CurrentAnthemPolicy C-07001

After-Hours, Emergency, and Miscellaneous E/M Services - Professional and Facility

Defines Anthem's reimbursement rules for after-hours evaluation and management (E/M) services billed by professional providers for commercial members; excludes facility providers. Applies to claims billed with appropriate CPT/HCPCS codes and places of service.

Policy Summary

PayerAnthem

PolicyAfter-Hours, Emergency, and Miscellaneous E/M Services - Professional and Facility

Policy CodePolicy C-07001

Change TypeNo material changes

Effective DateMar 1, 2025

Next Review Date

Key ActionBill after-hours services with place of service 11 or 20 and ensure services meet authorization and medical necessity guidelines.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5:00 p.m. - 8:00 a.m.Weekday after-hours window

AnytimeWeekend eligibility

99050, 99051Eligible CPT codes

99053, 99056, 99058, 99060Ineligible CPT codes

POS 11 or 20Required place of service

After-hours Reimbursement Criteria

After-hours reimbursement criteria

Covered when ALL of the following are met:

ALL of the following

Service billed with place of service 11 (office) or 20 (urgent care)
Rendered between 5:00 p.m. and 8:00 a.m. on weekdays, or anytime on weekends (eligibility based on arrival time, not time service commenced)
Service is reported by a professional (policy does not apply to facility providers)
ALL of the following
- Eligible CPT codes

Policy Summary

PayerAnthem

PolicyAfter-Hours, Emergency, and Miscellaneous E/M Services - Professional and Facility

Policy CodePolicy C-07001

Change TypeNo material changes

Effective DateMar 1, 2025

Next Review Date

Key ActionBill after-hours services with place of service 11 or 20 and ensure services meet authorization and medical necessity guidelines.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Not eligible for separate reimbursement

CPT 99053 (services provided between 10:00 PM and 8:00 AM at a 24‑hour facility) — not eligible for separate reimbursement.
CPT 99056 (services typically provided in the office, provided out of the office at request of patient) — not eligible for separate reimbursement.
CPT 99058 (services provided on an emergency basis in the office that disrupt other scheduled office services) — not eligible for separate reimbursement.
CPT 99060 (services provided on an emergency basis, out of the office, that disrupt other scheduled office services) — not eligible for separate reimbursement.

Applicable CPT/HCPCS Codes and Billing Details

Covered CPT CodesCPTCovered

99050	Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (eg, holidays, Saturday or Sunday), in addition to basic service. Eligible for separate reimbursement if reported without a preventive diagnosis and/or a preventive service.
99051	Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service. Eligible for separate reimbursement.

Not eligible for separate reimbursementCPTNot Covered

99053	Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service. Not eligible for separate reimbursement.
99056	Service(s) typically provided in the office, provided out of the office at request of patient, in addition to basic service. Not eligible for separate reimbursement.
99058	Service(s) provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service. Not eligible for separate reimbursement.
99060	Service(s) provided on an emergency basis, out of the office, which disrupts other scheduled office services, in addition to basic service. Not eligible for separate reimbursement.

Place of service and timing requirement

Required place of serviceClaims must be billed with place of service 11 (office) or 20 (urgent care) to be eligible for after-hours reimbursement

Weekday time windowRendered between 5:00 p.m. and 8:00 a.m. on weekdays (eligibility based on arrival time, not actual start time)

Weekend time windowRendered anytime on weekends (eligibility based on arrival time)

HolidaysIf a holiday falls on a weekday, weekday time windows (5:00 p.m. – 8:00 a.m.) apply; if on a weekend, anytime on that weekend is eligible

Authorization and Billing Guidance for Providers

Documentation Required

Authorization, documentation, and billing requirements — follow medical necessity and coding standards

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and the member's state of residence. Providers must follow proper billing and submission guidelines, using industry-standard CPT/HCPCS/revenue codes that are fully supported in the medical record or office notes. Failure to follow coding or billing guidelines may result in claim rejection or denial, and Anthem may recover or recoup claim payment.

Use industry-standard, compliant CPT, HCPCS, and/or revenue codes on all claim submissions.
Ensure documentation in the medical record/office notes fully supports billed services and codes.
Follow authorization and medical necessity requirements applicable to the procedure, diagnosis, and member's state of residence.
Noncompliance with coding/billing guidelines may lead to claim rejection/denial or recovery/recoupment of payments.

Key Definitions

General reimbursement policy definitions

ScopeApplies to professional providers billing eligible after-hours E/M services for commercial members; does not apply to facility providers

After-hours services (definition)Services billed with place of service 11 or 20 rendered between 5:00 p.m. and 8:00 a.m. on weekdays or anytime on weekends (based on arrival time)

Documentation and coding requirementServices must meet medical necessity and be billed using industry-standard CPT/HCPCS codes per applicable authorization and billing guidance

Preventive diagnosis note99050 is eligible for separate reimbursement only if reported without a preventive diagnosis and/or a preventive service

After-hours services

DefinitionAfter-hours services are services billed with place of service 11 (office) or 20 (urgent care) rendered between 5:00 p.m. and 8:00 a.m. on weekdays or anytime on weekends (eligibility determined by arrival time)

Eligible CPT codes (when criteria met)99050 and 99051 are identified as 'after-hours' services and are eligible for separate reimbursement when policy criteria are satisfied

Ineligible related CPT codes99053, 99056, 99058, and 99060 are not eligible for separate reimbursement