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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.

  • The hospital-based entity is a Rural Health Clinic (RHC).
  • The facility only furnishes services for which the beneficiary will not incur any deductible or coinsurance liability.
  • The facility only furnishes services for which the beneficiary liability is the same in both the provider-based and freestanding settings.

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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