Billing after-hours services

As part of our initiative to support primary care providers in becoming patient-centered medical homes, Priority Health reimburses fee for service codes 99050, 99051, 99053 (after hours) to the primary care provider (PCP) fee schedule on standard Priority Health contracts.

• Payment will be made for all members of fully funded HMO, POS and PPO plans, with the exception of members with health savings accounts (HSAs) with unmet deductibles.
• No modifier is necessary to bill these codes.
• These codes are not payable for members of self-funded or shared-funded plans.
• These codes are not payable for members of Medicare, Medicaid or MIChild plans.

Read more about reimbursement for these services.

Reimbursement rates

The reimbursement rates for these codes already exist in our standard fee schedules, based on your geographical region.
Call the Provider Help Line or your provider representative to request your region's fee schedule.

Example of 99050:

1. The PCP provides services to a member after the office is closed. This does not count for scheduled clinic hours or walk-in. 
2. The PCP should document the special circumstances of the visit within the medical record.
3. The PCP report CPT 99050 in addition to the basic service

Example of 99051:

1. Services provided in the office during regularly scheduled evenings, weekend or holiday office hours.
2. Priority Health considers "after hours" to be any scheduled appointment after 5:00pm EST and prior to 8:00am EST.
   
3. The PCP reports CPT 99051 in addition to the basic service.

Example of 99053:

• 99053 is appropriate to use when a PCP comes into the ER between 10 p.m. and 8 a.m. to treat a patient. 
• It is not appropriate for an on-duty ER physician.
• It is incidental to any Evaluation and Management (E&M) service(s), surgical service(s), laboratory service(s), etc., when provided by emergency room physicians, anesthesiologists, radiologists, laboratory staff or any other provider scheduled to be onsite at the time the service was rendered.

Example:

1. A member refuses treatment from an ER physician and requests that his/her PCP comes to the facility to treat the illness/injury. The rendering PCP is called to the 24-hour facility to render unscheduled services.
2. Documentation within the medical record indicates the special circumstances of the visit.
3. The PCP reports CPT 99053 in addition to the basic service.

PriortyMedicare after hours billing

Refer to Correct Coding Initiative (CCI) edits prior to billing after-hours care for PriorityMedicare^SM members.


Read the Priority Health After-Hours Service policy.
Read the Priority Health PCMH After-Hours Service reimbursement policy (65KB PDF)


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