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									                                               UNC School of Medicine

                       Procedure for Initiating a Business Associate Agreement

Please review the information provided in “HIPAA Awareness and Purchasing” below.

If you feel a BAA is needed or if you need further clarification as to whether a BAA is needed,
please send the following information to

    1.       Brief paragraph describing the relationship between UNC SOM and the vendor and
             services the vendor is providing to UNC SOM. How and why is PHI shared?

    2.       Payment method used to pay vendor. (contract, purchase requisition, purchase
             order, etc.)

    3.       Business name, address and phone number. Contact person’s name and phone

    4.       Your name, department and phone number.

                                                   HIPAA Awareness


    A. A business associate is a person or entity who provides certain functions or
       services for or to a covered entity, which involves access to protected health
       information (PHI), exposure to PHI or the transfer of PHI. Definition of “business
       associate” at 45 CFR 160.103. Note: “Transfer” should be considered more broadly to
       include access and/or exposure to PHI.
    B. A business associate is not a member of the covered entity’s workforce.
    C. A covered entity can also be the business associate of another covered entity.
    D. Business associate functions and activities include: claims processing or administration,
       data analysis, processing or administration; utilization review; quality assurance; billing;
       benefit management; practice management; and repricing.
    E. Business associate services are: legal; actuarial; accounting; consulting; data
       aggregation; management; administrative; accreditation; and financial.
    F. Examples of Business Associates include:
        A third party administrator who assists a health plan with claims processing.
        A CPA firm whose accounting services to a health care provider involves access to
           protected health information.
        A consultant who performs utilization reviews for a hospital.
        A health care clearinghouse that translates a claim from a non-standard format into a
           standard transaction on behalf of a health care provider and forwards the processed
           transaction to a payer.
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         An independent (contractor) medical transcriptionist who provides transcription
          services to a physician.
        Clinical services performed by a business associate on behalf of the covered entity;
          such as temporary staffing, lab services, etc...
    G. The rule has exceptions (see 45 CFR 164.502(e):
        Business associate requirements do not apply to covered entities that disclose PHI to
          other providers for treatment purposes. i.e. Discussion between a hospital and a
          physician with admitting privileges at the hospital.
        The collection and sharing of PHI by a health plan that is a public benefits program,
          such as Medicare, and an agency other than the agency administering the health
          plan, such as the Social Security Administration, that collects PHI to determine
          eligibility or enrollment, or determines such for the governmental program where the
          joint activities are authorized by law.
        With persons or organizations (i.e. janitorial services or electricians) whose functions
          or services to do not involve the use of PHI and where any access to PHI would be
        With a person or organization that acts merely as a conduit for PHI; i.e. US Postal
          Service, FedEx, or UPS.
        To disclose PHI to a researcher for research purposes, either with patient
          authorization, pursuant to a waiver under 45 CFR 164.512(i), or as a limited data set
          pursuant to 45 CFR 164.514(e).


         A. When purchasing commodities you want to make sure that you watch for:

             (1) Company access to protected data when delivering and installing equipment
             (2) Protected data stored on equipment returned to the vendor for any reason.
             (3) Prior to delivery, required installation of a preload on the equipment, giving access
                 to protected data.

         B. When purchasing services, you want to make sure that you watch for:

             (1) Services that require vendor personnel to have access to protected data.
             (2) Services in which we send protected data through means of electronic
             (3) Services in which we store protected data off site.
             (4) Services in which we have equipment repaired that has been used to store,
                 maintain, retrieve or alter protected data that may or may not have left a
                 signature trace of the information.

         C. When purchasing maintenance services, you want to make sure you watch for:

             (1) Maintenance that requires vendor personnel to have access to protected data.
             (2) Maintenance that requires vendor personnel to have telephonic/electronic access
                 to any equipment or system, which houses or transmits protected data.
             (3) Maintenance in which we have equipment repaired that has been used to store,
                 maintain, retrieve or alter protected data that may or may not have left a signature
                 trace of the information.

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         A. The Customer prepares the proper paperwork to initiate the type order required for
            the acquisition of supplies and/or services, taking into account the dollar thresholds

         B. The Customer ensures that the ten (10) digit account code is accurate, and that
            adequate funds are available in the account for the purchases by processing the
            paperwork through the proper accounting personnel.

         C. When using a requisition the following will happen:
            (1) The Purchasing Office shall receive your requisition and will date and time stamp
                the requisition upon receipt.
            (2) The requisition shall be checked to see if it has been approved by the proper
                accounting personnel:
                (b) If yes, the requisition shall be forwarded to the purchasing supervisor for
                    purchase action.
                (c) If no, the requisition will be sent downstairs to be reviewed and approved by
                    the proper accounting personnel and then sent to the purchasing supervisor.
            (3) The purchasing supervisor shall forward the requisition to the purchasing assistant
                to be entered into the system under the purchasing agent’s name who will handle
                the order.
            (4) The purchasing agent shall transfer the requisition using the method applicable to
                the type of requirement requested and the dollar value of the overall order.


         A. $0.00 – $2,500.00                FEDERALLY FUNDED:

                   Commodities:              No competition required. You may use:
                                                1. Check request
                                                2. P-Card (not allowed under HIPAA)
                                                3. Requisition

                   Services:                 No competition required. You may use:
                                                1. Requisition

         B. $0.00 - $5,000.00                STATE AND OTHER FUNDS:

                   Commodities:              No competition required. You may use:
                                                1. Check request
                                                2. P-Card (up to $2500.) (not allowed under HIPAA)
                                                3. Requisition

                   Services:                 No competition required. You may use:
                                                1. Requisition

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         C. $5,000.00 – $10,000.00                    ALL FUNDS:

                   Commodities / Services: Competition is required.
                   You must submit a valid requisition with a detailed description so that a UNC-CH
                   Request for Quote (RFQ) can be prepared. The RFQ can be mailed or faxed out
                   to the vendors, and returned in the same manner.

         D. $10,000.00          AND UP                ALL FUNDS:

                   Commodities / Services: Competition is required.
                   You must submit a valid requisition with a detailed description so that a UNC
                   Invitation for Bid (IFB) can be prepared. The IFB can be mailed or faxed out to the
                   vendors, but must be returned via the mail or courier service in a sealed envelope.
                   If the IFB is not a sole-source procurement or is over $25,000.00, then the IFB
                   must be placed on the States’ Internet Purchasing System for a period of no less
                   than ten (10) days.

         E. ANY DOLLAR AMOUNT                         PRIVATE FUNDS:

                   Commodities / Services: If you are using your Foundation account and do not go
                   through the Universities Purchasing System, there are no competition
                   requirements. But if you do use the Universities Purchasing System then the
                   requirements outlined above apply.
                   Note: Request for Proposal (RFP): An RFP can be used at any dollar value
                   where a detailed specification or the need for clarity is required.


         In an effort to reduce costs for frequently purchased items, the State Division of Purchase
         and Contract competitively awards contracts to cover designated state agencies for a
         period of one or more years. The University is obligated to purchase specified items from
         the appropriate State Term Contract Vendors. In situations where an item on State Term
         Contract has unnecessary features or does not have the particular features needed, a
         justification to purchase outside the contract must be provided for consideration by the
         University’s Purchasing Office and/or the State’s Division of Purchase and Contract. To
         look at the term contracts available, go to:


         One of the basic tenets of public purchasing is to obtain competition by soliciting multiple
         quotes/bids whenever possible. Purchase requisitions over $5,000 which designate only
         one source or brand as being capable of fulfilling the requiring activity's needs, must be
         accompanied by conclusive documentation (justification memorandum) which explains
         why the specified product and/or source is singularly able to meet those needs and no
         other product or source can do so. Acceptable justifications include situations where
         standardization and/or compatibility are the overriding consideration or when a desired
         product or service is for educational, training, experimental, developmental or research
         work. When accompanied by an appropriate justification, competition may also be waived
         for products needed for over-the-counter resale or when the requirement is for an
         authorized cooperative project with other governmental units or charitable non-profit
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         organizations. For additional guidance in preparing a justification memorandum, see
         MSD Policy 7 and Appendix 2 in the Business Manual.


         The University's Purchasing Office has the exclusive responsibility for executing contracts
         involving the expenditure of public funds except for purchases authorized under the Small
         Order Procedure (MSD Policy 9), rental or real property purchases (handled through the
         University's Property Office), and major construction projects (handled through the
         Facilities Planning Office). Budgetary authority to make purchases from allotted
         departmental budgets is furnished to the Purchasing Office either by signature on a
         Purchase Requisition (Form P 101) or by "on line" approval in the case of electronically
         transmitted requisitions. Purchases charged against University funds that are not made
         in accordance with the policies stated in the Business Manual are the personal
         responsibility of the individual placing the order.


         All written contracts/agreements must be included with the requisition so that
         Purchasing/Legal can review the content and legality of the agreement prior to it being
         sent to the vendor. When the written agreement is included with the requisition, the
         department must sign it before it is sent to the Purchasing Division.


         The Request for Payment of Independent Contractor is a Disbursement Services/Office
         of Sponsored Research form that provides departments with a method to pay for
         individual services. For more information see


         Consultant services shall mean work or task(s) performed by State employees or
         independent contractors possessing specialized knowledge, experience, expertise and
         professional qualifications to investigate assigned problems or projects and to provide
         counsel, review, analysis or advice in formulating or implementing improvements in
         programs or services. This includes but is not limited to the organization, planning,
         directing, control, evaluation and operation of a program, agency or department.

         For more information see

11. FUNDS:

         Type of Fund                          Account Code
         STATE                                 2 - *****
         STATE                                 3 - 8****
         TRUST                                 3 - _****
         TRUST                                 6 - *****
         FED/GRANTS                            4 - *****
         FED/GRANTS                            5 - *****
         CAPITAL IMPROVEMENT                   8 - *****
         AGENCY(FOUNDATION)                    9 - *****

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