Provider-Based: Off-Campus Outpatient Coinsurance Notice
When a Medicare beneficiary is treated in a hospital outpatient department or hospital-based entity that is not located on the main provider's campus, the hospital must provide written notice to the beneficiary of the amount of the beneficiary's potential financial liability. This notice would explain that the beneficiary will incur a coinsurance liability for the outpatient visit to the hospital and a coinsurance liability for the physician service.
This requirement does not apply in the following situations.
Select the PDF file below to obtain sample language that can be used to comply with this requirement. If applicable to the facility, please include an example on the hospital letterhead as part of the documentation for Question 4 in Section IV of the attestation statement.
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