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**Policies and Procedures

INDEX: November 14, 2014

Policy No. Title Effective Date
ADMINISTRATION
ADM 0001 Records Release and Copying Charges

10/17/13

ADM 0002A Compensation for Temporary Assignment to Exempt Positions 06/19/14
ADM 0003 Dues for Professional Business Organizations 11/13/13
ADM 0004 Gifts to Board Members See BOD 0004A
ADM 0005A Travel by Employees (Inter-Island and Out of State) (Procedure - ADM 0005B) 11/21/13
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ADM 0012 Donations RESCINDED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

ADM 019A

Adoption of Corporate-Wide Policies (Procedure-ADM 019B)

06/20/13

ADM 0020 Transfer of Custodial Control to Regional Boards RESCINDED
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 0026A Retention of Outside Counsel 4/19/12
ADM 0027 Risk Management Policy 06/20/13

ADM 0028

ADM 0028A

Settlement Policy

Claims Management and Settlement Policy (Procedure-ADM 0028B)

SUPERCEDED

4/19/12 

ADM 0030

ADM 0031

ADM 0032

ADM 0033

ADM 0034

ADM 0035

ADM 0036

Risk Management Plan

Conflict Resolution

Workplace Disruptive Behavior No-Tolerance

Smoke-Free Policy

Person Authorized to Accept Service of Process (Procedure-ADM 0034B)

Preservation of Information in Litigation or Anticipation of Litigation (Procedure-ADM 0035B)

Driving Vehicles for HHSC Business

06/20/13

08/12/10

08/12/10

PENDING

06/20/13

06/20/13

02/20/14

BOARD OF DIRECTORS
BOD 0004A Gifts to Board Members 06/19/14
CORPORATE COMPLIANCE

The Corporate Compliance Policies and Procedures have moved.

They can now be accessed here: HHSC Compliance Policies & Procedures

 

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 02/20/14
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 Payer 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 Processing Credit Balances and Potential Overpayments 02/20/14
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

FIN 1010A

FIN 1011A

FIN 1012A

FIN 1013A

FIN 1014A

FIN 1015A

FIN 1016A

FIN 1017A

FIN 1018A

FIN 1019A

FIN 1020A

FIN 1021A

FIN 1022A

FIN1023A

FIN 1024A

FIN 1025A

FIN 1026A

FIN 1027A

Cost Report Work Paper Documentation

Bad Debt Processing

Balancing Issues

Charge Reconciliation - Charge Error Worklist

Small Balances

Managing Denials

Eligibility Response

Late Charge Management

Medical Necessity

Payment Arrangements

Payment Variance

Remittance Processing

Change Patient Status

Referring Non Medical Staff

Balancing Guarantor Payments

Contractual Allowances

Managing Duplicate Persons and Medical Record Number

Health Information Management Balancing

Updating and Changing the Insurance Policy Effective Date

12/13/99

PENDING

PENDING

PENDING

PENDING

PENDING

PENDING

PENDING

PENDING

PENDING

PENDING

PENDING

PENDING

PENDING

PENDING

PENDING

PENDING

PENDING

PENDING

FIN P001 HHSC General Payroll Policy 11/13/08

FIN P002

HHSC General Payroll Info & Pay Dates

11/13/08

FINANCE - PAYROLL
HUMAN RESOURCES
HR 0001A Equal Employment Opportunity (Procedure HR 0001B) 11/21/13
HR 0002A Individuals with Disabilities (Procedure HR 0002B) 11/21/13
HR 0003A Non-Harassment Policy (Procedure HR 0003B) 11/21/13
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 0007A Exempt, Excluded Compensation Policy and Compensation Administration Manual 06/19/14
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
HR 015A Physician Employment Policy (Procedure-HR 015B) 10/13/11
HR 0016 Alcohol and Controlled Substances Testing Program for Exempt Excluded Employees 08/07/09
HR 0017 Outside Employment 08/12/10
HR 0018 Alcohol Free and Drug Free Working Environment PENDING
HR 0019A Negotiation of Memorandums of Understanding and Supplemental Agreements on Subjects of Collective Bargaining (Procedure-HR 0019B) 06/20/13
HR 0020A Telecommuting Program (Procedure - HR 0020B) 05/22/14

HR 0021A

 

HR 0022A

Break Time for Nursing Mothers, Act 249, 2013 and Fair Labor Standards Act (29 U.S.C. Section 207 (r)) (Procedure - HR 0021B)

Work Attendance During Disaster Situations

06/19/14

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

SUPERCEDED by ITD 0132A

ITD 0004 Information Security Policy SUPERCEDED by ITD 0051A
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 SUPERCEDED by ITD 0091A
ITD 0011 Information Stewardship Policy 03/01/02
ITD 0012 Password SUPERCEDED by ITD 0113A
ITD 0013 Certification/Internal Audit 10/04/04
ITD 0014 Security Awareness Training SUPERCEDED by ITD 0051A
ITD 0015 Risk Management SUPERCEDED by ITD 0109A
ITD 0016 Sanctions 10/01/07
ITD 0017 Electronic Mail Policy SUPERCEDED by ITD 0051A
ITD 0018 Internet Use Policy SUPERCEDED by ITD 0051A
ITD 0019 Appropriate Workstation Use 10/01/07
ITD 0020 Project Request Form (PRF) 06/03/04
ITD 0021 Contingency Plan SUPERCEDED by ITD 0051A
ITD 0022 Data Backup Policy SUPERCEDED by ITD 0105A
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 SUPERCEDED by ITD 0092A
ITD 0029 Facility Maintenance Records SUPERCEDED by ITD 0091A

ITD 0030

ITD 0031

ITD 0032

ITD 0032A

ITD 0033

ITD 0034

ITD 0051A

ITD 0082A

ITD 0091A

ITD 0092A

ITD 0105A

ITD 0107A

ITD 0109A

ITD 0111A

ITD 0113A

ITD 0131A

ITD 0132A

ITD 0151A

ITD 0152A

Data Integrity

Data Conversion

Blackberry Use

Mobile Device Use

Secure Handling of Social Security Numbers - Personal Information

Policy for Information Technology (IT) Governance

Information Security

Information Assets and Access During Employment

Secure Areas

Equipment Security

Backup

Media Handling

Monitoring

Business Requirement for Access Control

User Responsibilities

Reporting Information Security Events and Weaknesses

Management of Information Security Incidents and Improvements

Compliance with Legal Requirements

Compliance with Security Policies and Standards, and Technical Compliance

10/04/04

10/04/04

SUPERCEDED by ITD 0032A

06/21/12

09/01/07

10/14/10

10/17/13

10/17/13

10/17/13

10/17/13

10/17/13

10/17/13

10/17/13

10/17/13

10/17/13

10/17/13

10/17/13

10/17/13

10/17/13

 

 

 

 

 

 

INTERNAL AUDITOR
IA 001A Internal Audit Function Charter (Policy) 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 02/20/14
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 (Procedure - PAT 0012B) 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

PAT 1008A

PAT 1009A

Advance Directive Procedure

HHSC Hand Hygiene Policy (Procedure - PAT 1008B)

Computerized Provider Order Entry (CPOE) (Procedure - PAT 1009B)

01/04/02

08/16/12

10/17/13 

PROCUREMENT

PRO 0020

 

PRO 0021

Medical Staff Review of Patient Services Contracts

 

Purchasing Card Policy

RESCINDED
See: PUR 0020

PENDING

PURCHASING
PUR 0001 Designation of Procurement Responsibilities to theHHSC and Regional Facilities (Procedure-PUR 001B) 06/20/13
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

PUR 0027A

Small Purchases (including electronic procurements)

Fleet Vehicle Inventory and Disposal (Procedure - PUR 0027B)

07/21/10

10/30/14

RESEARCH

RES 0001

RES 001A

Quality: Corporate Institutional Review Board Policy

Corporate Institutional Review Board Policy

Superceded

08/16/12

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
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