After-hours primary care services
Commercial group HMO, EPO, POS and PPO plans
Commercial individual MyPriority® plans
Priority Health reimburses primary care providers (PCPs) for after-hours services to commercial plan members fee-for-service. No modifier is necessary to bill these codes.
Payment will be made for members of employer-sponsored and MyPrioritySM HMO, POS and PPO plans for the codes listed below.
These codes are not payable for members of Medicare, Medicaid, or Healthy Michigan Plan plans.
Before billing for after-hours care for Priority Health Medicare Advantage plan members, refer to Correct Coding Initiative (CCI) edits.
The reimbursement rates for these codes are stated in the standard fee schedules for your contract.
Go to our standard fee schedules.
Billable after-hours service codes
- Applies to services supplied to a member by a PCP when the office is normally closed. Scheduled clinic hours or walk-in hours do not apply.
- Document the special circumstances of the visit in the medical record.
- Report CPT 99050 in addition to the basic service.
- Applies to services supplied to a member by a PCP during regularly scheduled evening, weekend or holiday office hours.
- Priority Health considers "after hours" to be any scheduled appointment after 5:00pm EST and prior to 8:00am EST.
- Report CPT 99051 in addition to the basic service.
- Applies when a PCP comes into the ER between 10 p.m. and 8 a.m. to treat a patient.
- Not billable for an on-duty ER physician.
- 99053 is incidental to any 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.
- 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.
- Documentation within the medical record indicates the special circumstances of the visit.
- The PCP reports CPT 99053 in addition to the basic service.