AHA Responds to CMS Plan for Unique NPIs for Hospital Outpatient Departments

March 24, 2026

The Honorable Mehmet Oz, M.D.
Administrator
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244-1850

Dear Administrator Oz:

On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations; our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers; and the 43,000 health care leaders who belong to our professional membership groups, the American Hospital Association (AHA) is writing regarding the upcoming rulemaking implementing requirements related to hospital off-campus provider-based departments (PBDs). Specifically, the Centers for Medicare & Medicaid Services (CMS) will implement requirements of the Consolidated Appropriations Act of 2026 (CAA, 2026) that hospitals obtain a unique national provider identifier (NPI) for each of their off-campus PBDs and submit an attestation of compliance with the provider-based regulations. In doing so, we strongly urge the agency to implement these provisions in the least burdensome way possible and avoid subjecting hospitals and health systems, or CMS and its contractors, to lengthy and overly complex processes.

As part of President Trump’s Jan. 31, 2025, executive order, “Unleashing Prosperity Through Deregulation,” the AHA has responded to many requests for information (RFIs) describing ways to eliminate outdated or unnecessary regulations to reduce burden and increase transparency. The AHA fully supports the president’s goals and has made more than 100 suggestions to the Trump administration on this initiative. As such, we urge CMS to continue to follow such a path in its implementation of the NPI and attestation requirements mentioned above.

As background, the CAA, 2026 requires that for items and services furnished on or after Jan. 1, 2028, each hospital off-campus PBD must be assigned a unique health identifier (i.e., NPI) and submit an initial attestation demonstrating compliance with the provider-based regulations. In carrying out this provision, CMS is required to undertake rulemaking to establish the process for submitting an initial and subsequent attestation and for determining compliance with the provider-based regulations.

However, Sec. 6225 also indicates that until the rulemaking is complete, the agency may review attestations submitted in accordance with provisions in the current provider-based regulations.

The AHA has consistently raised concerns about policies that require separate NPIs for each off-campus PBD, both because it would be administratively burdensome to providers (some of whom have many off-campus PBDs) and also because it is unnecessary. For example, CMS can already identify the exact location in which outpatient services are furnished to a Medicare beneficiary — such information is readily available in claims data and providers’ enrollment information. Moreover, requiring separate NPIs will result in other unnecessary complexities for providers because NPIs are used in a wide variety of ways and on many different hospital platforms.¹ Similarly, we have heard concerns from our members about the significant burden that mandated attestations of provider-based status would entail, not only for them, but also for Medicare’s contractors. For example, a few of our large health systems, which have previously attempted to voluntarily obtain separate NPIs and submit attestations across several Medicare Administrative Contractors (MACs), stated that the current process varies across MACs, which tremendously increases provider burden. 

To that end, we provide the following recommendations with the goal of helping CMS implement these policies in the least burdensome way possible for both hospital off-campus PBDs and for CMS and MACs. Specifically, we recommend:

• CMS clarify in its rulemaking that Sec. 6225 does not require it to make a final determination that an off-campus PBD of a hospital or health system has provider-based status before Jan. 1, 2028. Rather, Sec. 6225 only requires that a hospital off-campus PBD must submit an attestation of compliance to CMS by that deadline.
• CMS accept any attestation of compliance with the provider-based rules for its off-campus PBD approved prior to Feb. 3, 2026 (the enactment date of the CAA, 2026) as the provider’s initial attestation under Sec. 6225, without further review. This should include those hospital off-campus PBDs that, between 2000 and 2002, received an affirmative provider-based determination, as CMS required following the April 7, 2000, outpatient prospective payment system final rule.
• CMS establish a standard submission and approval process across all its MACs and regional offices that applies to both the initial and the subsequent attestations. This process should detail what, if any, specific documentation is required to support an attestation. It should also, to the extent possible, employ the use of checkboxes that allow an off-campus PBD to confirm compliance with only the essential additional documentation. Site visits and/or remote audits should not be required except in extraordinary circumstances in which CMS has evidence that there has been a material misrepresentation or concealment of fact by the provider.
• CMS require only one attestation and one re-attestation, consistent with the provisions of Sec. 6225, which mandates only “an initial and subsequent attestation.”
  • However, if CMS opts to require periodic re-attestations, these should only occur in specified circumstances already described in the current provider-based regulations, such as when there is a material change in the relationship between the hospital and its off-campus PBD, such as a change in ownership.
• CMS establish a deadline of one calendar week after a hospital submits its application for a separate NPI for its off-campus PBD by which CMS must formally assign the separate NPI.
• CMS clarify that the establishment of a separate NPI does not interfere with the main provider’s authority to oversee and manage an off-campus PBD’s operations, such as through a centralized billing office and other properties reflecting the main provider’s ownership of its off-campus PBD, including the financial, administrative, and clinical integration and control of its off-campus PBDs.

Thank you for considering these issues. The AHA supports CMS’ efforts to reduce regulatory burdens and improve transparency and urges the agency to reflect this commitment in upcoming rulemaking on separate NPIs and required attestation. Please contact me if you have questions, or feel free to have a member of your team contact Roslyne Schulman, AHA director for policy, at (202) 626-2273 or rschulman@aha.org.

Sincerely,

/s/

Molly Smith
Group Vice President, Public Policy 

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