HHSC Policies and Procedures – Hawaii Health Systems Corporation

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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

Administration	Effective Date
ADM 0001 – Records Release and Copying Charges	Redesignated to ADM 0038A
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	09/23/21
ADM 0005B – Procedure	09/23/21
ADM 0006 – Use of HHSC State Vehicles	See HR 0018 A/B
ADM 0007B – Compliance with Antitrust Laws & Ethical Procurement	04/04/23
ADM 0008A – Corporate Policy on Responding to Government Agencies	07/27/23
ADM 0008B – Procedure	07/27/23
ADM 0009 – Corporate Policy on Credentialing and Background Checks	See HR 0024 A/B
ADM 0012 – Donations	Superseded by CMP 0013
ADM 0013A – Employee Housing and Rental Policy	09/23/21
ADM 0013B – Procedure	09/23/21
ADM 0015 – Physician Employment	Redesignated as HR 0015
ADM 0016A – HHSC Travel Policy for Corporate and Regional Board Member	07/27/23
ADM 0018 – Educational Assistance and Tuition Reimbursement	See HR 0022 A/B
ADM 0019A – Adoption of Corporate-Wide Policies	Rescinded
ADM 0019B – Procedure	Rescinded
ADM 0023 – (Eliminated)	N/A
ADM 0024 – Insurance	Pending
ADM 0025A – Attorney Billing Guidelines for Non-Insurance Matters	01/26/24
ADM 0026A – Retention of Outside Counsel	05/25/23
ADM 0027A – Risk Management Program	05/26/22
ADM 0027B – Risk Management Plan	05/26/22
ADM 0028 – Settlement Policy	Superseded by ADM 0028A
ADM 0028A – Claims Management and Settlement Policy	03/23/23
ADM 0028B – Procedure	03/23/23
ADM 0030A – Risk Management Plan	Superseded by ADM 0027B
ADM 0032 – Workplace Disruptive Behavior No-Tolerance	See HR 0029A/B
ADM 0033 – Tobacco Free Campus	04/27/17
ADM 0034A – Person Authorized to Accept Service of Process	07/27/23
ADM 0034B – Procedure	07/27/23
ADM 0035A – Preservation of Information in Litigation or Anticipation of Litigation	01/26/24
ADM 0035B – Procedure	01/26/24
ADM 0036A – Driving Vehicles for HHSC Business	07/27/23
ADM 0037A – HIPAA Records Release and Schedule of Charges	07/27/23
ADM 0038A – Records Release and Schedule of Charges	07/18/16
ADM 0045A – Legal Health Record	08/25/16

Board of Directors	Effective Date
BOD 0002A – Corporate Board Assumption of Regional Board Minimum Contractual Responsibilities	01/26/24

Compliance	Effective Date
CMP 0001A – HHSC Corporate Compliance Program	12/09/10
CMP 002A – Audit & Compliance Comm, Corp Compliance Comm, Chief CPO	10/13/11
CMP 002B – Procedure	10/13/11
CMP 003A – Regional Compliance Officer Responsibilities	10/13/11
CMP 003B – Procedure	10/13/11
CMP 004A – Compliance Hotline & Other Internal Methods of Reporting Non-Compliance	10/13/11
CMP 004B – Procedure	10/13/11
CMP 0005 – Code of Conduct	Superseded by CMP 0001A
CMP 006A – Compliance Disclosure Program	10/13/11
CMP 006B – Procedure	10/13/11
CMP 007A – Corporate Policy on Education and Training	10/13/11
CMP 007B – Procedure	10/13/11
CMP 008A – Retention of Records	10/13/11
CMP 008B – Procedure	10/13/11
CMP 009A – Compliance Investigations	10/13/11
CMP 009B – Procedure	10/13/11
CMP 010A – Compliance Reporting Standards	10/13/11
CMP 010B – Procedure	10/13/11
CMP 0011 – False Claims Acts and Whistleblower’s Protection Act	12/20/06
CMP 0013 – Use of State Resources in Support of Community Charities; Donations Prohibited	6/18/09
CMP 0014A – HIPAA Breach Notification	09/19/13
CMP 0015A – Identity Theft Prevention Program Policy (“Red Flag”)	12/19/13
CMP 015B – Procedure	12/19/13
CMP 0016A – Conflict of Interest	10/13/11
CMP 0016B – Procedure	10/13/11
CMP 0017A – Policy for Use of Social Networking and Other Electronic Media	10/13/11
CMP 0017B – Procedure	10/13/11
CMP 0018 – Non-Retaliation and Non-Retribution	02/11/11
CMP 0019A – Minimum Necessary	09/19/13
CMP 020A – HIPAA Privacy and Security Policy and Practices Requirements	09/20/12
CMP 021A – Privacy and Security Council	09/20/12
CMP 0022 – Non-Discrimination Policy for Language Access	Superceded by CMP 0101A
CMP 0023A – Grievance Process for Alleged Discrimination for Language Access	06/20/13
CMP 023B – Procedure	06/20/13
CMP 0024A – Use and Disclosure of PHI Subject to the Treatment, Payment and Health Care Operations Exception	09/19/13
CMP 0025A – HIPAA Complaint	09/19/13
CMP 0026A – Sanctions	09/19/13
CMP 0027A – HIPAA Training	09/19/13
CMP 0028A – Notice of Privacy Practices	09/19/13
CMP 0029A – HIPAA Authorizations for Use and Disclosure of Protected Health Information	09/19/13
CMP 0029B – Procedure	09/19/13
CMP 0030A – HIPAA Avert Threat Health and Safety Use Disclosure	09/19/13
CMP 0031A – HIPAA Business Associate Disclosure	10/17/13
CMP 0032A – HIPAA Decedents Use and Disclosure	09/19/13
CMP 0032B – Procedure	09/19/13
CMP 0033A – HIPAA De-Identification and Limited Data Use Disclosure	09/19/13
CMP 0034A – HIPAA Release of Facility Directory Information to Public and Press	09/19/13
CMP 0035A – HIPAA Educational Purposes Use and Disclosure	09/19/13
CMP 0036A – HIPAA Government Functions Use and Disclosure	09/19/13
CMP 0037A – HIPAA Health Oversight Activities Use and Disclosure	09/19/13
CMP 0038A – HIPAA Judicial and Administrative Proceedings Use and Disclosure	09/19/13
CMP 0039A – HIPAA Cadaveric Organ Donation Use and Disclosure	09/19/13
CMP 0040A – HIPAA Patient Right to Accounting of Disclosures	09/19/13
CMP 0041A – HIPAA Individual Right to Request Amendment	09/19/13
CMP 0042A – HIPAA Patient Right to Confidential Communications	09/19/13
CMP 0043A – HIPAA Patient Right to Request Restrictions	09/19/13
CMP 0044A – HIPAA Personal Representatives	09/19/13
CMP 0045A – HIPAA Public Health Activities Disclosures	09/19/13
CMP 0046A – HIPAA Research Purposes Use and Disclosure	09/19/13
CMP 0047A – HIPAA Verification Prior to Disclosure	09/19/13
CMP 0048A – HIPAA Victims of Abuse or Neglect Disclosures	09/19/13
CMP 0049A – HIPAA Patient Right to Access and Obtain Copies of Designated Record Set	09/19/13
CMP 0050A – HIPAA Release of Information for Law Enforcement Purposes	09/19/13
CMP 0051A – HIPAA Use and Disclosure for Involvement in Individual’s Care	09/19/13
CMP 0052A – HIPAA Departmental Release of Protected Health Information	09/19/13
CMP 0053A – Exclusions and Sanctions Policy	10/17/13
CMP 0053B – Procedure	10/17/13
CMP 0054A – Providing Electronic Protected Health Information (ePHI) to Patients	10/17/13
CMP 0055A – Fundraising Communications	09/19/13
CMP 0056A – Workforce Member Access to Protected Health Information (PHI)	02/22/18
CMP 0057A – Texting Patient Information Among Health Care Providers and Staff Members	07/26/18
CMP 0057B – Procedure	07/26/18
CMP 0058A – HIPAA Policy	11/17/22
CMP 0059B – Workforce Sanctions	09/01/24
CMP 0100A – Nondiscrimination (General)	07/25/19
CMP 0100B – Procedure	10/27/16
CMP 0101A – Nondiscrimination Policy for Language Access	07/25/19

Environment of Care	Effective Date
EOC 0002 – Corporate Policy on Medical Waste	11/01/00
EOC 0005A – Prohibition of Weapons on HHSC Premises	05/25/23
EOC 0005B – Prohibition of Weapons on HHSC Premises – Procedure	05/25/23

Finance	Effective Date
FIN 0002 – Corporate Policy on Financial Agreements with Physicians and Other Providers	07/01/04
FIN 0004 – Corporate Policy on Financial Arrangements with Referral Sources Other than Physicians	09/22/00
FIN 0005 – Invoice Approval for Payment	Pending
FIN 0009 – Debtor Tax Refund Setoff	02/22/18
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 0026 – Charge Description Master Policy	01/29/09
FIN 0027 – Disposal of 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 and Funding Requests to FISAC Policy	04/09/09
FIN 0100A – Medicare Outpatient Observation Notice – MOON	07/25/24
FIN 0100B – Procedure	07/25/24
FIN 0511 – Processing Credit Balances and Potential Overpayments	02/20/14
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 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
FIN P002 – HHSC General Payroll Info and Pay Dates	11/13/08

Health Information Management	Effective Date
HIM 0001A – Administrative Closure of Incomplete Medical Records	01/26/23
HIM 1002A – Medical Records: Coding and Documentation for Outpatient Services	10/25/18
HIM 1002B – Procedure	10/25/18
HIM 1003A – Medical Records: Coding and Documentation for Inpatient Services	10/25/18
HIM 1003B – Procedure	10/25/18
HIM 1010A – Medical Records: Query Policy	01/26/23
HIM 1010B – Procedure	01/26/23

Human Resources	Effective Date
HR 0001A – Equal Employment Opportunity	01/27/22
HR 0001B – Procedure	01/27/22
HR 0002A – Reasonable Accommodations	01/27/22
HR 0002B – Procedure	01/27/22
HR 0003A – Non-Harassment	01/27/22
HR 0003B – Procedure	01/27/22
HR 0004A – Workplace Violence/Abuse Non-Tolerance	01/27/22
HR 0004B – Procedure	01/27/22
HR 0005A – Transfer/Relocation Assistance	09/23/21
HR 0005B – Procedure	09/23/21
HR 0006A – HHSC General Human Resources System	09/23/21
HR 0006B – Procedure	09/23/21
HR 0007A – Exempt Excluded Compensation	09/23/21
HR 0007B – Procedure	09/23/21
HR 0008A – Placement of Employees Affected by Environmental Restrictions in the Workplace	09/23/21
HR 0008B – Procedure	09/23/21
HR 0009A – Return to Work Priority Program (RTWPP)	09/23/21
HR 0009B – Procedure	09/23/21
HR 0010A – Protection of Personnel Information Program	01/27/22
HR 0010B – Procedure	01/27/22
HR 0011A – Oversight of Employees	09/23/21
HR 0011B – Procedure	09/23/21
HR 0012A – Family Leave	01/27/22
HR 0012B – Procedure	01/27/22
HR 0013A – Standards of Dress Safety and Hygiene	05/26/22
HR 0014A – Workers Compensation Stipulation and Settlement Agreement and Orders	09/23/21
HR 0014B – Procedure	09/23/21
HR 0015A – Physician Employment	11/18/21
HR 0017A – Outside Employment	09/23/21
HR 0017B – Procedure	09/23/21
HR 0018A – Use of HHSC/State Vehicles	09/23/21
HR 0018B – Procedure	09/23/21
HR 0019A – Negotiation of Memorandums of Understanding, Supplement Agreements and Settlement or Tentative Agreement on Subjects of Collective Bargaining	01/27/22
HR 0019B – Procedure	01/27/22
HR 0020A – Telework Program	05/26/22
HR 0020B – Procedure	05/26/22
HR 0021A – Break Time for Nursing Mothers	01/27/22
HR 0021B – Procedure	01/27/22
HR 0022A – Educational Assistance & Tuition Reimbursement	09/23/21
HR 0022B – Procedure	09/23/21
HR 0023A – Health Care Personnel Influenza Program	01/27/22
HR 0024A – Background Checks	09/23/21
HR 0024B – Procedure	09/23/21
HR 0025A – Temporary Hazard Pay	09/23/21
HR 0025B – Procedure	09/23/21
HR 0026A – Alcohol-Free and Drug-Free Work Environment and Campus	11/18/21
HR 0026B – Procedure	11/18/21
HR 0029A -Workplace Disruptive Behavior No-Tolerance	01/27/22
HR 0029B – Procedure	01/27/22

Information Technology	Effective Date
For Authorized Users Only: Click here to access our IT Policies & Procedures	N/A
ITD 0005A – Information Systems Access	01/23/20
ITD 0026A – Patch Management	01/26/23
ITD 0026B – Procedure	01/26/23
ITD 0051A – Information Security	01/26/23
ITD 0051B – Procedure	01/26/23
ITD 0091A – Secure Areas	01/28/21
ITD 0131A – Reporting Information Security Events and Weaknesses	01/28/21
ITD 0151A – Compliance with Legal Requirements	01/23/20
Internal Auditor	Effective Date
IA 001A – Internal Audit Function Charter	10/13/11
Operations	Effective Date
OPN 0001 – Creation of Business Ventures by Regional System Boards	08/21/08
Patient Care	Effective Date
PAT 0001 – Patients’ Rights and Responsibilities	01/27/22
PAT 0002 – Anatomical Donation Policy	02/20/14
PAT 0003 – Emergency Care Transfers – COBRA	09/15/00
PAT 0003A – Emergency Medical Treatment and Labor Act (EMTALA)	05/26/22
PAT 0003B – Procedure	05/26/22
PAT 0004 – Corporate Policy on Confidential Patient Information	Rescinded
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 Collision	Refer to CMP 0050A
PAT 0013A – HHSC System Quality Structure	06/25/15
PAT 0014A – Our Care Our Choice Act (OCOCA)	01/28/21
PAT 0015A – Informed Consent	05/27/21
PAT 0015B – Procedure	05/27/21
PAT 1001 – Medical Records – 72 Hour Window Rule	09/15/00
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 Directives	11/14/19
PAT 1007B1 – Advance Health Care Directive Procedure	02/18/21
PAT 1007B2 – Advance Mental Health Care Directive Procedure	02/18/21
PAT 1008A – HHSC Hand Hygiene Policy	Rescinded
PAT 1008B – Procedure	Rescinded
PAT 1009A – Computerized Provider Order Entry – CPOE	10/17/13
PAT 1009B – Procedure	10/17/13
PAT 1010B – Procedure
Purchasing	Effective Date
PUR 0001A – Designation of Procurement Responsibilities to the HHSC and Regional Facilities	06/20/13
PUR 0001B – Procedure	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 Policy Competitive Sealed Proposals	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 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 0014B – Procedure	09/13/24
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 Purchases	10/01/07
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 Disposal	10/30/14
PUR 0027B – Procedure	10/30/14
Research	Effective Date
RES 0001 – Quality: Corporate Institutional Review Board Policy	Superseded
RES 001A – Corporate Institutional Review Board Policy	08/16/12
Telemedicine	Effective Date
TEL 0019A – Administrative Use of HHSC Video Teleconferencing System by Outside Agencies	01/28/21
TEL 0021A – Administrative Use of HHSC Video Teleconferencing System	01/28/21