CurrentBlue Cross Blue Shield - NevadaPolicy C-07001

After-Hours, Emergency, and Miscellaneous EIM Services reimbursement

Defines Anthem Blue Cross and Blue Shield reimbursement rules for separate payment of after-hours and related EIM services for professional and facility claims and specifies place-of-service and timing criteria; affects providers submitting claims for Anthem members.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyAfter-Hours, Emergency, and Miscellaneous EIM Services reimbursement

Policy CodePolicy C-07001

Change TypeRevised - applies to professional and facility providersPOS 20 reimbursement restricted with state exemptions

Effective DateJan 1, 2024

Next Review Date

Key ActionBill after-hours services with office place of service (POS 11) and ensure service arrival time falls within specified after-hours windows to qualify for separate reimbursement.

SourceLink

POLICY UPDATE CHANGES

Policy updated to apply to both professional and facility providers; no longer allows separate reimbursement for claims billed with POS 20, nor facility providers, with exemptions for Indiana and Ohio.

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

Anytimeweekend timing

99050, 99051eligible codes

99053, 99056, 99058, 99060not eligible codes

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.

After-Hours and EIM Separate Reimbursement Criteria

After-Hours/EIM reimbursement criteria

Covered when ALL of the following are met:

ALL of the following

ALL of the following
- Must be billed with office place of service (POS 11) to be eligible for separate reimbursement unless provider, state, federal, or contract requirements indicate otherwise
ALL of the following
- ALL of the following
  - Service arrival time between 5:00 p.m. and 8:00 a.m. on weekdays (based on arrival time, not actual service start time)
- ALL of the following
  - Anytime on weekends qualifies as after-hours (based on arrival time)
  - If a holiday falls on a weekday, services rendered between 5:00 p.m. and 8:00 a.m. that day are eligible; if a holiday falls on a weekend, services anytime on that weekend are eligible
ALL of the following
- Eligible codes: CPT 99050 and 99051 are eligible for separate reimbursement (99050 only when not reported with a preventive diagnosis or preventive service)
- Not eligible codes: CPT 99053, 99056, 99058, and 99060 are not eligible for separate reimbursement
ALL of the following
- Policy applies to both professional and facility providers; however, the policy no longer allows separate reimbursement for claims billed with POS 20 except where state-specific exemptions apply
- Exemptions: Indiana and Ohio allow reimbursement for services billed in POS 20 and the policy does not apply to facility providers in those states per state notes
ALL of the following
- Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and member's state of residence; follow proper billing and submission using CPT/HCPCS/revenue codes supported by medical record
- Policy may be superseded by provider, state, federal, or CMS mandates; Anthem may recoup payments if coding/billing guidelines are not followed

Relevant CPT Codes and Timing Definitions

After-hours and EIM CPT CodesCPT

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.
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.

Additional EIM CPT CodesCPTNot Covered

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.

After-hours time windows (timing rules)

Weekday after-hours window5:00 p.m. - 8:00 a.m. (based on arrival time)

Weekend after-hours windowAnytime on weekends (based on arrival time)

Holiday treatmentIf a holiday falls on a weekday, 5:00 p.m. - 8:00 a.m. applies; if on a weekend, anytime on that weekend applies

Billing, Authorization, and Documentation Requirements

Documentation Required

Authorization and documentation requirements

Authorization and documentation requirements: Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and be supported in the medical record or office notes. Use industry-standard CPT, HCPCS, and revenue codes on all claim submissions. Documentation must fully support billed services and timing (arrival time) when billing after-hours. Follow any applicable provider, state, federal, or CMS contract mandates that may supersede this policy.

Documentation must substantiate service, diagnosis, and arrival time for after-hours eligibility
Use CPT, HCPCS, and revenue codes; claims must be supported in the medical record/office notes
Services must meet authorization and medical necessity guidelines

Billing Rule

Definitions and Eligibility Notes

After-hours services (definition)

DefinitionServices provided outside regularly scheduled office hours and identified by CPT codes 99050 and 99051; considered 'after-hours' for reimbursement purposes.

Timing basisEligibility determined by member arrival time, not necessarily by when the service commenced.

Place-of-service requirementMust be billed with office place of service (POS 11) to qualify for after-hours reimbursement unless state/contract overrides apply.

Eligibility criteria for after-hours reimbursement

Required place of serviceBilled with office POS 11 to be eligible for separate after-hours reimbursement.

Weekday timingMember arrival between 5:00 p.m. and 8:00 a.m. qualifies as after-hours.