CurrentUnitedHealthcarePolicy 2025R3003A

Reimbursement for standby and hospital-mandated on-call services

Defines UnitedHealthcare's reimbursement stance for physician or other qualified health care professional standby services and hospital-mandated on-call services billed on CMS 1500 forms for Commercial and Individual Exchange plans.

Policy Summary

PayerUnitedHealthcare

PolicyReimbursement for standby and hospital-mandated on-call services

Policy CodePolicy 2025R3003A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionDo not submit claims for CPT 99360, 99026, or 99027 for separate reimbursement; report an appropriate CPT if a direct patient service is provided.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3CPT/HCPCS codes referenced

2Codes not reimbursed

AllCommercial plans

AllIndividual Exchange

Standby and On-Call Coverage Rules

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UnitedHealthcare does not reimburse physician or other qualified health care professional standby services submitted with CPT 99360.

UnitedHealthcare does not reimburse hospital-mandated on-call services billed with CPT 99026 or CPT 99027 because they do not involve direct patient contact.

Exception — report appropriate service code if direct patient care is provided

If the standby clinician provides a direct, face-to-face service to the patient (for example, tissue examination during frozen section), report the appropriate CPT code for that service (e.g., 88331).
If a physician is requested to attend at delivery and provides stabilization of a newborn, bill the direct face-to-face services using CPT 99464 (these are not considered standby services).

Policy applies to services billed on CMS 1500 forms for UnitedHealthcare Commercial and Individual Exchange plans; UnitedHealthcare may exercise discretion and other factors may affect reimbursement.

Billing and Prior Authorization Guidance

Billing Rule

Do not bill standby or hospital-mandated on-call codes for separate reimbursement

Do not submit claims for physician standby services (CPT 99360) or hospital-mandated on-call services (CPT 99026, 99027) for separate reimbursement. If a standby clinician provides a direct, face-to-face service to the patient, report the appropriate CPT code for that service (for example, tissue examination during frozen section would be billed with CPT 88331).

Do not bill CPT 99360 for separate reimbursement — standby services are not reimbursed.
Do not bill CPT 99026 or 99027 for separate reimbursement — hospital-mandated on-call services are not reimbursed.
If direct patient care is provided by the standby clinician, report the appropriate CPT for that direct service (e.g., 88331).

Key Definitions

inv-04: Standby services

DefinitionPhysician or other qualified health care professional standby services are prolonged attendance requested by another individual without direct (face-to-face) patient contact; care or services may not be provided to other patients during this period.

CPT referenceCPT code 99360 is used to report these standby services (per CPT definition).

LimitationsNot used to report time spent proctoring another individual or if the standby period ends with a procedure subject to a surgical package by the standby individual.

CMS alignmentCMS considers physician standby services included in facility payment and not separately reimbursable.

inv-05: Hospital-mandated on-call services

DefinitionHospital-mandated on-call services are services required by the hospital for on-call attendance that do not involve direct patient contact and are not separately reimbursable.

CPT referencesCPT codes 99026 and 99027 are used for hospital mandated on-call services.

Reimbursement stanceUnitedHealthcare does not reimburse hospital-mandated on-call services billed under CPT 99026 and 99027 because they do not involve direct patient contact.

CMS alignmentThese services are considered included in facility payment and not separately reimbursable per CMS policy.