry. The HICN is being phased out of CMS over time, but is still needed at this time. | |||
Cite the legal authority to use the SSN. | 42 CFR 401.101–401.148, 1106(a) of the Social Security Act, 42 U.S.C. 1306(a) and E.O. 9397. | |||
Identify legal authorities governing information use and disclosure specific to the system and program. | 42 CFR 401.101–401.148, 1106(a) of the Social Security Act, 42 U.S.C. 1306(a) and E.O. 9397. | |||
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. | 09-90-1901 HHS Correspondence, Comment, Customer Service, and Contact List Records SORN history: 86 FR 12699 (3/4/21) | |||
Identify the sources of PII in the system: Directly from an individual about whom the information pertains |
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Identify the sources of PII in the system: Government Sources |
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Identify the sources of PII in the system: Non-Government Sources |
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Identify the OMB information collection approval number and expiration date | Approved under OMB control number 0938-1419. Expiration of 03/31/2025. | |||
Is the PII shared with other organizations? | Yes | |||
Identify with whom the PII is shared or disclosed and for what purpose. | Within HHS | |||
Within HHS Explanation: SWIFT receives PII within cases received from the Immediate Office of the Secretary. CMS may respond back to these cases with documents that contain PII. FOIA - CMS does not disclose a record for any reason other than FOIA requests. | ||||
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)). | The Correspondence module shares information with the Secretary’s Policy System (SPS) at the Immediate Office of the Secretary. An Interconnection Security Agreement (ISA) has been documented between The Office of the Secretary and CMS for secure information flow through the SWIFT and SPS system. | |||
Describe the procedures for accounting for disclosures | CMS never discloses a record for a reason other than FOIA. This is an internal system to CMS, only CMS employees and authenticated contractors have access to SWIFT. Although the FOIA Public Portal is a public-facing website, no FOIA records are provided to the requestor through the website.
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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 notified by SORN 09-90-1901 HHS Correspondence, Comment, Customer Service, and Contact List Records The policy governing the FOIA Public Portal is the FOIA Paperwork Reduction Act (PRA) Package (OMB control number 0938-1419). A PRA Disclosure statement is available on the FOIA Public Portal web site notifying users that their personal information will be collected.
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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. | The constituent may opt-out of the collection of their PII by not signing the Privacy Act release form and not providing the information. However, the constituent is informed by the assigned Region or Component that in order to fully address their concerns this information may be needed. | |||
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. | After Correspondence and FOIA requests are fulfilled there is no longer a need for the requester's PII. All FOIA records in the SWIFT tracking system are removed in accordance with the Agency’s records management schedule then forwarded to the National Archives and Records Administration (NARA). Requesters are notified about major system changes that impact the use of PII through a revised System of Record notice in the Federal Register. CMS SWIFT users receive email notifications about major system changes and maintenance releases. | |||
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. | Individuals who have a concern or complaint may contact the Freedom of Information Group, and reasonably identify the record and specify the information to be contested, state the corrective action sought and the reasons for the correction with supporting justification. (These procedures are in accordance with Department regulation 45 CFR 5b.7.) Contact CMS FOIA Office Service Center, (410) 786-5353, fax (443) 380-7260. | |||
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. | No process exists since records are only used to answer the constituent's inquiry and is no longer needed nor used upon completion of the case. This process can take anywhere from 10 to 30 business days for the case to be closed. | |||
Identify who will have access to the PII in the system and the reason why they require access. |
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Describe the procedures in place to determine which system users (administrators, developers, contractors, etc.) may access PII. | The Business Owner and SWIFT Contractor adhere to the principles of least privilege and the separation of duties when deciding which users may access PII. The Business Owner limits the users to employees who require access to PII in order to accomplish their job responsibilities. The SWIFT Contractor assigns contractor personnel to the appropriate role for their job responsibilities. SWIFT System Administrators handle daily operations and maintenance including user account creation and trouble shooting. Tier III personnel have create, read, update, and delete (CRUD) access to the SWIFT data. | |||
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. | The Business Owner and SWIFT Contractor adhere to the principles of least privilege and the separation of duties when deciding which users may access PII. Additionally, within the SWIFT Correspondence application, there are two types of roles - power user and gatekeeper. The Business Owner determines which employees are assigned to each role based on their job responsibilities. A power user can create and edit folders, refer folders to other components or gatekeeper boxes, add documents to folders, perform searches and close out folders. Gatekeepers do not have the ability to create or edit the folder data. They can respond to assignments given to them by the power users. When they respond they can add documents to the response which is added to the folder. Gatekeepers can perform a read only search of all the folders. | |||
Identifying 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. | Annual mandatory privacy and security awareness training is required for all CMS users and contractors that access the CMS network. Annual mandatory Role-Based Training (RBT) is required for all Contractors with elevated privileges. Rules of behavior for the SWIFT system are reinforced every time the system is accessed. | |||
Describe training system users receive (above and beyond general security and privacy awareness training) | New SWIFT users are trained at their desks on basic SWIFT operation. Group training is also provided by the Contractor on an as-needed basis. Additional group and advanced training is provided as new updates are implemented. Annual mandatory Role-Based Training (RBT) is required for all Contractors with elevated privileges. | |||
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. | Data is store and destroyed following the CMS Records schedule which follows NARA General Record Schedules (GRS). GENERAL RECORDS SCHEDULE GRS 5.1: Common Office Records 010 Administrative records maintained in any agency office- per Disposition Authority: DAA-GRS-2016-0016-0001. Temporary. Destroy when business use ceases. GRS 5.1 Common Office Records 020 Non-recordkeeping copies of electronic records- per Disposition DAA-GRS-2016-0016-0002. Temporary. Destroy immediately after copying to a recordkeeping system or otherwise preserving, but longer retention is authorized if required for business use. GRS 5.1 Common Office Records 030 Records of non-mission related internal agency committees- per Disposition DAA-GRS-2016-0016-0003. Temporary. Destroy when business use ceases. GRS 5.2 Transitory and Intermediary Records 010 Transitory Records- per Disposition DAA-GRS-2017-0003-0001. Temporary. Destroy when no longer needed for business use, or according to agency predetermined time period or business rule. GRS 5.2 Transitory and Intermediary Records 020 Intermediary Records- per Disposition DAA-GRS-2017-0003-0002. Temporary. Destroy upon verification of successful creation of the final document or file, or when no longer needed for business use, whichever is later. Notes and Exclusions apply to retention schedules listed above. For more information, please refer to the appropriate retention schedule. | |||
Describe, briefly but with specificity, how the PII will be secured in the system using administrative, technical, and physical controls. | Administrative controls: The Business Owner and SWIFT Contractor adhere to the principles of least privilege and the separation of duties when deciding which users may access PII. The request and approval of access is controlled through the CMS End User Agreement (EUA) system and role-based functions for individual users. Technical controls: The system sits behind the HHS firewall (meaning only accessible within the HHS network), multi-factor authentication is used in conjunction with an Active Directory, all traffic is encrypted, audit logs are in place, and anomalous activity is monitored (e.g. system activity outside specific hours). Accounts are maintained in an encrypted data storage facility using Active Directory tools. Accounts are only accessible by administrative personnel who have established user ID and password. Physical controls: The physical controls include door locks, personnel badges and security guards at the data center where the system resides. |