Compliance Policies

These policies apply to UMMS Shared Service employees only. Affiliate employees must reference the affiliate-specific policy, which may include an addendum.

• CC-1103 Physicians and Referral Source Relationships Policy
• CC-1201 Procedures for Managing Compliance Concerns
  • CC-1201A Privacy Concerns
  • CC-1201B Escalation
  • CC-1201C External Resources
• CC-1202 Development of Corporate Policies and Procedures
  • CC-1202A Federal Identification Numbers for all Entities (Grouped by System)
  • CC-1202B Policy Template
  • CC-1202C Policy Summary
  • CC-1202D Implementation Plan Sample
• CC-1203 Identifying and Returning Overpayments
• CC-1204 Non-Retaliation and Internal Reporting of Suspected Violations of Compliance Policies or Legal/Regulatory Obligation
• CC-1205 False Claims Act & Whistleblower Protection Education
• CC-1206 Compliance Education
• CC-1207 Screening & Exclusion or OIG/GSA Exclusion Review
• CC-1208 Conflicts of Interest
• CC-1301 Vendor Relationships Policy 
• CC-1302 Use of non-Public Information Policy 
• CC-1303 Lobbying and Political Campaign Contributions 
• CC-1304 Offering or Providing Gifts to Patients 
• CC-1305 Gifts, Meals and Entertainment to or from Referral Sources 
• CC-1306 Standards of Business Conduct Certification
  
  • CC-1306A Standards of Business Conduct Document
• CC-1307 Business Associate Agreements
  
  • CC-1307A Business Associate Decision Matrix
  • CC-1307B Business Associate Addendum
• CC-1308 Notice of Privacy Practices Policy 
  • Notice of Privacy Brochure
  • Notice of Privacy Poster - English
  • Notice of Privacy Poster - Spanish
• CC-1309 Medicare Advance Beneficiary Notice of Non-Coverage (ABN)
  
  • CC-1309A (ABN form-English 
  • CC-1309B (ABN form-Spanish)
• CC-1310 Medical Identity Theft/Insurance Fraud Template 
• CC-1401 Inpatient v. Outpatient/Observation Services 
• CC-1402 Physician Contracting Initiation and Administration 
  •  CC-1402A Physician Timesheet
• CC-1403 Hospital Regulated Clinics - Charging for Same Day Procedures and Evaluation and Management Visits 
• CC-1501 HIPAA-Marketing 
• CC-1502 HIPAA-Fundraising 
• CC-1504 Privacy - Authorizations, Uses, and Disclosures (AUD)
• CC-1505 Responding to Nonroutine Govt Inquiries
  
  • CC-1505A Responding to Nonroutine Govt Inquiries Attachment A
• CC-1506 Physician Lease Arrangements
• CC-1507 Nondiscrimination in Health Programs 
• CC-1601 Telephone Consumer Protection Act
• CC-1605 Intellectual Property 
• CC-1606 Communicating with Persons with Disabilities
  
  • CC-1606A Attachment A Waiver of Interpretation Services
• CC-1607 Communicating with Persons with Limited English Proficiency
  
  • CC-1607A Attachment A Waiver of Interpretation Services
• CC-1608 Notice of Nondiscrimination 
• CC-1610 Fraud Reporting and Investigations
• CC-1615 HIPAA Patient Right of Access
• CC-1702 New and Discontinued Services and Locations
• CC-1803 Minimum Necessary Standard
• CC1804 Privacy - Health Information Exchange
  • FAQ's
  • Patient Health Information Exchange Information
• CC-1805 Consent to Treat Policy
• UMMS Privacy Sanctions Policy 
  • CC-2001 Sanctions Policy Training

Policies are revised or added on a quarterly basis. If you are unable to locate the policy that you need, please email compliance@umm.edu.