SECTION .0300 – GOVERNING AUTHORITY MANAGEMENT

10A NCAC 13C .0301      GOVERNING AUTHORITY

(a)  The facility's governing authority shall adopt bylaws or other operating policies and procedures to assure that:

(1)           a named individual is identified who is responsible for the overall operation and maintenance of the facility. The governing authority shall have methods in place for the oversight of the individual's performance;

(2)           annual meetings of the governing authority shall be conducted if the governing authority consists of two or more individuals. Minutes shall be maintained of such meetings;

(3)           a policy and procedure manual is created that is designed to ensure professional and safe care for the patients. The manual shall be reviewed annually and revised in accordance with facility policy. The manual shall include provisions for administration and use of the facility, compliance, personnel quality assurance, procurement of outside services and consultations, patient care policies, and services offered; and

(4)           annual reviews and evaluations of the facility's policies, management, and operation are conducted.

(b)  When services such as dietary, laundry, or therapy services are purchased from others, the governing authority shall be responsible for assuring the supplier meets the same local and State standards the facility would have to meet if it were providing those services using its own staff.

(c)  The governing authority shall provide for the selection and appointment of the professional staff and the granting of clinical privileges and shall be responsible for the professional conduct of these persons.

(d)  The governing authority shall establish 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 20 most common outpatient imaging procedures and 20 most common outpatient surgical procedures based on the primary Current Procedure Terminology Code (CPT). 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, 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 ambulatory surgical 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 ambulatory surgical facility to a minor, in accordance with G.S. 131E-91(d)(6).

History Note:        Authority G.S. 131E-91; 131E-147.1; 131E-149; 131E-214.13(f); 131E-214.14;

Eff. October 14, 1978;

Amended Eff. November 1, 1989; November 1, 1985; December 24, 1979;

Temporary Amendment Eff. May 1, 2014;

Amended Eff. November 1, 2014;

Readopted Eff. January 1, 2021.