Handbook of Operating Procedures

Exclusion Check Guidelines

The following guidelines will be implemented by the appropriate University of Texas Health Science Center at Houston ("university") departments and personnel to comply with HOOP Policy 114 Exclusion Checks.

PROCEDURES


I. Post-Offer Applicants, Applicants for Residency Programs Who are Classified as Employees Upon Commencement of their Residency Program, and Employees

Human Resources ("HR") is responsible for conducting exclusion checks for post-offer applicants and employees in accordance with HOOP Policy 114 Exclusion Checks. The School of Dentistry's Office of Student Affairs ("SDOSA") is responsible for conducting exclusion checks for applicants considered for enrollment in a School of Dentistry residency program who will be considered employees upon the commencement of their residency program in accordance with HOOP Policy 114 Exclusion Checks.

A. Post-Offer Applicants

  1. If a post-offer applicant is found to be a potential match, HR will immediately inform the Office of Institutional Compliance ("OIC") in writing. OIC will confirm the post-offer applicant under consideration has been excluded, debarred or designated and will determine the scope of the exclusion, debarment or designation.
  2. If the match is confirmed, OIC will consult with the Office of International Affairs to determine if the post-offer applicant is subject to any visa requirements. 

    a. Classified and Administrative & Professional:

    If the match is confirmed, OIC will inform HR immediately in writing. HR will inform the manager of the hiring department, and HR shall rescind the offer of employment to the post-offer applicant.

    b. Faculty:

    If the match is confirmed, OIC will inform HR, the dean of the appropriate school, and the chair of the hiring department in writing. The dean of the appropriate school and the chair of the hiring department shall rescind the offer of employment to the post-offer applicant.

  3. For a post-offer applicant to be reconsidered for hiring, he/she must provide sufficient documentation to OIC of his/her removal from the applicable federal or state list. Upon OIC’s confirmation of the documentation, the post-offer applicant may be reconsidered for hire. OIC will inform HR of the results of the confirmation check.

B. Applicants for School of Dentistry Residency Programs Who Are Classified as Employees Upon Commencement of their Residency Programs

This section of the guidelines only applies to applicants for residency programs at the School of Dentistry.

  1. If a School of Dentistry resident candidate is found to be a potential match, SDOSA will immediately inform OIC in writing. OIC will confirm that the incoming resident under consideration by the School of Dentistry has been excluded, debarred or designated and will determine the scope of the exclusion, debarment or designation.
  2. If the match is confirmed, OIC will consult with the Office of International Affairs to determine if the resident candidate is subject to any visa requirements.
  3. If OIC verifies the listing of the incoming resident, OIC will inform the SDOSA immediately in writing. The SDOSA will not offer placement to the applicant.
  4. For a School of Dentistry resident program applicant to be reconsidered for placement, he/she must provide sufficient documentation to OIC of his/her removal from the applicable federal or state list. Upon OIC’s confirmation of the documentation, the incoming resident may be reconsidered for placement. OIC will inform SDOSA of the results of the confirmation check.
  5. Current School of Dentistry residents are subject to the provisions indicated below for employees.

C. Employees

  1. If an employee is found to be a potential match, HR will immediately notify OIC in writing. OIC will confirm the employee has been excluded, debarred or designated and will determine the scope of the exclusion, debarment or designation.
  2. If the match is confirmed, OIC will consult with the Office of International Affairs to determine if the employee is subject to any visa requirements.
  3. OIC will immediately advise the appropriate dean, administrator or vice president of the necessary actions to be taken. The Chief Operating and Financial Officer, the appropriate executive vice president, the Vice President for Public Affairs, and the Vice President and Chief Human Resources Officer will be copied on this communication.
  4. An employee confirmed on an applicable exclusion list will be given a grace period of three working days to provide sufficient documentation to demonstrate mistaken identity. During this grace period, the employee will be placed on paid administrative leave. The appropriate dean, administrator or vice president shall immediately advise the affected employee of his/her status in writing. The Chief Operating Officer, the appropriate executive vice president, the Vice President for Public Affairs, and the Vice President and Chief Human Resources Officer will be copied on this communication. If the employee is a clinical provider, the appropriate dean or administrator will effectuate the removal of the affected employee from all clinical schedules during the grace period. The appropriate dean or administrator will also take appropriate action to ensure all claims for reimbursement to federal or state health care programs for clinical services performed by the affected employee are held during the grace period. If the affected employee is a School of Dentistry resident, the affected employee will be placed on paid administrative leave and removed from clinical rotation and participation in ongoing research during the grace period.
  5. Upon expiration of the grace period, if the affected employee cannot provide sufficient documentation to demonstrate mistaken identity, appropriate steps will be taken as listed below.
  6. If OIC determines the scope of the debarment, exclusion or designation is such that it can be remedied within a reasonable amount of time, the affected employee or resident will be placed on suspension without pay for up to 30 calendar days. Reimbursement claims submitted for clinical services performed by the employee or resident will not be paid while the employee is excluded, debarred or designated. If the affected employee is a resident, the affected employee will also be placed on academic suspension for up to 30 calendar days. The suspension period and/or academic suspension period shall begin on the date notification is sent to the employee. The appropriate dean, administrator or vice president shall immediately advise the affected employee of his/her status in writing. The Chief Operating Officer, the appropriate executive vice president, the Vice President for Public Affairs, and the Vice President and Chief Human Resources Officer will be copied on this communication.
  7. The affected employee may be returned to regular status upon providing sufficient documentation to OIC that he/she has been removed from the applicable federal or state list(s) and upon confirmation by OIC of the employee’s documentation. OIC will inform HR and the appropriate dean, administrator or vice president of the results of the confirmation check. The Chief Operating Officer, the appropriate executive vice president, and the Vice President for Public Affairs will be copied on this communication.
  8. If, at the end of the initial 30 calendar day leave period, the employee has not been removed from the applicable list(s), but the employee is able to provide sufficient documentation of his/her efforts to be removed, HR and OIC may approve an additional 30 calendar day suspension without pay period. If the affected employee is a School of Dentistry resident, the SDOSA will be consulted to determine whether an extension of the suspension is warranted. If, at the end of this second suspension period, the employee or School of Dentistry Resident has not been removed from the applicable list(s), the employee or School of Dentistry Resident will be terminated by the appropriate dean, administrator or vice president.
  9. If OIC determines that the scope of the debarment, exclusion or designation is such that it cannot be remedied within a reasonable amount of time, the affected employee or resident will be terminated. The appropriate dean, administrator or vice president shall immediately advise the affected employee of his/her status in writing.
  10. Clinical Providers – The appropriate dean, administrator or vice president shall be responsible for determining if the affected employee is a clinical provider.

    a. Medical School

    Any affected employee of the Medical School will be removed from all clinical schedules and services. The Dean shall coordinate with the President & Chief Executive Officer of UT Physicians ("UTP") to suspend immediately the billing privileges of the affected employee and to remove the affected employee from all clinical schedules. The affected employee’s billing privileges will be suspended as of the date OIC confirms the affected employee is excluded, debarred or designated.

    The affected employee’s billing privileges will not be reinstated and the affected employee will not be returned to clinical schedules until he/she provides sufficient documentation to OIC that he/she has been reinstated to all federal/state programs from which he/she was previously excluded and OIC has confirmed the documentation. OIC will inform the Dean of the results of the confirmation check. Claims for reimbursement for clinical services performed by the affected employee may not be submitted until the affected employee has been reinstated to all federal/state programs from which he/she was previously excluded. The affected employee will not be returned to clinical schedules until the affected employee has been reinstated to all federal/state programs from which he/she was previously excluded.

    b. School of Nursing

    Any affected employee of the School of Nursing will be removed from all clinical schedules and services. The Dean shall coordinate with the Director of The University of Texas Health Services ("UTHS") to suspend immediately the billing privileges of the affected employee and to remove the affected employee from all clinical schedules. The affected employee’s billing privileges will be suspended as of the date OIC confirms the affected employee is excluded, debarred or designated. UTHS will evaluate if further action must be taken. The Director of UTHS shall be responsible for ensuring that no claims for reimbursement are submitted for clinical services performed by that employee until further notification is received from OIC.

    The affected employee’s billing privileges will not be reinstated and the affected employee will not be returned to clinical schedules until the employee provides sufficient documentation to OIC that he/she has been reinstated to all federal/state programs from which he/she was previously excluded and OIC has confirmed the documentation. OIC will inform the Dean and the Director of UTHS of the results of the confirmation check. UTHS shall not submit any claims for reimbursement for clinical services performed by the affected employee until OIC has notified the Dean and the Director of UTHS that the affected employee has been reinstated to all federal/state programs from which he/she was previously excluded.

    c. School of Dentistry

    Any affected employee of the School of Dentistry will be removed from all clinical schedules and services. The Associate Dean for Patient Care shall inform the Dean and coordinate with the Director of Patient Services to suspend immediately the billing privileges of the affected employee and to remove the affected employee from all clinical schedules. The affected employee's billing privileges will be suspended as of the date OIC confirms the affected employee is excluded, debarred or designated. The Director of Patient Services will evaluate if further action must be taken. The affected employee's billing privileges will not be reinstated, nor will the affected employee be returned to clinical schedules, until the employee provides sufficient documentation to OIC that he/she has been reinstated to all federal/state programs from which he/she was previously excluded and OIC has confirmed the documentation. OIC will inform the Associate Dean for Patient Care of the results of the confirmation check. The Director of Patient Services shall not submit any claims for reimbursement for clinical services performed by the affected employee until the Associate Dean for Patient Care has notified the Director of Patient Services that the affected employee has been reinstated to all federal/state programs from which he/she was previously excluded.

    d. School of Public Health

    Any affected employee of the School of Public Health will be removed from all clinical schedules and services. The Dean shall coordinate with the Director of The University of Texas Health Services ("UTHS") to suspend immediately the billing privileges of the affected employee and to remove the affected clinical employee from all clinical schedules. The affected employee's billing privileges will be suspended as of the date OIC confirms the affected employee is excluded, debarred or designated. UTHS will evaluate if further action must be taken. The Director of UTHS shall be responsible for ensuring that no claims for reimbursement are submitted for clinical services performed by that employee until further notification is received from OIC. The affected employee's billing privileges will not be reinstated and the affected employee will not be returned to clinical schedules until the employee provides sufficient documentation to OIC that he/she has been reinstated to all federal/state programs from which he/she was previously excluded and OIC has confirmed the documentation. OIC will inform the Dean and the Director of UTHS of the results of the confirmation check. UTHS shall not submit any claims for reimbursement for clinical services performed by the affected employee until OIC has notified the Dean and the Director of UTHS that the affected employee has been reinstated to all federal/state programs from which he/she was previously excluded.

    e. The University of Texas Harris County Psychiatric Center (“UTHCPC")

    The UTHCPC Director of Financial Operations shall coordinate with the affected employee's clinical supervisor, line supervisor, or administrator to suspend immediately the billing privileges of the affected employee and to remove the affected employee from all clinical schedules. The affected employee's billing privileges will be suspended as of the date OIC confirms the affected employee is excluded, debarred or designated. The UTHCPC Director of Financial Operations will evaluate if further action must be taken, including adjustments to the UTHCPC cost report. The UTHCPC Director of Financial Operations shall ensure that no claims for reimbursement are submitted for clinical services performed by that employee until further notice is received from OIC.

    The affected employee's billing privileges will not be reinstated and the affected employee will not be returned to clinical schedules until the employee provides sufficient documentation to OIC that he/she has been reinstated to all federal/state programs from which he/she was previously excluded and OIC has confirmed the documentation. OIC will inform the UTHCPC Director of Financial Operations of the results of the confirmation check. Neither UTHCPC, nor its third-party billing contractor, shall submit any claims for reimbursement to any state or federal health care program for clinical services performed by the affected employee until OIC has notified the UTHCPC Director of Financial Operations that the affected employee has been reinstated to all federal/state programs from which he/she was previously excluded.

  11. Employees Who Receive Funds for Research Purposes – Should an employee be confirmed by OIC as being excluded, debarred or designated, the appropriate dean, administrator or vice president, in coordination with the Office of Sponsored Projects, shall:
  • Determine if the affected employee receives funds for research purposes;
  • Determine if the grant providing agency must be notified of the affected employee’s status;
  • Determine if any grant funds must be refunded or rebudgeted; and
  • Ensure that grant funds are properly expended, refunded or rebudgeted as necessary.

II. Residents Employed by the UT System Medical Foundation

These provisions apply to all Medical School residents, School of Dentistry residents enrolled in the Oral & Maxillofacial Surgery residency program, and School of Public Health Occupational Medicine residents. The Office of Graduate Medical Education ("OGME") is responsible for conducting exclusion checks for applicants considered for enrollment in a university residency program who will be considered UT System Medical Foundation employees upon the commencement of their residency program and for residents currently enrolled in university residency programs who are considered UT System Medical Foundation employees in accordance with HOOP Policy 114 Exclusion Checks.

A. Applicants for Residency Programs

  1. If a residency applicant is found to be a potential match, OGME will immediately inform OIC in writing. OIC will confirm whether the residency candidate under consideration has been excluded, debarred or designated and will determine the scope of the exclusion, debarment or designation.
  2. If OIC confirms the match, OIC will consult with the Office of International Affairs to determine if the resident is subject to any visa requirements.
  3. If OIC verifies the listing of the residency candidate, OIC will inform the appropriate associate dean and OGME immediately in writing. The appropriate associate dean and the residency program director will rescind the offer of placement to the incoming resident.
  4. For a residency candidate to be reconsidered for placement, he/she must provide sufficient documentation to OIC of his/her removal from the applicable federal or state list. Upon OIC's confirmation of the documentation, the incoming resident candidate may be reconsidered for placement. OIC will inform the appropriate associate dean and the OGME of the results of the confirmation check.

B. Residents Currently Enrolled in University Residency Programs

  1. If a resident is found to be a potential match, OGME will immediately notify OIC in writing. OIC will confirm whether the resident has been excluded, debarred or designated and will determine the scope of the exclusion, debarment or designation.
  2. If the match is confirmed, OIC will consult with the Office of International Affairs to determine if the resident is subject to any visa requirements.
  3. OIC will immediately advise the appropriate associate dean and OGME of the necessary actions to be taken. The Chief Operating Officer, the Executive Vice Dean for Clinical Affairs, the appropriate dean, and the Vice President for Public Affairs will be copied on this communication.
  4. A resident confirmed on an applicable exclusion list will be given a grace period of three working days to provide sufficient documentation to demonstrate mistaken identity. During this grace period, the resident will be suspended with pay. The appropriate associate dean and the residency program director shall immediately advise the affected resident of his/her status in writing. The Chief Operating Officer, the Executive Vice Dean for Clinical Affairs, the appropriate dean and the Vice President of Public Affairs will be copied on this communication. During this grace period, the affected resident will be removed from clinical rotation and participation in ongoing research.
  5. Upon expiration of the grace period, if the affected resident cannot provide sufficient documentation to demonstrate mistaken identity, appropriate steps will be taken as listed below.
  6. If OIC determines the scope of the debarment, exclusion or designation is such that it can be remedied within a reasonable amount of time, the affected resident will be placed on suspension without pay for up to 30 calendar days. The suspension period shall begin on the date notification is sent to the resident. The appropriate associate dean and the residency program director shall immediately advise the affected resident of his/her status in writing. The Chief Operating Officer, Executive Vice Dean for Clinical Affairs, the appropriate dean, the OGME and the Vice President of Public Affairs will be copied on this communication.
  7. The affected resident may be returned to regular status upon providing sufficient documentation to OIC that he/she has been removed from the applicable federal or state list and upon confirmation by OIC of the employee’s documentation. OIC will inform the appropriate associate dean and the OGME of the results of the confirmation check.
  8. If, at the end of the initial 30 calendar day suspension period, the affected resident has not been removed from the applicable list, but the affected resident is able to provide sufficient documentation of his/her efforts to be removed, the appropriate associate dean, in consultation with OIC, may approve an additional 30 calendar day period of suspension without pay.  If, at the end of this second suspension period, the affected resident has not been removed from the applicable list(s), the affected resident's training agreement will be terminated by the appropriate associate dean and the residency program director.
  9. If OIC determines that scope of the debarment, exclusion or designation is such that it cannot be remedied within a reasonable amount of time, the affected resident's training agreement will be terminated by the appropriate associate dean and the residency program director.

III. Vendors

Procurement Services (“Procurement”) is responsible for conducting the appropriate exclusion checks for vendors maintained by Procurement in accordance with HOOP Policy 114 Exclusion Checks.

A. New Vendors

If a new vendor is found to be a potential match, Procurement will immediately notify the requesting department in writing. Procurement will not issue a new vendor code for the vendor and the university will not do business with the vendor if the vendor is confirmed as being excluded, debarred or designated.

For a vendor to be considered re-eligible to do business with the university, the vendor must provide sufficient documentation to Procurement of its removal from the applicable federal or state list. Upon confirmation of the documentation, the vendor may be considered eligible to do business with the university.

B. Existing Vendors

If a vendor is found to be a potential match, Procurement will immediately notify the vendor in writing.

Procurement will immediately inactivate the vendor code for the vendor.

No payments or reimbursements will be processed to the vendor while the vendor code is inactivated except for payments for services provided to the university prior to confirmation of the vendor’s listing on an applicable exclusion list. The vendor code for the affected vendor may be reactivated upon provision of sufficient documentation to Procurement by the vendor that it has been removed from the applicable federal or state list.

IV. Records

Each responsible party must retain documentation demonstrating the appropriate verifications occurred in accordance with HOOP Policy 114 Exclusion Checks and these guidelines. The documentation includes all documents pertaining to potential and confirmed matches and shall be retained as required by the Records Retention Schedules.