The Centers for Medicare & Medicaid Services (CMS) finalized the mandatory provider-based attestation and separate National Provider Identifier (NPI) requirements for off-campus hospital outpatient departments (HOPDs) under Section 6225 of the Consolidated Appropriations Act, 2026.
The requirements, finalized in the Calendar Year (CY) 2027 OPPS/ASC Final Rule (CMS-1850-FC), establish new Medicare payment conditions effective January 1, 2028.
CMS provided several important operational clarifications, including a streamlined electronic attestation process that will not require supporting documentation at submission. CMS also repeatedly indicated that additional subregulatory guidance will be forthcoming.
Key Provisions of the Final Rule
- Separate NPIs: Hospitals must obtain a separate NPI for each applicable off-campus department, generally at the physical address level (including suites/floors) reported on the hospital’s CMS-855A enrollment, rather than for each specialty or service line.
- Mandatory Attestations: Existing off-campus HOPDs must submit initial provider-based attestations by December 31, 2027, with subsequent attestations required at intervals not exceeding five years.
- Streamlined Process: CMS will establish a centralized electronic attestation system that will not require supporting compliance documentation at submission.
- Enrollment Requirements: Hospitals must obtain address-specific NPIs and update PECOS enrollment records before submitting attestations.
- Compliance Verification: CMS will conduct subsequent compliance reviews through documentation requests, random sampling, targeted audits, and potential site visits.
- Prior Attestations: Previously completed provider-based attestations will not satisfy the new mandatory requirements.
- Additional Guidance: CMS anticipates issuing further guidance addressing documentation, attestation procedures, billing, compliance reviews, and other implementation details.
Streamlined Electronic Attestations
CMS confirmed that initial attestations will serve as certifications of compliance with the applicable provider-based requirements under 42 CFR § 413.65. Hospitals will not be required to submit supporting documentation with their attestations.
Instead, CMS intends to verify compliance through subsequent audits, documentation requests, and potential site visits. Hospitals generally will have up to 60 days to respond to requests for supporting documentation.
Importantly, CMS confirmed that a timely submitted attestation satisfies the statutory submission requirement even if CMS has not completed its review or issued a provider-based determination.
Separate NPI and Enrollment Requirements
CMS clarified that the separate NPI requirement applies at the enrolled off-campus location level, rather than to individual specialties or service lines. For example, an off-campus department furnishing both laboratory and radiology services would generally require one NPI.
However, CMS emphasized the importance of location information reported in PECOS, including suite and floor designations. Hospitals operating multiple departments within a building should evaluate their existing CMS-855A enrollment configurations to determine the appropriate enrollment and NPI structure.
Hospitals must obtain the applicable NPIs and update PECOS before submitting attestations.
CMS also indicated that it is developing billing mechanisms to accommodate multiple department NPIs on a single hospital outpatient claim, with additional operational guidance forthcoming.
Other Payer Considerations
CMS continues to address the new NPI requirements primarily in the context of traditional Medicare. Although CMS acknowledged concerns regarding Medicare Advantage authorizations, coordination of benefits, supplemental coverage, and potential NPI mismatches across payers, it did not establish requirements governing the use of these NPIs by other payers.
Hospitals should begin evaluating whether and how address-specific NPIs will be incorporated into Medicare Advantage, Medicaid, and commercial payer enrollment and billing, along with the necessary implementation timelines.
Scope of Applicable Departments
Section 6225 generally applies to excepted and nonexcepted off-campus HOPDs seeking reimbursement under the OPPS or applicable payment systems pursuant to Section 1833(t)(21). Hospitals participating in the AHEAD Model that do not seek payment under the OPPS or the applicable payment systems referenced in Section 1833(t)(21) likewise would not be subject to these payment conditions.
CMS confirmed that remote inpatient locations, critical access hospitals, provider-based rural health clinics, and FQHCs (including “look-alikes”) are outside the statutory scope. Outpatient departments located within 250 yards of a remote inpatient hospital location are also generally treated as on-campus for purposes of the applicable provider-based requirements, rather than as off-campus departments subject to Section 6225, and are also out of scope.
CMS also addressed laboratory-only and PT/OT/ST-only departments historically excluded from provider-based determinations under 42 CFR § 413.65(a)(1)(ii). Although CMS declined to establish a categorical exemption for these facilities, it separately clarified that facilities not seeking payment under the OPPS or applicable payment systems referenced in Section 1833(t)(21) would not be compelled to comply with Section 6225.
The application of these provisions to laboratory-only and therapy-only departments therefore warrants further clarification. Advis intends to seek specific confirmation from CMS that off-campus departments not billing under the OPPS are exempt from both the separate NPI and provider-based attestation requirements.
Compliance Reviews and Outstanding Guidance
Although the initial attestation process will be streamlined, hospitals remain responsible for demonstrating compliance with all applicable provider-based requirements.
CMS may conduct remote audits, on-site reviews, and other investigations to verify compliance. Hospitals with minor attestation deficiencies may be afforded opportunities for correction before an adverse determination, although such opportunities are not guaranteed.
CMS clarified that failure to satisfy the Section 6225 requirements affects Medicare reimbursement for the individual noncompliant off-campus department, rather than the hospital’s entire OPPS reimbursement.
Notably, CMS did not provide additional clarification concerning space sharing and co-location arrangements, including shared waiting areas, registration functions, and affiliated physician practices. Given CMS’s historically varied enforcement of these requirements, existing guidance and prior enforcement experience remain important considerations for risk-based compliance decisions.
Recommended Preparations and Advis Assistance
Despite the streamlined submission process, hospitals should begin preparing for Section 6225 implementation during CY 2027. Advis recommends:
- Department Inventory and Enrollment: Identify applicable off-campus departments, evaluate CMS-855A configurations, and develop a plan for obtaining address-specific NPIs and updating PECOS.
- Other Payer Coordination: Begin engaging Medicare Advantage, Medicaid, and commercial payers to determine whether and how address-specific NPIs will be incorporated into enrollment, contracting, and claims processing. Establish payer-specific implementation timelines to ensure adequate readiness before January 1, 2028.
- Provider-Based Compliance: Review compliance with 42 CFR § 413.65, particularly complex space-sharing, co-location, and integration arrangements.
- Public-Facing Requirements: Prioritize readily observable compliance elements, including signage, websites, and hospital department identification. These may be among the first sources CMS evaluates when identifying potential compliance concerns.
- Supporting Documentation: Organize licensure, accreditation, staffing, financial integration, and other records to support future CMS reviews.
Advis is actively assisting hospitals and health systems nationwide with Section 6225 readiness, including department inventories, compliance assessments, NPI and PECOS planning, and development of system-wide attestation processes.
We will continue monitoring forthcoming CMS guidance and providing updates as implementation details become available.
Source: CMS CY 2027 OPPS/ASC Final Rule (CMS-1850-FC) – https://public-inspection.federalregister.gov/2026-22739.pdf
Related Advis Publications:
- CY 2027 OPPS/ ASC Final Rule
- CY 2027 OPPS/ASC Proposed Rule
- CMS Proposes Mandatory HOPD Attestation Process
Published November 5, 2026