Current through Register Vol. 39, No. 6, September 16, 2024
(a) The governing body shall adopt written
bylaws, policies, rules, and regulations in accordance with all requirements
contained in this Subchapter and in accordance with the community
responsibility of the facility. The written bylaws, policies, rules, and
regulations shall:
(1) state the
objectives;
(2) describe the powers
and duties of the governing body officers and committees and the
responsibilities of the chief executive officer;
(3) state the qualifications for governing
body membership, the procedures for selecting members, and the terms of service
for members, officers and committee chairmen;
(4) describe the authority delegated to the
chief executive officer and to the medical staff. No assignment, referral, or
delegation of authority by the governing body shall relieve the governing body
of its responsibility for the conduct of the facility. The governing body shall
retain the right to rescind any such delegation;
(5) require governing body approval of the
bylaws of any auxiliary organizations established by the facility;
(6) require the governing body to review and
approve the bylaws of the medical staff;
(7) establish procedures for processing and
evaluating the applications for medical staff membership and for the granting
of clinical privileges;
(8)
establish a procedure for implementing, disseminating, and enforcing a
Patient's Bill of Rights as set forth in Rule.3302 of this Subchapter and in
compliance with
G.S.
131E-117; and
(9) require the governing body to institute
procedures to provide for:
(A) orientation of
newly elected governing body members to board functions and
procedures;
(B) the development of
procedures for periodic reexamination of the relationship of the governing body
to the total facility community; and
(C) the recording of minutes of all governing
body and executive committee meetings and the dissemination of those minutes,
or summaries thereof, after the governing body and executive committee meetings
to all members of the governing body.
(b) The governing body shall provide written
policies and procedures to assure billing and collection practices in
accordance with
G.S.
131E-91. These policies and procedures shall
include:
(1) a financial assistance policy as
defined in
G.S.
131E-214.14(b)(3);
(2) how a patient may obtain an estimate of
the charges for the statewide 100 most frequently reported Diagnostic Related
Groups (DRGs), where applicable, 20 most common outpatient imaging procedures,
and 20 most common outpatient surgical procedures. The policy shall require
that the information be provided to the patient in writing, either
electronically or by mail, within three business days;
(3) how a patient or patient's representative
may dispute a bill;
(4) issuance of
a refund within 45 days of the patient receiving notice of the overpayment when
a patient has overpaid the amount due to the facility;
(5) providing written notification to the
patient or patient's representative at least 30 days prior to submitting a
delinquent bill to a collections agency;
(6) providing the patient or patient's
representative with the facility's charity care and financial assistance
policies, if the facility is required to file a Schedule H, federal form
990;
(7) the requirement that a
collections agency, entity, or other assignee obtain written consent from the
facility prior to initiating litigation against the patient or patient's
representative;
(8) a policy for
handling debts arising from the provision of care by the facility involving the
doctrine of necessaries, in accordance with
G.S.
131E-91(d)(5); and
(9) a policy for handling debts arising from
the provision of care by the facility to a minor, in accordance with
G.S.
131E-91(d)(6).
(c) The governing body shall
ensure that the bylaws, rules, and regulations of the medical staff and the
bylaws, rules, policies, and regulations of the facility shall not be in
conflict.
(d) The written policies,
rules, and regulations shall be reviewed every three years, revised as
necessary, and dated to indicate when last reviewed or revised.
(e) To qualify for licensure or license
renewal, each facility must provide to the Division, upon application, an
attestation statement in a form provided by the Division verifying compliance
with the requirements of this Rule.
(f) On an annual basis, on the license
renewal application provided by the Division, the facility shall provide to the
Division the direct website address to the facility's financial assistance
policy. This Paragraph applies only to facilities required to file a Schedule
H, federal form 990.
Authority
G.S.
131E-79;
131E-91;
131E-214.8;
131E-214.13(f);
131E-214.14;
Eff.
January 1, 1996;
Temporary Amendment Eff. May 1, 2014;
Amended Eff. November 1, 2014;
Readopted Eff. July 1,
2020.
