(a)  The governing body shall adopt written 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 policies, rules, and regulations shall:

(1)           state the purpose of the facility;

(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 Board approval of the bylaws of any auxiliary organizations established by the hospital;

(6)           require the governing body to review and approve the bylaws of the medical staff organization;

(7)           establish a procedure 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 board members to specific board functions and procedures;

(B)          the development of procedures for periodic reexamination of the relationship of the board 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, on a regular basis to all members of the governing body.

(b)  The governing body shall assure 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 hospital;

(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 hospital 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 hospital to a minor, in accordance with G.S. 131E-91(d)(6).

(c)  The written policies, rules, and regulations shall be reviewed every three years, revised as necessary, and dated to indicate when last reviewed or revised.

(d)  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. 

(e)  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 Rule applies only to facilities required to file a Schedule H, federal form 990.


History Note:        Authority G.S. 131E-79; 131E-91; 131E-214.13(f); 131E-214.14; S.L. 2013-382, s. 10.1; S.L. 2013-382, s. 13.1;

Eff. January 1, 1996;

Temporary Amendment Eff. May 1, 2014;

Amended Eff. November 1, 2014.