Currentpriority healthPolicy N/A

After Hours and Weekend Care (Professional)

Defines Priority Health reimbursement and billing rules for primary care after-hours and weekend professional services for commercial fee-for-service members; excludes Medicare, Medicaid, and Healthy Michigan Plan members and includes place-of-service and documentation requirements.

Policy Summary

Payerpriority health

PolicyAfter Hours and Weekend Care (Professional)

Policy CodePolicy N/A

Change TypePlace-of-service rules addedadministrative formatting

Effective DateN/A

Next Review DateFeb 20, 2026

Key ActionFor Medicare indications not meeting NCD/LCD or specific medical policy, complete a Pre-Service Organization Determination (PSOD).

SourceLink

POLICY UPDATE CHANGES

Transitioned policy from a webpage into this PDF document.

Added the place of service (POS) requirements for codes 99050 and 99051.

After-hours care billed with POS 20 or a specialty of urgent care will be denied.

3CPT codes discussed

After-hours definedAfter-hours window

POS denialPOS denial

ExcludedExcluded populations

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 Coverage Criteria

After-hours coverage criteria

Covered when ALL of the following criteria are met:

ALL of the following

Member is enrolled in an employer-sponsored or MyPrioritySM commercial plan (HMO, POS, or PPO).
Not payable for Medicare, Medicaid, or Healthy Michigan Plan members.
Service is provided by a primary care provider (PCP) on a fee-for-service basis.

ALL of the following

Use the applicable CPT code for the after-hours service (99050, 99051, or 99053).
No modifier is necessary to bill these codes.
For Medicare Advantage members, check Correct Coding Initiative (CCI) edits before billing. If Medicare NCD/LCD or specific medical policy criteria are not met, follow Pre-Service Organization Determination procedures.

ONE of

CPT 99050: Applies when the office is normally closed (scheduled clinic or walk-in hours do not apply). Report in addition to the basic service. Document the special circumstances in the medical record.
CPT 99051: Applies during regularly scheduled evening, weekend or holiday office hours; Priority Health defines after-hours as any scheduled appointment after 5:00 pm EST and prior to 8:00 am ET. Report in addition to the basic service. Document the special circumstances in the medical record.
CPT 99053: Applies when a PCP comes into the emergency department between 10:00 pm and 8:00 am to treat a patient; not billable for an on-duty ER physician. CPT 99053 is incidental to other services provided by on-site ER staff and is reported in addition to the basic service when applicable. Payment for 99053 is bundled into payment for other services provided on the same day. Document the special circumstances in the medical record.

ALL of the following

Allowed places of service for CPT 99050 and 99051 include: 03, 05, 07, 11, 49, 50, 71, 72.
Claims for after-hours care billed with place of service 20 or a specialty of urgent care will be denied.

ALL of the following

The medical record must document the special circumstances of the visit for any after-hours code billed.

ALL of the following

Failure to meet these coding, place-of-service, eligibility, or documentation requirements may result in claim denial, recoupment, or further payment integrity review.

ALL of the following

Follow Priority Health policy specifics and related provider manual guidance for Medicare PSOD and CCI edits as applicable.

After-hours Professional Visit Codes and Billing Rules

After-hours professional visit codesCPTCovered

99050	Services provided when the office is normally closed; report in addition to basic service.
99051	Services during regularly scheduled evening, weekend or holiday office hours; after 5:00pm to before 8:00am; report in addition to basic service.
99053	PCP comes to ER between 10 p.m. and 8 a.m.; not billable for on-duty ER physicians; incidental to other services and bundled into same-day payments; report in addition to basic service.

inv-03: 99053 bundling

Bundle rulePayment for CPT 99053 is bundled into payment for other services provided on the same day.

Service contextApplies when a PCP comes into the ER between 10 p.m. and 8 a.m. to treat a patient.

Incidental to ER services99053 is incidental to any E&M, surgical, laboratory, or other services when provided by ER physicians, anesthesiologists, radiologists, laboratory staff or other scheduled onsite providers.

Not billable for on-duty ER physicians99053 is not billable for an on-duty ER physician.

DocumentationMedical record must document the special circumstances of the visit (e.g., member requests PCP care instead of ER physician).

Provider Requirements and Pre-Service Determinations

Prior Authorization

Pre-Service Organization Determination (PSOD) required for Medicare

For Medicare indications that do not meet the criteria of an NCD, local LCD, or specific medical policy, complete a Pre-Service Organization Determination (PSOD) before submitting the request for coverage. See the Provider Manual for more information on how to obtain a PSOD.

Key Definitions

inv-05: After-hours definition

After-hours windowAny scheduled appointment after 5:00pm EST and prior to 8:00am ET.

99050 exception99050 applies when the office is normally closed (services provided when office is normally closed).

Plan applicabilityCovered for commercial employer-sponsored and MyPriority SM HMO, POS and PPO plans; not payable for Medicare, Medicaid or Healthy Michigan Plan members.

Modifier guidanceNo modifier is necessary to bill these after-hours codes.

inv-06: 99053 ER attendance

DefinitionWhen a PCP comes into the ER between 10 p.m. and 8 a.m. to treat a patient.