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HSN Medicare Outpatient PAF Data Submission

This section provides information about HSN Medicare Outpatient PAF Data Submission.

HSN Medicare Outpatient PAF Data Submission

The Health Safety Net Office requires hospitals to provide data on their outpatient Medicare charges and payments. This data is used to determine the proposed Health Safety Net outpatient per visit rates.

For HSN Fiscal Year 2022 rate setting, hospitals must provide data from their FY2020 Medicare Provider Statistical and Reimbursement (PS&R) report and CMS-2552 report. Further instructions are listed below:

Medicare Outpatient Data Submission Instructions (PDF) Word

Once you have read the instructions, please click the link below to download the Data Submission Form:

Outpatient Payment-on-Account Factor Submission Form 

Once complete, hospitals should email the Data Submission file to Reports are due by 5:00 PM on Friday, July 30, 2021. Supporting documents should be scanned to a PDF file and emailed along with the Data Submission Form.

Any questions for the Health Safety Net Office can be sent to the above email address as well.

Thank you for your participation.