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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyUniversity of Utah After-Hours Coverage | OpenPaye…
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    CurrentUniversity of Utah Health PlansPolicy REIMB-028

    After-Hours Codes Coverage

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    This policy governs separate reimbursement for after-hours CPT codes in office or clinic settings for Commercial, CHIP, and Healthy U Medicaid plans, including covered and non-reimbursed codes, billing conditions, provider eligibility, documentation, and Medicaid applicability.

    Policy Summary
    PayerUniversity of Utah Health Plans
    PolicyAfter-Hours Codes Coverage
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective Date03/26/2025
    Next Review Date03/26/2026
    Key ActionSubmit CPT 99050 only for qualifying office or clinic services provided outside regularly posted office hours or on days the office is normally closed.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    99050Covered after-hours CPT code
    4 codesCodes not separately reimbursed in specified settings
    13Eligible primary care provider specialties
    10 PM–8 AMCPT 99053 facility time window

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    3
    Plan populations

    Coverage Criteria

    Commercial Plans/CHIP — CPT 99050 Coverage Criteria

    CPT 99050 is covered for an after-hours charge when services are provided in an office/clinic setting consistent with <strong>all</strong> of the following conditions:

    ALL of the following

    • After-hours services are provided in the office at times other than regularly posted office hours, or on days when the office is closed (for example, holidays, Saturday, or Sunday), in addition to the basic service.
    • The provider will submit documentation to substantiate additional payment for after-hours services upon request.
    • Services are billed with a covered evaluation and management (E/M) service CPT code, but not a preventive service code.

    • The provider billing the service is a primary care provider practicing in one of the following areas

      • Adolescent Medicine
      • Pediatric-Adolescent
      • General Pediatrics
      • Family Nurse Practitioner
      • Nurse Practitioner
      • Pediatric Nurse Practitioner
      • Advanced Registered Nurse Practitioner
      • Family Medicine
      • General Practice
      • Geriatric Medicine
      • Obstetrics & Gynecology, where the provider has indicated PCP status
      • General Internal Medicine, where the provider has indicated PCP status
      • Certified Nurse Midwife

    Separate Reimbursement Exclusions

    The following after-hours charges are not separately reimbursed under the stated circumstances:

    Separate reimbursement exclusions

    • CPT codes 99051, 99053, 99056, and 99060 are submitted for an after-hours charge when services are provided in an office/clinic setting during regularly scheduled evening, weekend, or holiday office hours, or at a 24-hour facility.

      These codes will be denied as provider liability.

    • An after-hours CPT code is submitted for a service provided at the patient's request for the patient's convenience.
    • An after-hours CPT code is submitted with a Virtual Visit.
    • Services are rendered in an urgent care clinic or setting.

      Coverage is processed based on the procedure/service itself; copays may differ based on the member's benefits.

    Medicaid Coverage Determination

    For Medicaid Plans, coverage is determined by the State of Utah Medicaid program. Apply the following determination rule:

    Medicaid coverage determination

    • Determine coverage under the State of Utah Medicaid program.
    • If Utah State Medicaid has no published coverage position and InterQual criteria are not available, apply the U of U Health Plans Commercial criteria.
    • For the most up-to-date Medicaid policies and coverage, consult the Utah Medicaid official publications website or the Utah Medicaid code Look-Up tool: https://medicaid.utah.gov/utah-medicaidofficial-publications/
    • CPT/HCPCS codes covered by Utah State Medicaid may still require further evaluation to determine medical necessity for coverage.

    After-Hours Coding

    Covered after-hours office serviceCPTCovered
    99050Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g., holidays, Saturday or Sunday), in addition to basic service
    After-hours codes not separately reimbursed in specified settingsCPTNot Covered
    99051Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service
    99053Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service
    99056Service(s) typically provided in the office, provided out of the office at request of patient, in addition to basic service
    99060Service(s) provided on an emergency basis, out of the office, which disrupts other scheduled office services, in addition to basic service
    CPT 99053 Time Window
    CodeCPT 99053
    Time windowBetween 10:00 PM and 8:00 AM
    Facility settingA 24-hour facility
    Service relationshipIn addition to the basic service
    CPT 99050 Service Timing
    CodeCPT 99050
    Qualifying timingOutside regularly posted office hours or on days the office is normally closed

    Provider Billing Requirements

    Documentation Required

    Maintain Supporting Documentation

    Submit documentation to substantiate additional payment for after-hours services when requested by the Plan.

    Billing Rule

    Bill 99050 for Qualifying After-Hours Care

    Bill CPT 99050 for qualifying after-hours services provided in an office or clinic, in addition to the basic service, when the service occurs outside regularly posted office hours or on a day the office is closed, such as a holiday, Saturday, or Sunday.

    Billing Rule

    Pair With a Covered E/M Service

    Definitions

    After-Hours Care
    TimingServices provided outside regular posted office hours
    Clinical purposeTo treat a patient's urgent illness or condition
    Required practitionerAn individual physician or other health care professional is required to render the services
    Bundled Code
    CMS statusStatus B (Bundled Code)
    Payment treatmentPayment for covered services is always bundled into payment for other services
    Separate paymentThere are no RVUs or payment amount for these codes, and no CMS 1500 separate payment is made
    Policy Summary
    PayerUniversity of Utah Health Plans
    PolicyAfter-Hours Codes Coverage
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective Date03/26/2025
    Next Review Date03/26/2026
    Key ActionSubmit CPT 99050 only for qualifying office or clinic services provided outside regularly posted office hours or on days the office is normally closed.
    SourceLink
    On This Page
    Coverage CriteriaAfter-Hours CodingProvider Billing RequirementsDefinitions
    Examples of normally closed daysHolidays, Saturdays, or Sundays
    Service relationshipIn addition to the basic service

    Bill the after-hours service with a covered evaluation and management (E/M) CPT code. Do not pair the after-hours code with a preventive service code.

    Billing Rule

    Confirm Eligible Primary Care Provider Specialty

    The billing provider must be a primary care provider practicing in an eligible specialty.

    • Adolescent Medicine
    • Pediatric-Adolescent
    • General Pediatrics
    • Family Nurse Practitioner
    • Nurse Practitioner
    • Pediatric Nurse Practitioner
    • Advanced Registered Nurse Practitioner
    • Family Medicine
    • General Practice
    • Geriatric Medicine
    • Obstetrics & Gynecology, where the provider has indicated PCP status
    • General Internal Medicine, where the provider has indicated PCP status
    • Certified Nurse Midwife
    Denial Risk

    Avoid Non-Reimbursable After-Hours Submissions

    Do not submit after-hours codes for separate reimbursement when services are provided during regularly scheduled evening, weekend, or holiday office hours, or at a 24-hour facility. Such submissions are denied as provider liability. Services rendered in an urgent care clinic or setting are processed based on the procedure or service itself, and member copays may differ.

    • 99051
    • 99053
    • 99056
    • 99060
    Denial Risk

    Exclude Convenience and Virtual-Visit Billing

    Do not separately bill an after-hours charge when the service was provided at the patient's request for convenience or when the after-hours code is submitted with a Virtual Visit.

    • Patient-convenience requests are excluded.
    • Virtual Visit submissions are excluded.
    Note

    Apply Utah Medicaid Coverage Hierarchy

    For Medicaid Plans, apply Utah State Medicaid coverage policies and the Utah Medicaid code Look-Up tool. If Utah Medicaid has no published coverage position and InterQual criteria are unavailable, apply U of U Health Plans Commercial criteria. A code covered by Utah State Medicaid may still require further evaluation to determine medical necessity.

    • Utah Medicaid official publications: https://medicaid.utah.gov/utah-medicaidofficial-publications/
    • Use the Utah Medicaid code Look-Up tool for current code coverage information.
    Modifier effectA modifier will not override the edit