Written by Amanda McGurk · Published November 10, 2026 · Last reviewed November 10, 2026
Yes. Under CMS-1850-FC, Medicare will not pay for services an off-campus hospital outpatient department furnishes on or after January 1, 2028, unless the department bills under its own NPI and the hospital has filed a provider-based attestation. Departments already open must attest by December 31, 2027.
| Requirement | Number or date | What it means for your revenue cycle |
|---|---|---|
| Payment condition starts | January 1, 2028 | Claims for a non-compliant off-campus department stop being paid under the OPPS (or under 1833(t)(21) for nonexcepted departments) |
| Initial attestation window for existing departments | January 1, 2026 to December 31, 2027 | Approvals filed before January 1, 2026 do not count toward this window |
| NPIs per department | 1 per address listed in PECOS | One address with lab and radiology still needs only one NPI |
| Subsequent attestation | No more than 5 years after the last one was submitted | Re-attestation becomes a recurring compliance calendar item |
| Documentation turnaround if CMS asks | Generally no more than 60 days | Your evidence file has to exist before the request arrives |
| CMS volume estimate | 16,488 attestations from 1,832 hospitals | About 9 departments per hospital, at 8 hours each |
CMS published the rule in the Federal Register on November 6, 2026 (91 FR 70284). The figures above come from the preamble and the new regulation text at 42 CFR 419.23 and 413.65(b)(6).
What is the off-campus department NPI and attestation requirement?
The requirement is a Medicare payment condition created by section 6225 of the Consolidated Appropriations Act, 2026 (Public Law 119-75, enacted February 3, 2026). It adds paragraph (23) to section 1833(t) of the Social Security Act. It covers payment under the OPPS and, for nonexcepted off-campus departments, payment under the applicable payment system in section 1833(t)(21). An off-campus outpatient department of a provider is a hospital department that sits off the main campus and outside 250 yards of a remote location of the hospital.
For each such department, three things must be true before Medicare pays: the department has its own NPI and bills under it, the hospital submitted an initial provider-based attestation in the 2 years before the service date, and the hospital submits later attestations on time. The rule text at 42 CFR 419.23 states it as "No payment may be made under this part for items and services furnished on or after January 1, 2028" unless those conditions hold.
Why is this a revenue cycle problem and not a paperwork task?
Payment never depended on proving provider-based status. The final rule says that since 2000, "a provider has needed to submit an attestation only if it wishes to obtain a CMS determination of provider-based status." Many hospitals have off-campus sites that never went through an attestation.
From January 1, 2028, that gap turns into unpaid claims. CMS notes that a failure "would affect payments for the items and services furnished by a specific off-campus outpatient department of a provider, not all OPPS payments to the main provider." So one missed clinic can go unnoticed until its remittances come back short.
CMS expects the workload to be large. In its burden estimate, it counts 16,488 attestations from 1,832 main providers, about 9 per hospital, and raised the time per attestation from 5 hours in the proposed rule to 8 hours in the final rule after commenters said the original figure was too low.
What changed in the CY2027 OPPS final rule?
CMS issued CMS-1850-FC on November 4, 2026, as part of the CY2027 OPPS/ASC final rule . The rule is effective January 1, 2027, and the NPI and attestation condition applies to services on or after January 1, 2028. CMS finalized these points:
- One NPI per address. A department "is identified by the hospital's submission of its physical facility location in the enrollment system," including suite or floor number. A single address "needs only one NPI even if multiple types of services are being provided there."
- NPI and PECOS come first. Before attesting, the hospital must obtain the department NPI and update its enrollment record in PECOS. A department must already be on the hospital's Form CMS-855A enrollment.
- Timely filing counts. An initial attestation filed in the 2-year window satisfies the requirement even if CMS has not issued a provider-based determination before the department's first service.
- Old approvals do not carry over. CMS says attestations submitted before the statutory 2-year period "do not meet the initial attestation requirement."
- No de minimis exception. A site that does not seek OPPS payment does not have to comply.
- Exclusions. Critical Access Hospitals, Indian Health Service and Tribal facilities under 413.65(m), and certain FQHCs under 413.65(n) are outside the attestation requirement. CMS also said provider-based Rural Health Clinics are entities, not departments, and that AHEAD Model hospitals not paid under section 1833(t) are not covered.
- Multiple NPIs on one claim. Commenters warned that the standard claim format allows only one billing NPI, while same-day outpatient services belong on one claim. CMS is "taking measures to allow the entry of multiple NPIs within a claim," the hospital's claim-level NPI plus service-line NPIs. Detailed billing instructions are still to come.
The rule also creates a standardized attestation form and a centralized electronic system. Until both are in place, hospitals may keep sending attestations to their servicing MAC under the existing 413.65(b)(3) process.
Off-campus provider-based attestation or CMS determination: which one gets you paid?
Teams mix up three items. The department NPI is an identifier that must appear on the claim for the off-campus site. The provider-based attestation is the hospital's formal statement that the site meets 42 CFR 413.65 on location, licensure, clinical, financial and administrative integration, public awareness and ownership. A CMS provider-based determination is the review outcome that may follow.
Under the new 419.23(c), a timely attestation is enough for payment even if CMS has not issued its determination. A missing NPI on the claim has no such cushion.
How should hospitals and billing companies prepare before December 31, 2027?
Take a health system with the CMS average of 9 off-campus addresses. At CMS's estimate of 8 hours per attestation, the filings alone take 72 hours. NPI applications, Form CMS-855A changes and payer loading come on top. If PECOS lists two suites at one street address as separate locations, review each one before you assume one NPI covers both. Do not request extra NPIs per service line.
- Build the department inventory from PECOS. Match every outpatient location by exact address, suite and floor. Mark each as on-campus, within 250 yards of a remote location, or off-campus.
- Fix enrollment gaps first. Add any missing location through Form CMS-855A before you attest.
- Obtain one NPI per off-campus address and update PECOS.
- Run a 413.65 gap review for each site and assemble the evidence file. CMS anticipates giving hospitals "a reasonable period, generally not to exceed 60 days" to produce documents on request.
- File initial attestations inside the window. Do not wait for the centralized system if your date is close.
- Set up claims and clearinghouse routing so the department NPI reaches the right claim field once CMS publishes billing guidance. Test claims for each site before January 1, 2028.
- Load new NPIs with Medicare Advantage and commercial payers. Commenters warned CMS that new NPIs "could trigger new prior authorization requirements for MA patients" and cause supplemental claim denials from NPI mismatches. CMS set no rules for how other payers use the new NPIs, so ask each one.
- Put re-attestation on the calendar. The next attestation is due no more than 5 years after the submission date, and CMS plans to set the cadence in 2028 rulemaking.
Billing companies that submit hospital outpatient claims cannot file the attestation for their client. You can own steps 6 and 7, then watch for remittances that tie short pays to one department NPI. The CARC denial guide explains how those patterns show up on the remittance advice, and payer-specific coding requirements covers the commercial side.
How does CMS plan to check attestations?
CMS describes layered review. It will screen every attestation for completeness and consistency with PECOS. Flagged filings move to targeted documentation review. For extended review, CMS expects to focus on hospitals with a single off-campus department and to pull a random sample for hospitals with several. If a sampled department fails a requirement, "we may extend the review of that requirement to departments not included in the sample." Failure to produce documents on time can lead to a non-compliance finding and payment recovery under 413.65(k).
How does MediCodio AI fit into off-campus department billing?
MediCodio AI does not obtain NPIs, update PECOS or file attestations. Those stay with your enrollment and compliance teams. The coding work does change: the same service now has to reach the claim under the right department, and auditors will look for a clean record of what was coded and why.
CODIO AI applies AI medical coding to assign codes, modifiers and units with real-time NCCI, MUE and LCD/NCD checks. Each code ships with its documentation passage and the compliance rule behind it, a 100% code-level audit trail your auditors can open per chart. Complete charts flow through AutoPilot for fully autonomous coding. Charts where the documentation is thin or contradictory stay in CoPilot, where certified coders review and finalize the output. See how this works for hospitals and for RCM companies .
What has not changed?
The provider-based rules at 42 CFR 413.65 still define whether a site qualifies. This NPI condition is separate from the CY2027 site-neutral payment for imaging without contrast in excepted off-campus departments, which starts a year earlier. Rate changes are covered in our CY2027 ASC final payment rule guide and our comparison of ASC payment rates vs hospital outpatient . For professional claims, see our CY2027 physician fee schedule final rule guide .
Frequently asked questions
Do off-campus hospital outpatient departments need their own NPI in 2028?
Yes. For items and services furnished on or after January 1, 2028, Medicare will not pay under the OPPS for an off-campus outpatient department unless that department has an NPI separate from the main hospital and bills under it. CMS codified the rule at 42 CFR 419.23 in the CY2027 OPPS final rule.
When must hospitals submit the provider-based attestation?
Departments furnishing services on or before January 1, 2028 must submit the initial attestation between January 1, 2026 and December 31, 2027. Departments that open later must attest within the 2 years before their first billed service. A subsequent attestation is due no more than 5 years after the last submission.
Does one off-campus address with several services need several NPIs?
No. CMS defines a department by its physical address in PECOS, including suite or floor. One address needs one NPI even when it offers several services, such as laboratory and radiology. If PECOS lists separate suites or floors at one street address, review each listing with your enrollment team before you request NPIs.
If one department misses the deadline, does the whole hospital lose OPPS payment?
No. CMS says a failure affects payment for items and services furnished by that specific off-campus department, not all OPPS payments to the main provider. Track compliance site by site, because one missed address can lose Medicare payment while the rest of the hospital is paid as usual.
Which hospitals and sites are excluded from the requirement?
Critical Access Hospitals, provider-based Rural Health Clinics, Indian Health Service and Tribal facilities, certain FQHCs and AHEAD Model hospitals not paid under section 1833(t) are outside it. On-campus departments and sites within 250 yards of a remote location are not off-campus departments. Sites not seeking OPPS payment need not comply.
Book a Demo to run an accuracy review on your own charts, including claims from your off-campus departments.
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