The Fox Group has extensive experience helping hospitals and health systems navigate Medicare enrollment, provider-based compliance, and the operational requirements affecting off-campus hospital outpatient departments. That experience makes one point clear. Even a seemingly narrow requirement, such as obtaining a separate National Provider Identifier, can create significant compliance, billing, systems, and reimbursement consequences if planning begins too late.
Executive Summary – Key Takeaways
- Off-campus HOPDs must obtain separate NPIs and complete attestations by year-end 2027.
- Hospitals should begin coordinating NPI and attestation readiness now.
- Revenue cycle, information systems, and compliance teams should plan together.
- Failure to meet the requirements may result in lower Medicare payment rates.
Table of contents
- New NPI and Attestation Requirements for Off-Campus HOPDs
- How Do You Apply for an NPI number?
- Who should be involved in the process of applying for an additional separate NPI?
- How will Medicare payments to Provider-Based Off-Campus Outpatient Departments Change in the Future?
- What Should Hospitals Do Now?
- Off-Campus HOPD NPI Requirements: Frequently Asked Questions
New NPI and Attestation Requirements for Off-Campus HOPDs
Section 6225 of the Consolidated Appropriations Act of 2026 establishes two requirements for off-campus provider-based departments, effective at the end of 2027:
- Off-campus provider-based departments must complete an attestation process demonstrating compliance with the requirements for payment as an off-campus outpatient department.
- Hospitals and health systems must request and receive a separate National Provider Identifier (NPI).
For more detail on the compliance review and submission process, see our guide to provider-based attestation readiness for off-campus HOPDs.
For several years, various components of the Federal Government have cast a critical eye on Medicare payment differences. Medicare has paid one rate for services furnished in a freestanding physician office or clinic. It has paid another rate when those services were furnished in hospital outpatient departments.
Members of Congress and officials at the Centers for Medicare & Medicaid Services (CMS) have questioned this difference. They have asked why Medicare pays different rates for ostensibly the same patient care at different locations.
How Do You Apply for an NPI number?
Applying for a unique national provider identifier is relatively straightforward. CMS operates the National Plan and Provider Enumeration System (NPPES) website. Users must be individual providers or users working on behalf of a provider or organization. Users can access a six-page Application/Update Form to make a new application or update existing information.
Who should be involved in the process of applying for an additional separate NPI?
In a typical hospital facility or health system, several departments or functions would participate in completing an accurate application for a new NPI number. Because of the severe consequences of failing the off-campus HOPD NPI requirements, a cross-department team approach is highly advisable.
- Revenue Cycle Teams: Managers or directors oversee billing and collections activities. The team may also include staff members who handle payer enrollment.
- Information Systems Directors: They will ensure billing and accounts receivable systems are reconfigured with the new NPI number. They will also ensure workflows identify claims from the outpatient remote location. The workflows will associate those claims with the new outpatient services NPI number.
- Compliance Professionals: They will provide guidance on completing the NPI and attestation requirements. This includes financial and clinical integration, plus management and governance oversight.
How will Medicare payments to Provider-Based Off-Campus Outpatient Departments Change in the Future?
Non-excepted off-campus outpatient departments cannot bill under the Outpatient Prospective Payment System (OPPS). They will instead be paid using the Medicare Physician Fee Schedule (PFS). This is likely to reduce reimbursement for provider-based services furnished to Medicare beneficiaries.
The new requirements for off-campus outpatient departments include a separate NPI and attestation requirements. They are another step in CMS’s campaign toward site-neutral payments for physician services.
The goal is to align Medicare payments for physician services between settings. Those settings include private, freestanding clinics or offices and hospital outpatient facilities, on or off campus.
The Bipartisan Budget Act of 2015 set November 2, 2015, as the date for dividing HOPDs into two cohorts. Off-campus HOPDs billing under OPPS are exempt from changes affecting their provider-based status.
Beginning January 1, 2028, off-campus HOPDs that fail to submit a current provider-based attestation and bill under a location-specific NPI will be ineligible for Medicare payment for that department’s services. That will be regardless of whether the department is excepted (OPPS) or non-excepted (PFS-equivalent rate). Payment rate is governed separately by BBA 2015 § 603 excepted status. One caveat: a rule implementing Section 6025 is in the works, and still in proposed form (comments close August 31, 2026). So the operational details could shift in the final rule.
What Should Hospitals Do Now?
Now is the time to get organized for the NPI requirements and attestation requirements. It may seem like a long time until the new requirements are in effect. But the deadline will be here sooner than we think.
Hospitals can use our off-campus HOPD compliance checklist to review current operations, supporting documentation, and potential gaps before attestation.
As compliance consultants to hospitals, we know that far-off deadlines do not weigh as heavily. Next month’s accounts receivable report or financial statements often receive more immediate attention. So get organized now, and get busy!
Off-Campus HOPD NPI Requirements: Frequently Asked Questions
Each off-campus HOPD covered by Section 6225 must use an NPI that is separate from the main hospital’s NPI.
CMS guidance treats individual off-campus outpatient departments as hospital subparts for NPI purposes. The CY 2027 proposed rule would require the main provider to obtain an NPI for each affected provider-based department. The provider would then submit its attestation and update its Medicare enrollment information.
An off-campus HOPD should obtain an Entity Type 2 organizational NPI as a subpart of the hospital.
The application should identify the parent organization’s legal business name and taxpayer identification number when the subpart does not have its own. An authorized official with legal authority must certify the application, although another employee or representative may prepare it on the organization’s behalf.
No. NPPES enumeration alone does not satisfy Medicare enrollment, billing, or provider-based attestation requirements.
Obtaining an NPI does not replace Medicare enrollment or certification, and changes made in NPPES do not automatically update PECOS. CMS has proposed requiring hospitals to obtain the department’s NPI, update PECOS, bill services under that NPI, and submit the required provider-based attestation.
Hospitals should verify affected locations, obtain each NPI, update PECOS, complete the attestation process, and then test claims.
CMS has proposed placing NPI enumeration and the PECOS update before attestation submission. Operationally, hospitals should also test location-master mapping, charge capture, claim generation, clearinghouse routing, remittance posting, denials, and reporting before January 1, 2028. This work requires coordinated involvement from enrollment, compliance, revenue cycle, information systems, and operations.
Medicare payment may not be made for affected services billed under the main hospital’s NPI after January 1, 2028.
Section 6225 conditions payment on the department obtaining and billing under its separate NPI and the main provider satisfying the applicable attestation requirements. This is more significant than a routine demographic error or an automatic reduction to a lower rate; it creates a direct payment-eligibility risk.
An earlier provider-based determination should not be assumed to automatically satisfy the new attestation requirement.
CMS is considering a streamlined process for departments that received provider-based determinations before January 1, 2026 and remain compliant. That process could involve submitting a letter with evidence of the prior determination, but the approach is not yet final. Hospitals should retain prior approval records and documentation demonstrating continued compliance with 42 C.F.R. § 413.65.