HHSC Policies and Procedures

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Administration  –  Board of Directors  –  Compliance  –  Environment of Care  –  Finance  –  Health Information Management  –  Human Resources  –  Information Technology  –  Internal Auditor  –  Operations  –  Patient Care  –  Purchasing  –  Research  –  Telemedicine

AdministrationEffective Date
ADM 0001 – Records Release and Copying ChargesRedesignated to ADM 0038A
ADM 0003 – Dues for Professional Business Organizations11/13/13
ADM 0004 – Gifts to Board MembersSee BOD 0004A
ADM 0005A – Travel by Employees Inter-Island and Out of State09/23/21
ADM 0005B – Procedure
ADM 0006 – Use of HHSC State VehiclesSee HR 0018 A/B
ADM 0007B – Compliance with Antitrust Laws & Ethical Procurement04/04/23
ADM 0008A – Corporate Policy on Responding to Government Agencies07/27/23
ADM 0008B – Procedure
ADM 0009 – Corporate Policy on Credentialing and Background ChecksSee HR 0024 A/B
ADM 0012 – DonationsSuperseded by CMP 0013
ADM 0013A – Employee Housing and Rental Policy09/23/21
ADM 0013B – Procedure
ADM 0015 – Physician EmploymentRedesignated as HR 0015
ADM 0016A – HHSC Travel Policy for Corporate and Regional Board Member07/27/23
ADM 0018 – Educational Assistance and Tuition ReimbursementSee HR 0022 A/B
ADM 0019A – Adoption of Corporate-Wide PoliciesRescinded
ADM 0019B – Procedure
ADM 0023 – (Eliminated)N/A
ADM 0024 – InsurancePending
ADM 0025A – Attorney Billing Guidelines for Non-Insurance Matters01/26/24
ADM 0026A – Retention of Outside Counsel05/25/23
ADM 0027A – Risk Management Program05/26/22
ADM 0027B – Risk Management Plan
ADM 0028 – Settlement PolicySuperseded by ADM 0028A
ADM 0028A – Claims Management and Settlement Policy03/23/23
ADM 0028B – Procedure
ADM 0030A – Risk Management PlanSuperseded by ADM 0027B
ADM 0032 – Workplace Disruptive Behavior No-ToleranceSee HR 0029A/B
ADM 0033 – Tobacco Free Campus04/27/17
ADM 0034A – Person Authorized to Accept Service of Process07/27/23
ADM 0034B – Procedure
ADM 0035A – Preservation of Information in Litigation or Anticipation of Litigation01/26/24
ADM 0035B – Procedure
ADM 0036A – Driving Vehicles for HHSC Business07/27/23
ADM 0037A – HIPAA Records Release and Schedule of Charges07/27/23
ADM 0038A – Records Release and Schedule of Charges07/18/16
ADM 0045A – Legal Health Record08/25/16

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Board of DirectorsEffective Date
BOD 0002A – Corporate Board Assumption of Regional Board Minimum Contractual Responsibilities01/26/24

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ComplianceEffective Date
CMP 0001A – HHSC Corporate Compliance Program12/09/10
CMP 002A – Audit & Compliance Comm, Corp Compliance Comm, Chief CPO10/13/11
CMP 002B – Procedure
CMP 003A – Regional Compliance Officer Responsibilities10/13/11
CMP 003B – Procedure
CMP 004A – Compliance Hotline & Other Internal Methods of Reporting Non-Compliance10/13/11
CMP 004B – Procedure
CMP 0005 – Code of ConductSuperseded by CMP 0001A
CMP 006A – Compliance Disclosure Program10/13/11
CMP 006B – Procedure
CMP 007A – Corporate Policy on Education and Training10/13/11
CMP 007B – Procedure
CMP 008A – Retention of Records10/13/11
CMP 008B – Procedure
CMP 009A – Compliance Investigations10/13/11
CMP 009B – Procedure
CMP 010A – Compliance Reporting Standards10/13/11
CMP 010B – Procedure
CMP 0011 – False Claims Acts and Whistleblower’s Protection Act12/20/06
CMP 0013 – Use of State Resources in Support of Community Charities; Donations Prohibited6/18/09
CMP 0014A – HIPAA Breach Notification09/19/13
CMP 0015A – Identity Theft Prevention Program Policy (“Red Flag”)12/19/13
CMP 015B – Procedure
CMP 0016A – Conflict of Interest10/13/11
CMP 0016B – Procedure
CMP 0017A – Policy for Use of Social Networking and Other Electronic Media10/13/11
CMP 0017B – Procedure
CMP 0018 – Non-Retaliation and Non-Retribution02/11/11
CMP 0019A – Minimum Necessary09/19/13
CMP 020A – HIPAA Privacy and Security Policy and Practices Requirements09/20/12
CMP 021A – Privacy and Security Council09/20/12
CMP 0022 – Non-Discrimination Policy for Language AccessSuperceded by CMP 0101A
CMP 0023A – Grievance Process for Alleged Discrimination for Language Access06/20/13
CMP 023B – Procedure
CMP 0024A – Use and Disclosure of PHI Subject to the Treatment, Payment and Health Care Operations Exception09/19/13
CMP 0025A – HIPAA Complaint09/19/13
CMP 0026A – Sanctions09/19/13
CMP 0027A – HIPAA Training09/19/13
CMP 0028A – Notice of Privacy Practices09/19/13
CMP 0029A – HIPAA Authorizations for Use and Disclosure of Protected Health Information09/19/13
CMP 0029B – Procedure
CMP 0030A – HIPAA Avert Threat Health and Safety Use Disclosure09/19/13
CMP 0031A – HIPAA Business Associate Disclosure10/17/13
CMP 0032A – HIPAA Decedents Use and Disclosure09/19/13
CMP 0032B – Procedure
CMP 0033A – HIPAA De-Identification and Limited Data Use Disclosure09/19/13
CMP 0034A – HIPAA Release of Facility Directory Information to Public and Press09/19/13
CMP 0035A – HIPAA Educational Purposes Use and Disclosure09/19/13
CMP 0036A – HIPAA Government Functions Use and Disclosure09/19/13
CMP 0037A – HIPAA Health Oversight Activities Use and Disclosure09/19/13
CMP 0038A – HIPAA Judicial and Administrative Proceedings Use and Disclosure09/19/13
CMP 0039A – HIPAA Cadaveric Organ Donation Use and Disclosure09/19/13
CMP 0040A – HIPAA Patient Right to Accounting of Disclosures09/19/13
CMP 0041A – HIPAA Individual Right to Request Amendment09/19/13
CMP 0042A – HIPAA Patient Right to Confidential Communications09/19/13
CMP 0043A – HIPAA Patient Right to Request Restrictions09/19/13
CMP 0044A – HIPAA Personal Representatives09/19/13
CMP 0045A – HIPAA Public Health Activities Disclosures09/19/13
CMP 0046A – HIPAA Research Purposes Use and Disclosure09/19/13
CMP 0047A – HIPAA Verification Prior to Disclosure09/19/13
CMP 0048A – HIPAA Victims of Abuse or Neglect Disclosures09/19/13
CMP 0049A – HIPAA Patient Right to Access and Obtain Copies of Designated Record Set09/19/13
CMP 0050A – HIPAA Release of Information for Law Enforcement Purposes09/19/13
CMP 0051A – HIPAA Use and Disclosure for Involvement in Individual’s Care09/19/13
CMP 0052A – HIPAA Departmental Release of Protected Health Information09/19/13
CMP 0053A – Exclusions and Sanctions Policy10/17/13
CMP 0053B – Procedure
CMP 0054A – Providing Electronic Protected Health Information (ePHI) to Patients10/17/13
CMP 0055A – Fundraising Communications09/19/13
CMP 0056A – Workforce Member Access to Protected Health Information (PHI)02/22/18
CMP 0057A – Texting Patient Information Among Health Care Providers and Staff Members07/26/18
CMP 0057B – Procedure07/26/18
CMP 0058A – HIPAA Policy11/17/22
CMP 0100A – Nondiscrimination (General)07/25/19
CMP 0100B – Procedure10/27/16
CMP 0101A – Nondiscrimination Policy for Language Access07/25/19

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Environment of CareEffective Date
EOC 0002 – Corporate Policy on Medical Waste11/01/00
EOC 0005A – Prohibition of Weapons on HHSC Premises05/25/23
EOC 0005B – Prohibition of Weapons on HHSC Premises – Procedure05/25/23

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FinanceEffective Date
FIN 0002 – Corporate Policy on Financial Agreements with Physicians and Other Providers07/01/04
FIN 0004 – Corporate Policy on Financial Arrangements with Referral Sources Other than Physicians09/22/00
FIN 0005 – Invoice Approval for PaymentPending
FIN 0009 – Debtor Tax Refund Setoff02/22/18
FIN 0010 – Prompt Pay Discounts of Account Receivables09/08/05
FIN 0011 – Cash Management08/21/08
FIN 0012 – Payroll Funding08/21/08
FIN 0013 – Operational Budgeting08/21/08
FIN 0014 – Governmental Budgeting08/21/08
FIN 0015 – Capital Budgeting08/21/08
FIN 0016 – Municipal Lease Financing11/13/08
FIN 0017 – Debt Management11/13/08
FIN 0018 – Investments11/13/08
FIN 0019 – Accounts Receivable Valuation04/09/09
FIN 0020 – Funds Allocation11/13/08
FIN 0021 – Operating Lease Policy11/13/08
FIN 0022 – Short Term Debt and Revolving Lines of Credit11/13/08
FIN 0023 – Third Party Payer Contracting11/13/08
FIN 0024 – Revenue Cycle Management11/13/08
FIN 0026 – Charge Description Master Policy01/29/09
FIN 0027 – Disposal of Real Property04/09/09
FIN 0028 – Real Estate Leases01/29/09
FIN 0029 – Accounting01/29/09
FIN 0030 – Acquisition and Disposal of Assets04/09/09
FIN 0031 – Banking01/29/09
FIN 0032 – Preparing Submitting and Managing Cost Reports01/29/09
FIN 0033 – Region to Region Loans01/29/09
FIN 0034 – Submission of Project and Funding Requests to FISAC Policy04/09/09
FIN 0100A – Medicare Outpatient Observation Notice – MOON04/27/17
FIN 0511 – Processing Credit Balances and Potential Overpayments02/20/14
FIN 0520 – Charity Care 06/01/04
FIN 0521 – Small Balance Write-Offs of Accounts Receivable 02/10/99
FIN 0522 – Write-Off of Patient Accounts Receivable Greater Than 365 Days 02/10/99
FIN 0527 – Medical Supply and Equipment Billing Policy 01/01/07
FIN 1001 – Standardized Work Paper Package 12/13/99
FIN 1002 -Cost Report Review12/13/99
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 1010A – Bad Debt ProcessingPending
FIN 1011A – Balancing IssuesPending
FIN 1012A – Charge Reconciliation – Charge Error WorklistPending
FIN 1013A – Small BalancesPending
FIN 1014A – Managing DenialsPending
FIN 1015A – Eligibility ResponsePending
FIN 1016A – Late Charge ManagementPending
FIN 1017A – Medical NecessityPending
FIN 1018A – Payment ArrangementsPending
FIN 1019A – Payment VariancePending
FIN 1020A – Remittance ProcessingPending
FIN 1021A – Change Patient StatusPending
FIN 1022A – Referring Non-Medical StaffPending
FIN 1023A – Balancing Guarantor PaymentsPending
FIN 1024A – Contractual AllowancesPending
FIN 1025A – Managing Duplicate Persons and Medical Record NumberPending
FIN 1026A – Health Information Management BalancingPending
FIN 1027A – Updating and Changing the Insurance Policy Effective DatePending
FIN P001 – HHSC General Payroll Policy 11/13/08
FIN P002 – HHSC General Payroll Info and Pay Dates 11/13/08

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Health Information ManagementEffective Date
HIM 0001A – Administrative Closure of Incomplete Medical Records01/26/23
HIM 1002A – Medical Records:  Coding and Documentation for Outpatient Services10/25/18
HIM 1002B – Procedure10/25/18
HIM 1003A – Medical Records:  Coding and Documentation for Inpatient Services10/25/18
HIM 1003B – Procedure10/25/18
HIM 1010A – Medical Records:  Query Policy01/26/23
HIM 1010B – Procedure01/26/23

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Human ResourcesEffective Date
HR 0001A – Equal Employment Opportunity01/27/22
HR 0001B – Procedure
HR 0002A – Reasonable Accommodations01/27/22
HR 0002B – Procedure
HR 0003A – Non-Harassment01/27/22
HR 0003B – Procedure
HR 0004A – Workplace Violence/Abuse Non-Tolerance01/27/22
HR 0004B – Procedure
HR 0005A – Transfer/Relocation Assistance09/23/21
HR 0005B – Procedure
HR 0006A – HHSC General Human Resources System09/23/21
HR 0006B – Procedure
HR 0007A – Exempt Excluded Compensation09/23/21
HR 0007B – Procedure
HR 0008A – Placement of Employees Affected by Environmental Restrictions in the Workplace09/23/21
HR 0008B – Procedure
HR 0009A – Return to Work Priority Program (RTWPP)09/23/21
HR 0009B – Procedure
HR 0010A – Protection of Personnel Information Program01/27/22
HR 0010B – Procedure
HR 0011A – Oversight of Employees09/23/21
HR 0011B – Procedure
HR 0012A – Family Leave01/27/22
HR 0012B – Procedure
HR 0013A – Standards of Dress Safety and Hygiene05/26/22
HR 0014A – Workers Compensation Stipulation and Settlement Agreement and Orders 09/23/21
HR 0014B – Procedure
HR 0015A – Physician Employment11/18/21
HR 0017A – Outside Employment09/23/21
HR 0017B – Procedure
HR 0018A – Use of HHSC/State Vehicles09/23/21
HR 0018B – Procedure
HR 0019A – Negotiation of Memorandums of Understanding, Supplement Agreements and Settlement or Tentative Agreement on Subjects of Collective Bargaining01/27/22
HR 0019B – Procedure
HR 0020A – Telework Program05/26/22
HR 0020B – Procedure
HR 0021A – Break Time for Nursing Mothers01/27/22
HR 0021B – Procedure
HR 0022A – Educational Assistance & Tuition Reimbursement09/23/21
HR 0022B – Procedure
HR 0023A – Health Care Personnel Influenza Program01/27/22
HR 0024A – Background Checks09/23/21
HR 0024B – Procedure
HR 0025A – Temporary Hazard Pay09/23/21
HR 0025B – Procedure
HR 0026A – Alcohol-Free and Drug-Free Work Environment and Campus11/18/21
HR 0026B – Procedure
HR 0029A -Workplace Disruptive Behavior No-Tolerance01/27/22
HR 0029B – Procedure

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Information TechnologyEffective Date
For Authorized Users Only: Click here to access our IT Policies & ProceduresN/A
ITD 0005A – Information Systems Access01/23/20
ITD 0026A – Patch Management01/26/23
ITD 0026B – Procedure
ITD 0051A – Information Security01/26/23
ITD 0051B – Procedure
ITD 0091A – Secure Areas01/28/21
ITD 0131A – Reporting Information Security Events and Weaknesses01/28/21
ITD 0151A – Compliance with Legal Requirements01/23/20
Internal AuditorEffective Date
IA 001A – Internal Audit Function Charter10/13/11
OperationsEffective Date
OPN 0001 – Creation of Business Ventures by Regional System Boards08/21/08
Patient CareEffective Date
PAT 0001 – Patients’ Rights and Responsibilities01/27/22
PAT 0002 – Anatomical Donation Policy 02/20/14
PAT 0003 – Emergency Care Transfers – COBRA09/15/00
PAT 0003A – Emergency Medical Treatment and Labor Act (EMTALA)05/26/22
PAT 0003B – Procedure
PAT 0004 – Corporate Policy on Confidential Patient Information 12/06/01
PAT 0005 – Determination and Documentation of Brain Death 04/12/01
PAT 0010 – Reporting Blood and Urine Alcohol and Drug Contents of Persons Involved in a Vehicle CollisionRefer to CMP 0050A
PAT 0013A – HHSC System Quality Structure06/25/15
PAT 0014A – Our Care Our Choice Act (OCOCA)01/28/21
PAT 0015A – Informed Consent05/27/21
PAT 0015B – Procedure
PAT 1001 – Medical Records – 72 Hour Window Rule09/15/00
PAT 1002B – Procedure
PAT 1003B – Procedure
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 1007A – Advance Health Care Directives11/14/19
PAT 1007B1 – Advance Health Care Directive Procedure02/18/21
PAT 1007B2 – Advance Mental Health Care Directive Procedure02/18/21
PAT 1008A – HHSC Hand Hygiene PolicyRescinded
PAT 1008B – Procedure
PAT 1009A – Computerized Provider Order Entry – CPOE 10/17/13
PAT 1009B – Procedure
PAT 1010B – Procedure
PurchasingEffective Date
PUR 0001A – Designation of Procurement Responsibilities to the HHSC and Regional Facilities06/20/13
PUR 0001B – Procedure
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 Policy Competitive Sealed Proposals07/21/10
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 Directors04/17/08
PUR 0012 – Capital Equipment Purchase Review by Materials and Contract Management Team 10/01/07
PUR 0014A – Legal Review of RFP – IFB and Contracts 11/17/22
PUR 0015 – Contract Technical Representative Duties 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 Purchases10/01/07
PUR 0019 – Requesting Purchasing and 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
PUR 0027A – Fleet Vehicle Inventory and Disposal10/30/14
PUR 0027B – Procedure
ResearchEffective Date
RES 0001 – Quality: Corporate Institutional Review Board PolicySuperseded
RES 001A – Corporate Institutional Review Board Policy08/16/12
TelemedicineEffective Date
TEL 0019A – Administrative Use of HHSC Video Teleconferencing System by Outside Agencies01/28/21
TEL 0021A – Administrative Use of HHSC Video Teleconferencing System01/28/21