Policies and Procedures
INDEX: May 23, 2012
| 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| ADM 0012 | Donations | RESCINDED See: CMP 0013 |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 |
|
Adoption of Corporate-Wide Policies (Policy) Adoption of Corporate-Wide Policies and Procedures (Procedure) |
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 0026A | Retention of Outside Counsel (Policy) | 4/19/12 |
| ADM 0027 | Risk Management Policy | 11/13/08 |
|
ADM 0028 ADM 0028A ADM 0028B |
Settlement Policy Claims Management and Settlement Policy Claims Management and Settlement Procedure |
SUPERCEDED 4/19/12 4/19/12 |
|
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 |
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| CORPORATE COMPLIANCE | ||
| CMP 0001 |
HHSC Corporate Compliance Program |
A12/09/10 |
|
Audit & Compliance Comm, Corp Compliance Comm, Chief CPO (Policy) Audit & Compliance Comm, Corp Compliance Comm, Chief CPO (Procedure) Regional Compliance Officer Responsibilities (Policy) Regional Compliance Officer Responsibilities (Procedure) |
10/13/11 10/13/11 10/13/11 10/13/11 |
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Compliance Hotline & Other Internal Methods of Reporting Noncompliance (Policy) Compliance Hotline & Other Internal Methods of Reporting Noncompliance (Procedure) |
10/13/11 10/13/11 |
|
| CMP 0005 | Code of Conduct (Superseded by CMP 0001, effective July 1, 2006) | Refer CMP 0001 |
|
Compliance Disclosure Program (Policy) Compliance Disclosure Program (Procedure) |
10/13/11 10/13/11 |
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Corporate Policy on Education and Training (Policy) Corporate Policy on Education and Training (Procedure) |
10/13/11 10/13/11 |
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Retention of Records (Policy) Retention of Records (Procedure) |
10/13/11 10/13/11 |
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Compliance Investigations (Policy) Compliance Investigations (Procedure) |
10/13/11 10/13/11 |
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CMP 0011 CMP 0012 CMP 0013 CMP 0014 CMP 0015 CMP 0016A CMP 0016B CMP 0017A CMP 0017B CMP 0018 |
Compliance Reporting Standards (Policy) Compliance Reporting Standards (Procedure) False Claims Acts and Whistleblower's Protection Act HHSC Corporate Arrangements Inclusive of Hilo Medical Center Use of State Resources in Support of Community Charities; Donations Prohibited Data Breach Response Identity Theft Prevention Program Policy ("Red Flag") Conflict of Interest (Policy) Conflict of Interest (Procedure) Policy for Use of Social Networking and Other Electronic Media Policy for Use of Social Networking and Other Electronic Media (Procedure) Non-Retaliation and Non-Retribution |
10/13/11 10/13/11 12/20/06 10/24/07 06/18/09 02/12/10 04/06/10 10/13/11 10/13/11 10/13/11 10/13/11 02/11/11 |
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| 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 1010A FIN 1011A FIN 1012A FIN 1013A FIN 1014A FIN 1015A |
Cost Report Work Paper Documentation Bad Debt Processing Balancing Issues Charge Reconciliation - Charge Error Worklist Small Balances Managing Denials Eligibility Response |
12/13/99 PENDING PENDING PENDING PENDING PENDING PENDING |
| 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 |
|
Physician Employment Policy (Policy) Physician Employment Procedures (Procedure) |
10/13/11 10/13/11 |
|
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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 | 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 | 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 1008A PAT 1008B |
Advance Directive Procedure HHSC Hand Hygiene Policy HHSC Hand Hygiene Procedure |
01/04/02 PENDING PENDING |
| 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 |
