Policies and Procedures
INDEX: November 16, 2011
| Policy No. | Title | Effective Date |
|---|---|---|
| ADMINISTRATION | ||
| ADM 0001 | Records Release and Copying Charges |
08/21/08 |
| ADM 0002 | Compensation for Temporary Assignment to Exempt Positions | 06/29/00 |
| ADM 0003 | Dues for Professional Business Organizations | 07/01/02 |
| ADM 0004 | Gifts to Board Members | 06/05/98 |
| ADM 0005 | Travel (Inter-Island and Out of State) | 04/14/11 |
| ADM 0006 | Use of HHSC/State Vehicles | 06/01/00 |
| ADM 0007 | Corporate Policy on Compliance with Antitrust Laws | 09/20/00 |
| ADM 0008 | Corporate Policy on Responding to Government Agencies | 09/20/00 |
| ADM 0009 | Corporate Policy on Credentialing and Background Checks | 11/30/00 |
| ADM 0010 | Basic Life Support Training | 10/04/02 |
| ADM 0011 | Corporate Policy and Procedure for Reporting and Processing Long Term Care Quality Indicators to the Quality Council | 12/19/01 |
| ADM 0012 | Donations | RESCINDED See: CMP 0013 |
| ADM 0013 | Employee Housing and Rental Policy | 11/17/05 |
| ADM 0014 | Employed and Contracted Practitioner Credentialing | 04/17/08 |
| ADM 0015 | Re-designated as HR 0015 -Physician Employment | 01/26/06 |
| ADM 0016 | HHSC Travel Policy for Corporate and Regional Board Members | 04/14/11 |
| ADM 0017 | Credentialing for Interpretative Reading of Off-site Services | 04/17/08 |
| ADM 0018 | Educational Assistance & Tuition Reimbursement | 01/25/07 |
|
POLICY: Adoption of Corporate-Wide Policies PROCEDURE: Adoption of Corporate-Wide Policies and Procedures |
10/13/11 10/13/11 |
|
| ADM 0020 | Transfer of Custodial Control to Regional Boards | 11/13/08 |
| ADM 0021 | Expedited Credentialing | 04/17/08 |
| ADM 0022 | Credentialing Requirements | 04/17/08 |
| ADM 0023 | Eliminated | |
| ADM 0024 | Insurance | PENDING |
| ADM 0025 | Attorney Billing Guidelines for Non-Insurance Matters | 11/13/08 |
| ADM 0026 | Retention of Outside Counsel (Non--Insurance Related Matters) | 11/13/08 |
| ADM 0027 | Risk Management Policy | 11/13/08 |
| ADM 0028 | Settlement Policy | 11/13/08 |
|
Claims Management Policy Risk Management Plan Conflict Resolution Workplace Disruptive Behavior No-Tolerance |
01/29/09 01/12/10 08/12/10 08/12/10 |
|
| CORPORATE COMPLIANCE | ||
| CMP 0001 |
HHSC Corporate Compliance Program |
A12/09/10 |
|
POLICY: Audit & Compliance Comm, Corp Compliance Comm, Chief CPO PROCEDURE: Audit & Compliance Comm, Corp Compliance Comm, Chief CPO POLICY: Regional Compliance Officer Responsibilities PROCEDURE: Regional Compliance Officer Responsibilities |
10/13/11 10/13/11 10/13/11 10/13/11 |
|
|
POLICY: Compliance Hotline & Other Internal Methods of Reporting Noncompliance PROCEDURE: Compliance Hotline & Other Internal Methods of Reporting Noncompliance |
10/13/11 10/13/11 |
|
| CMP 0005 | Code of Conduct (Superseded by CMP 0001, effective July 1, 2006) | Refer CMP 0001 |
|
POLICY: Compliance Disclosure Program PROCEDURE: Compliance Disclosure Program |
10/13/11 10/13/11 |
|
|
POLICY: Corporate Policy on Education and Training PROCEDURE: Corporate Policy on Education and Trainin |
10/13/11 10/13/11 |
|
|
POLICY: Retention of Records PROCEDURE: Retention of Records |
10/13/11 10/13/11 |
|
|
POLICY: Compliance Investigations PROCEDURE: Compliance Investigations |
10/13/11 10/13/11 |
|
|
POLICY: Compliance Reporting Standards PROCEDURE: Compliance Reporting Standards |
10/13/11 10/13/11 |
|
| CMP 0011 | False Claims Acts and Whistleblower's Protection Act | 12/20/06 |
| CMP 0012 | HHSC Corporate Arrangements Inclusive of Hilo Medical Center |
10/24/07 |
|
CMP 0019A CMP 0019B |
Use of State Resources in Support of Community Charities; Donations Prohibited Data Breach Response Identity Theft Prevention Program Policy ("Red Flag") POLICY: Conflict of Interest PROCEDURE: Conflict of Interest POLICY: Policy for Use of Social Networking and Other Electronic Media PROCEDURE: Policy for Use of Social Networking and Other Electronic Media Non-Retaliation and Non-Retribution HIPAA Violation Disciplinary Policy HIPAA Violation Disciplinary Procedure |
06/18/09 02/12/10 04/06/10 10/13/11 10/13/11 10/13/11 10/13/11 02/11/11 PENDING PENDING |
| ENVIRONMENT OF CARE | ||
| EOC 0001 | Laboratory Packaging and Shipping of Dangerous Goods | 01/12/00 |
| EOC 0002 | Corporate Policy on Medical Waste | 11/01/00 |
| EOC 0003 | Single Use Devices | 05/01/01 |
| FINANCE | ||
| FIN 0001 | Protocol Fund | 07/11/02 |
| FIN 0002 | Corporate Policy on Financial Arrangements with Physicians and Other Providers | 07/01/04 |
| FIN 0003 | Corporate Policy on Vendor Relationships | RESCINDED |
| FIN 0004 | Corporate Policy on Financial Arrangements with Referral Sources Other than Physicians | 09/22/00 |
| FIN 0005 | Invoice Approval for Payment | PENDING |
| FIN 0006 | Critical Access Hospitals | 11/13/08 |
| FIN 0007 | Notice of Medicare Non-Coverage in a Skilled Nursing Facility | 12/05/01 |
| FIN 0008 | Notice of Medicare Non-Coverage in a Skilled Nursing Facility (65C Plus) | 12/05/01 |
| FIN 0009 | Debtor Tax Refund Setoff | 10/22/04 |
| FIN 0010 | Prompt Pay Discounts of Account Receivables | 09/08/05 |
| FIN 0011 | Cash Management | 08/21/08 |
| FIN 0012 | Payroll Funding | 08/21/08 |
| FIN 0013 | Operational Budgeting | 08/21/08 |
| FIN 0014 | Governmental Budgeting | 08/21/08 |
| FIN 0015 | Capital Budgeting | 08/21/08 |
| FIN 0016 | Municipal Lease Financing | 11/13/08 |
| FIN 0017 | Debt Management | 11/13/08 |
| FIN 0018 | Investments | 11/13/08 |
| FIN 0019 | Accounts Receivable Valuation | 04/09/09 |
| FIN 0020 | Funds Allocation | 11/13/08 |
| FIN 0021 | Operating Lease Policy | 11/13/08 |
| FIN 0022 | Short Term Debt and Revolving Lines of Credit | 11/13/08 |
| FIN 0023 | Third Party Player Contracting | 11/13/08 |
| FIN 0024 | Revenue Cycle Management | 11/13/08 |
| FIN 0025 | Revenue Cycle, Quality Management Reporting | 11/13/08 |
| FIN 0026 | Charge Description Master Policy | 01/29/09 |
| FIN 0027 | Disposal or Real Property | 04/09/09 |
| FIN 0028 | Real Estate Leases | 01/29/09 |
| FIN 0029 | Accounting | 01/29/09 |
| FIN 0030 | Acquisition and Disposal of Assets | 04/09/09 |
| FIN 0031 | Banking | 01/29/09 |
| FIN 0032 | Preparing, submitting, and managing cost reports | 01/29/09 |
| FIN 0033 | Region to Region Loans | 01/29/09 |
| FIN 0034 | Submission of Project & Funding Requests to FISAC Policy | 04/09/09 |
| FIN 0501 | Referred Laboratory Testing | 09/15/00 |
| FIN 0502 | Laboratory Reflex Orders | 09/15/00 |
| FIN 0503 | Laboratory Stat Fees and Call Backs | 09/15/00 |
| FIN 0504 | Laboratory Anatomical and Surgical Pathology Services | 09/15/00 |
| FIN 0505 | Calculated Laboratory Lists | 09/15/00 |
| FIN 0506 | Advance Beneficiary Notice | 09/15/00 |
| FIN 0507 | Laboratory Standing Orders | 09/15/00 |
| FIN 0508 | Laboratory Services in Skilled Nursing Facilities | 09/15/00 |
| FIN 0509 | Laboratory Patient Records | 09/15/00 |
| FIN 0510 | Laboratory Custom Profiles | 09/15/00 |
| FIN 0511 | Refunding Overpayments | 12/08/00 |
| FIN 0512 | Laboratory Specimen Collection Fee | 09/15/00 |
| FIN 0513 | Laboratory Urinalysis Procedure | 09/15/00 |
| FIN 0514 | Outpatient Services and Medicare Three Day Window (72 Hour Rule) | 09/15/00 |
| FIN 0515 | laboratory Medical Necessity | 09/15/00 |
| FIN 0516 | Critical Pathway Laboratory Orders | 09/15/00 |
| FIN 0517 | Laboratory Handling Charges | 09/15/00 |
| FIN 0518 | Laboratory Hematology Procedures | 09/15/00 |
| FIN 0519 | Laboratory Organ and Disease Panels | 09/15/00 |
| FIN 0520 | Charity Care | 06/01/04 |
| FIN 0521 | Small balance Write Off of Accounts Receivable | 02/10/99 |
| FIN 0522 | Write Off of Patient Accounts Receivable Greater Than 365 Days | 02/10/99 |
| FIN 0523 | Unlisted Laboratory Procedure Codes | 09/22/00 |
| FIN 0524 | Outpatient Laboratory Test Orders | 09/26/00 |
| FIN 0525 | Changing ICD-9, CPT-4, and HCPCS Codes | 11/15/00 |
| FIN 0526 | Tracking Rejected Claims | 12/06/01 |
| FIN 0527 | Medical Supply and Equipment Billing Policy | 01/01/07 |
| FIN 1001 | Standardized Work Paper Package | 12/13/99 |
| FIN 1002 | Cost Report Review | 12/13/99 |
| FIN 1003 | Representation/Submission | 12/13/99 |
| FIN 1004 | Protested Items | 12/13/99 |
| FIN 1005 | Review for Non-Allowable Costs | 12/13/99 |
| FIN 1006 | Fiscal Intermediary Audits | 12/13/99 |
| FIN 1007 | Cost Report Errors | 12/13/99 |
| FIN 1008 | Disclosure/Transmittal Letter | 12/13/99 |
| FIN 1009 | Cost Report Work Paper Documentation | 12/13/99 |
| FIN P001 | HHSC General Payroll Policy | 11/13/08 |
| HHSC General Payroll Info & Pay Dates |
11/13/08 |
|
| FINANCE - PAYROLL | ||
| HUMAN RESOURCES | ||
| HR 0001 | Equal Employment Opportunity | 01/12/00 |
| HR 0002 | Individuals with Disabilities | 02/01/05 |
| HR 0003 | Non-Harassment Policy | 01/12/00 |
| HR 0004 | Workplace Violence/Abuse Non-Tolerance | 08/10/00 |
| HR 0005 | Relocation Assistance Policy | 01/25/07 |
| HR 0006 | Personnel System General Policy | 09/13/07 |
| HR 0007 | Exempt, Excluded Compensation Policy and Compensation Administration Manual | 06/12/08 |
| HR 0008 | Placement of Employees Who are Disabled by Work-Related Injury or Illness Involving Environmental Restrictions | 04/17/08 |
| HR 0009 | Return to Work Priority Procedures | 04/17/08 |
| HR 0010 | Protection of Personnel Information Program | 05/13/08 |
| HR 0011 | Oversight of Employees | 04/17/08 |
| HR 0012 | Family Leave | 04/17/08 |
| HR 0013 | Standards of Dress, Grooming, and Related Behaviors | 06/12/08 |
| HR 0014 | Workers' Compensation Stipulation and Settlement Agreement and Orders | 01/29/09 |
|
POLICY: Physician Employment Policy PROCEDURE: Physician Employment Procedures |
10/13/11 10/13/11 |
|
|
HR 0018 |
Alcohol and Controlled Substances Testing Program for Exempt Excluded Employees Alcohol Free and Drug Free Working Environment |
08/07/09 08/12/10 PENDING |
| INFORMATION TECHNOLOGY | ||
| ITD 0001 | PC Hardware and Software - Acquisition & Use | 09/15/00 |
| ITD 0002 | Security Configuration Management | 10/04/04 |
| ITD 0003 | Security Incident Response Policy | 07/27/01 |
| ITD 0004 | Information Security Policy | 10/04/04 |
| ITD 0005 | Information System Access Policy | 10/04/04 |
| ITD 0006 | Remote access Policy | 10/04/04 |
| ITD 0007 | Personnel Security Policy | PENDING |
| ITD 0008 | Termination | 07/01/02 |
| ITD 0009 | Data Classification | 07/01/02 |
| ITD 0010 | Physical Access | 10/04/04 |
| ITD 0011 | Information Stewardship Policy | 03/01/02 |
| ITD 0012 | Password | 10/04/04 |
| ITD 0013 | Certification/Internal Audit | 10/04/04 |
| ITD 0014 | Security Awareness Training | 07/01/02 |
| ITD 0015 | Risk Management | 09/01/02 |
| ITD 0016 | Sanctions | 10/01/07 |
| ITD 0017 | Electronic Mail Policy | 10/04/04 |
| ITD 0018 | Internet Use Policy | 09/01/02 |
| ITD 0019 | Appropriate Workstation Use | 10/01/07 |
| ITD 0020 | Project Request Form (PRF) | 06/03/04 |
| ITD 0021 | Contingency Plan | 09/01/02 |
| ITD 0022 | Data Backup Policy | 10/04/04 |
| ITD 0023 | Disposal/Reuse of Electronic Storage Media | 10/04/04 |
| ITD 0024 | Wireless Policy | 09/12/06 |
| ITD 0025 | Anti-Virus | 07/01/02 |
| ITD 0026 | Security Patches | 10/04/04 |
| ITD 0027 | Contingency Plan | 10/04/04 |
| ITD 0028 | Physical Accountability of IT Equipment | 10/04/04 |
| ITD 0029 | Facility Maintenance Records | 10/04/04 |
| ITD 0030 | Data Integrity | 10/04/04 |
| ITD 0031 | Data Conversion | 10/04/04 |
| ITD 0032 | Blackberry Use | 05/30/07 |
| ITD 0033 | Secure Handling of Social Security Numbers - Personal Information | 09/01/07 |
| ITD 0034 | Policy for Information Technology (IT) Governance | 10/14/10 |
| INTERNAL AUDITOR | ||
| IA 001A | POLICY: Internal Audit Function Charter | 10/13/11 |
| OPERATIONS | ||
| OPN 0001 | Creation of Business Ventures by Regional System Boards | 08/21/08 |
| PATIENT CARE | ||
| PAT 0001 | Hospital Patients' Rights, Notice and Grievance Procedure | 08/01/02 |
| PAT 0002 | Anatomical Donation Policy | 04/12/01 |
| PAT 0003 | Emergency Care, Transfers (COBRA) | 09/15/00 |
| PAT 0004 | Corporate Policy on Confidential Patient Information | 12/06/01 |
| PAT 0005 | Determination and Documentation of Brain Death | 04/12/01 |
| PAT 0006 | Patient Discharge Policy | 05/10/01 |
| PAT 0007 | Informed Consent for Treatment or Procedures to Induce Abortions in Minors | 01/14/02 |
| PAT 0008 | Corporate Policy on Do Not Resuscitate Orders | 12/05/01 |
| PAT 0009 | Percutaneous Exposure Control Plan | 10/04/02 |
| PAT 0010 | Reporting Blood and Urine Alcohol and Drug Contents of Persons Involved in a Vehicle Collision | PENDING |
| PAT 0011 | Patient Safety Program | 07/01/01 |
| PAT 0012 | Disclosure of Unanticipated Outcomes | 08/01/02 |
| PAT 0013 | HHSC System Quality Structure | 08/21/08 |
| PAT 1001 | Medical Records: 72 Hour Window Rule | 09/15/00 |
| PAT 1002 | Medical Records: Coding and Documentation for Outpatient Services | 09/15/00 |
| PAT 1003 | Medical Records: Coding and Documentation for Inpatient Services | 09/15/00 |
| PAT 1004 | Medical Records: Coding Orientation and Training/Continuing Education | 09/15/00 |
| PAT 1005 | Medical Records: Coding References and Tools | 09/15/00 |
| PAT 1006 | Medical Records: Skilled Nursing Facilities/Units | 09/15/00 |
| PAT 1007 | Advance Directive Procedure | 01/04/02 |
| PROCUREMENT | ||
| PRO 0020 |
Medical Staff Review of Patient Services Contracts |
RESCINDED See: PUR 0020 |
| PURCHASING | ||
| PUR 0001 | Designation of Procurement Responsibilities to the Facilities | 04/17/08 |
| PUR 0002 | Corporate Office Procurement Dollar Thresholds/Quick Reference | 07/21/10 |
| PUR 0003 | Corporate Office Competitive Sealed Bid Process (IFB) | 07/21/10 |
| PUR 0004 | Corporate Office Emergency Procurements | 10/01/07 |
| PUR 0005 | Corporate Office Competitive Sealed Services | 07/21/10 |
| PUR 0006 | Authority to Procure Personal Services | 10/01/07 |
| PUR 0007 | Contracts | 10/01/07 |
| PUR 0008 | Construction and Capital Improvement Projects | 10/01/07 |
| PUR 0009 | Corporate Office Material and Equipment Inventory and Disposal | 10/01/07 |
| PUR 0010 | Procurement Reporting to HHSC Board of Directors | 04/17/08 |
| PUR 0011 | Oral Proposals | RESCINDED |
| PUR 0012 | Capital Equipment Purchase Review by Materials and Contract Management Team | 10/01/07 |
| PUR 0013 | Standards of Conduct Applicable to HHSC | RESCINDED |
| PUR 0014 | Legal review of RFP/IFB and Contracts | 10/01/07 |
| PUR 0015 | Contract Technical Representative Dutites | 10/01/07 |
| PUR 0016 | Corporate/System Wide Contracts: Sole Source Procurement | 07/21/10 |
| PUR 0017 | Corporate and System-Wide Contracts: Exempt Procurement | 10/01/07 |
| PUR 0018 | Procurement Protests for Chapter 103D Purchases | 10/01/07 |
| PUR 0019 | Requesting Purchasing & Acquisition Assistance from corporate Contract Management | 10/01/07 |
| PUR 0020 | Medical Staff Review of Patient Services Contracts | 11/01/06 |
| PUR 0021 | Release of Contract and Procurement Information | 10/01/07 |
| PUR 0022 | Vendor Visitation and Interaction Rules | 11/01/06 |
| PUR 0023 | Authority to Procure Professional Services | 10/01/07 |
| PUR 0024 | Procurement Violations | 10/01/07 |
| PUR 0025 | Requesting Review and Approval of Group Purchasing Organization Agreements | 11/13/08 |
| PUR 0026 | Small Purchases (including electronic procurements) | 07/21/10 |
| RESEARCH | ||
| RES 0001 | Quality: Corporate Institutional Review Board Policy | 11/14/02 |
| TELEMEDICINE | ||
| TEL 0001 | Telemedicine Policy | 02/12/02 |
| TEL 0002 | Patient Rights and Responsibilities During Use of Telemedicine/Telehealth Consultations | 11/10/99 |
| TEL 0003 | Grand Rounds | 12/13/99 |
| TEL 0004 | Scheduling a Telemedicine Consultation | 12/13/99 |
| TEL 0005 | Emergency Telemedicine Consultations | 12/13/99 |
| TEL 0006 | Telemedicine Electronic Signature Policy | 12/13/99 |
| TEL 0007 | Failure of Telemedicine Equipment | 12/13/99 |
| TEL 0008 | Scope of Service - Telemedicine | 01/11/00 |
| TEL 0009 | Priority of the Telemedicine Workstation and/or Video Conference Equipment and Transmission | 01/11/00 |
| TEL 0010 | Telemedicine Workstation Orientation for Health Care Providers | 01/11/00 |
| TEL 0011 | Telemedicine Operational Satisfaction Survey | 01/11/00 |
| TEL 0012 | Telemedicine Consultant Satisfaction Survey | 01/11/00 |
| TEL 0013 | Telemedicine Provider Satisfaction Survey | 01/11/00 |
| TEL 0014 | Telemedicine Patient Satisfaction Survey | 01/11/00 |
| TEL 0015 | Use of the Vidar Scanner for Sending TeleRadiological Images (Surescan) | 10/17/03 |
| TEL 0016 | How to Turn On and Shut Down the Telemedicine System | 01/09/01 |
| TEL 0017 | Standardized Date and Time Format in Telemedicine System | PENDING |
| TEL 0018 | Changing Your Password in the Medreach Telemedicine Software | 04/24/01 |
| TEL 0019 | Administrative Use of HHSC Video Teleconferencing System by Outside Agencies | 10/15/03 |
| TEL 0020 | Project Request Form (PRF) | PENDING |
| TEL 0021 | Administrative Use of HHSC Video Teleconferencing System | 10/15/03 |
