Based on nationally-recognized infection prevention and control guidelines considered and selected by the governing body. 


In solo physician or dental organizations, an outside physician or dentist is involved to provide peer-based review. 


Upon reciept of a completed reappointment application, the organization will conduct primary or secondary source verfication items listed in Standards 2.II.B.3.c-f.  At the time of reappointment consideration by the governing body, the entire reappointment application and the peer review activities and results, completed in accordance with Chapter 2.III, will be considered.

UC Policy
Credentialing of Professional Staff


Completion of a formal reappointment application which includes, at a minumum:

1. Updated personal information

2. Completed attestation questions found in 2.II.B.3.g.

3. A formal statement releasing the organization from any liability in connection with credentiallng decisions

4. A formal statement confirming that the information submitted is accurate and complete

5. Applicant signature and date

UC Policy
Credentialing of Professional Staff


Effective Date: 
Tue, 11/22/2016
Wed, 03/21/2018
Wed, 03/21/2018

Ortho slips billing documentation for orthopedic or other medical supplies that are chargeable and dispensed to student patients.  They are checked to ensure billing is complete.

  • Acquire ortho slips and sort by date and patient
  • Open visit note for that patient and date
  • Review visit note for appropriate documentation and billing.  Search under supplies (already billed) and in the body of the note, under Nursing, in Activity and in any Addendum
  • If documented and billed, securely shred ortho slip
  • If documented and NOT billed: Add addendum stating "Dispensed certain product (with code number on line 2)
  • IM biller (if not addressed by biller) to alert to add product to patient ticket
  • Securely shred completed ortho slips 
  • If NOT documented, review visit and if probable, add addendum to complete the documentation with product and code number, then IM biller to alert to add product to patient ticket
  • If not probable, then IM the clinician to ask if dispensed to patient; follow up as necessary
  • Securely shred completed ortho slips 


Effective Date: 
Thu, 10/06/2016
Mon, 03/26/2018

The University of California Santa Cruz Student Health Services complies with the OIG Medical Billing and Coding Compliance Requirements.  Staff are trained and updated regularly (note: ICD-10).  These include the seven components for a voluntary compliance program:

• Conducting internal monitoring and auditing;

• Implementing compliance and practice standards;

• Designating a compliance officer or contact;

• Conducting appropriate training and education;

• Responding appropriately to detected offenses and developing corrective action;

• Developing open lines of communication; and

• Enforcing disciplinary standards through well-publicized guidelines

The compliance guidelines are available via the attached link.


Form Type: 
Form Number: 


Effective Date: 
Mon, 06/20/2016

All inquiries for the Insurance and Billing Departments at UCSC Student Health Services will be funneled through the UCSC Request Tracker (RT) for Insurance and Billing.  The Request Tracker is not a secure system and any content that contains PHI must be removed and responded to securely and if necessary documented in the EMR under Admin Notes.

This customer service documentation and resolution system provides auto-replies and standardized answers to common questions.  It is also a continuous documentation system that allows for follow up or allows return to a topic or request since that information and data are retrievable, and all communications that are received are addressed in an orderly and timely fashion.  The goal is to have as much resolved as possible at the first contact.

Any communications from outside providers or which contain referral requests or PHI will be prioritized. 

Staff will complete the shared daily tasks to make sure that all duties are complete.

Utilization and productivity data will be collected monthly via built in reports.


Insurance and Billing advocates will manage all inquiries through the UCSC Request Tracker.  The advocates will follow specific procedures listed in the RT Binder and other communication methods.

Insurance and Billing advocates will monitor the RT queue and each will "take" or transfer ownership of the oldest ticket and respond to the ticket as appropriate with articles that provide standardized text on common questions or specific answers as necessary.  Tickets that are tagged as needing referral assistance are prioritized due to possible timely need of information and/or content that contains PHI, which must be removed, and addressed  securely.

Once a ticket is "taken" then it is "open".  Once the inquiry is addressed, then the ticket can be changed to "resolved".  If necessary, the ticket can be designated as "stalled" which means it is pending due to the need for additional information prior to resolution.

An advocate can tag a ticket with another staff member's name if that staff member has already been working with the case.


All emails sent to automatically go into the RT.


Phone calls and walk-in inquiries that can be answered with a quick response do not need to be entered into the Request Tracker. All other requests will be entered into the Request Tracker and responded to according to established procedures. 

Referrals or other inquiries containing PHI will be managed securely through the EMR.






Effective Date: 
Mon, 04/18/2016
Tue, 03/13/2018
Fri, 01/31/2020

At times SHS Management may be alerted to a student of concern via various sources such as campus police, Academic Advising, and Student Conduct.  SHS staff may also become aware of a student of concern, in which case they should alert their manager to this situation ASAP.  If the SHS Management determines that this is information all SHS staff should be alerted to, the following process is to be following: 

A “Third Party" note is created by SHS Management in the student’s medical record with details of the concern. The entry “Student of Concern – alert your supervisor” with managers initials and date will be made in 3 places in the EMR:

1. Scheduler Comments (OpenRegistration > Registration > Scheduler Comments)

2. Clinical Comments (OpenChart > Clinical Comments > All Divisions)

3. Admin Alert (OpenRegistration > Admin Alert)

A Broadcast Instant Message will be sent via the EMR to the “Alert Group” comprised of management and IT staff. Laboratory management or IT will add an alert in the “Harvest” lab interface program. Pharmacy management or IT will add the alert in the “Propharm” prescription interface program.


  1. Open the patient
  2. Click “…” under alerts
  3. Add in text from PNC IM
  4. Save patient

If a student has never had a lab test ordered they will not show up in Harvest.  In this case, 
enter a 99999 with testing or student of concern in comment box, and then cancel the lab. 
That will trigger enough data to go to Harvest for Lab Manager or IT to do the notification on.


  1. Open the patient
  2. Click on the note icon (paper with a thumbtack)
  3. Select New
  4. Title with the IM title from PNC
  5. Add in body of note
  6. Set Priority = High
  7. Save

This system of alert notification will help assure all SHS staff have immediate access to any student of concern alerts relevant to staff and/or student safety.  In the event a student with this alert system in place presents or contacts the SHS, all staff should immediately alert their supervisor for further instructions.


Effective Date: 
Wed, 04/06/2016
Mon, 03/26/2018
Mon, 03/26/2018

The optometrists at UCSC will endeavor to  assist primary care providers with consults for eye problems.

The optometrists may be busy with patients so will come to primary care when convenient - between patients or when waiting for dilation.


A clinician or nurse may consult with optometrist by coming by in person or calling optometry phone to determine if the patient needs to be seen as add-on. Often clinicians come to Optometry and together decide whether to add the patient in to the schedule or for the optometrist to go to the exam room, or to consult less severe.

As necessary, the optometrist will help examine the patient and communicate any findings to the clinician for the clinician to document in the medical record.

Occasionally, the optometrist may be too busy to consult, or the situation may need more acute treatment i.e. ER.  The optometrist will let the charge nurse know of that fact.

There will be no extra charges for the consultation.


Key Points: 
  • The optometrist may be available to consult with SHS clinicians on ophthalmologic illnesses or injuries when time permits
  • The clinician will complete the care and notes
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