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UNM Policy Office

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1 University of New Mexico
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Regents' Policy Manual - Section 3.7: Health Sciences Center Institutional Compliance Program

Adopted Date: 12-14-2010
Amended: 09-12-2014

(replaces RPM 2.13.3 and RPM 2.13.4)

Applicability

This policy applies to the academic and clinical programs, facilities and services operating under the University of New Mexico Health Sciences Center (HSC) and its component units, clinics, centers, programs, and subsidiary corporations described in RPM 3.4. This policy also applies to those operations of the University that are deemed to be “health care components” of the University as set forth below.

Institutional Compliance Program

The HSC will attempt to ensure at all times that its business (internally and with outside contractors) is conducted in accordance with the highest ethical standards and in compliance with the various federal and state laws and regulations applicable to its activities. To fulfill these obligations, the HSC has adopted and implemented an Institutional Compliance Program, which will include all compliance functions related to clinical, research and educational efforts at the HSC. These functions include, without limitation, clinical and clinical trials compliance, human research protection, animal research, biosafety, conflict of interest in research, human subjects protection, use of animals in education and research, export control compliance, research integrity, and fiscal compliance related to billing and federal grants, FERPA, and other educational compliance activities, as described in Section 5 of Regents policies and corresponding policies set forth in the Faculty Handbook (collectively, the “HSC Institutional Compliance Programs and Requirements”).

HIPAA and HITECH

Under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and Health Information Technology for Economic and Clinical Health Act, contained in the American Recovery and Reinvestment Act of 2009 (“HITECH Act”), and the regulations issued by the Department of Health and Human Services with respect thereto (collectively, the “HIPAA Regulations”) the University is hereby deemed a “hybrid covered entity” within the meaning of the HIPAA Regulations. Certain components of the University have been designated by the Regents as “health care components” of the University. The “health care components” of the “hybrid covered entity” shall, at a minimum, include, but not be limited to, the HSC and the UNM Health System as described and defined in Section 1 of RPM 3.4 and the Office of University Counsel. Additionally, the University and the UNM Hospital each sponsor self-insured group health benefit plans for the benefit of their respective employees and their dependents and certain other self-insured medical, dental, prescription drug, and vision health benefit plans (collectively, the “UNM/UNMH Self-Insured Health Plans”). The UNM/UNMH Self-Insured Health Plans shall be considered an “organized health care arrangement” within the meaning of HIPAA, HITECH Act, and the HIPAA Regulations. As a an organized health care arrangement and covered entity within the University, the UNM/UNMH Self-Insured Health Plans are considered “health care components” within the meaning of HIPAA and the HIPAA Regulations. All components of this organized health care arrangement will comply with HIPAA, HITECH Act, and the HIPAA Regulations, including all informatics technology security.

The Chancellor for Health Sciences will designate an individual to serve as the HSC Compliance Director to oversee, implement and report on the HSC Institutional Compliance Program and Requirements. Additionally, the President of the University shall delegate to the Chancellor for Health Sciences responsibility to assure compliance with HIPAA, HITECH Act, and the HIPAA Regulations and to designate an individual to serve as the Privacy Officer for the University’s health care components and the organized health care arrangement.

Implementation

Certain components of the University designated by the Regents as “health care components” of the University are listed in Exhibit A to this policy. Exhibit A will be replaced with a resolution of the Regents adopted on an annual basis that designates the “health care components” of the University.

References

University Research Park and Economic Development Act, N.M. Stat. ann. § 21-28-1 et seq. (1978, as amended); The Administrative Simplification Provisions of the Health Insurance Portability & Accountability Act of 1996 (HIPAA), codified at 42 U.S.C. § 1320d. Regulations pursuant to HIPAA codified at 45 C.F.R., Parts 160, 162, and 164; American Recovery and Reinvestment Act of 2009 (ARRA), Title XIII, Health Information Technology for Economic and Clinical Health Act (HITECH Act); RPM 3.4 “Health Sciences Center and Services”; RPM 3.5 “Health Sciences Center Board of Directors”; RPM 3.6 “UNM Hospital Board of Trustees”; University Business Policy 2200, "Reporting Misconduct and Retaliation"; HSC Institutional Compliance Plan; and HSC Code of Conduct/Organizational Ethics; UNM’s HIPAA Compliance Policy for Certain Health Plans Offered by the University; UNM Hospital HIPAA Policy.

EXHIBIT A

THE UNIVERSITY OF NEW MEXICO Health Care Components Designated
As a Hybrid Entity Pursuant to Regulations
Promulgated Pursuant to the Health Insurance Portability & Accountability
Act of 1996, As Amended Amended: December 7, 2010

The University of New Mexico ("UNM"), as a hybrid covered entity under 42 C.F.R. Part 164.504, hereby designates the following operations as health care components for purposes of complying with the Health Insurance Portability and Accountability Act of 1996:

  1. The Health Sciences Center (and its component units, centers, and programs as defined in RPM 3.4) and the UNMH Facilities (as defined in RPM 3.4), excluding the Tumor Registry and the Office of the State Medical Investigator for the State of New Mexico in fulfilling its statutory duties as coroner; 

  2. UNM Medical Group, Inc., a New Mexico non-profit and University Research Park and Economic Development Act corporation (“UNMMG”), including, without limitation, any and all clinics operated and/or managed by UNMMG; 

  3. Telemedicine, telehealth and/or teleradiology programs (including, without limitation, Project ECHO) on all UNM campuses; 

  4. Counseling Assistance & Referral Services; 

  5. Center for Family & Adolescent Research; 

  6. Center for Exercise; 

  7. Psychology Clinic; 

  8. Speech and Hearing Sciences; 

  9. Employee Health Promotion Program; 

  10. Any and all Lobo Clinics; 

  11. Student Health Center, excluding those activities thereof covered by the Family Education Rights and Privacy Act, 20 U.S.C. § 1232g, as amended; 

  12. Office of the University Counsel; 

  13. Safety and Risk Services Department; 

  14. Internal Audit Department; 

  15. UNM Medical Plan (as defined in RPM 3.4), including, without limitation, the following: 

    1. UNM Medical Plan (for health benefits) 

    2. Delta Dental (for dental benefits) 

    3. Flexible Healthcare Spending Benefit (for flexible spending accounts) 

    4. Prescription Drugs 

  16. Human Resources Department in carrying out and discharging Plan administration duties in respect of the UNM Medical Plan; 

  17. Information Technologies Department when accessing or providing mission support services in respect of the UNM Health Sciences Center, the UNM Medical Plan, and/or any of the departments, centers, or programs identified in this Exhibit A; and

  18. UNM Hospitals self-insured Health Benefit Plans including, without limitation, the following: 

    1. UNM Hospitals group health benefit plan (for health benefits) 

    2. Delta Dental (for dental benefits) 

    3. Flexible Healthcare Spending Benefit (for flexible spending accounts) 

    4. Prescription Drugs