After-hours and Weekend Care

Policy Name:
After-hours and Weekend Care

Effective Date:
November 1, 2013

Last Revised Date:
January 23, 2015

PURPOSE:
This policy provides Horizon Blue Cross Blue Shield of New Jersey’s business rules for the reimbursement of after-hours and weekend care (CPT® Codes 99051-99060). This policy applies to participating and non-participating professional providers.

Scope:
All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
  • COB
  • ITS Host Medicare Advantage
  • FEP Non-Par

All Insured and Administrative Services Only (ASO) accounts are included.

Definitions:
99050:Service(s) delivered in the office outside of regularly scheduled office hours, in addition to basic service
99051:Service(s) delivered in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service
99053:Service(s) delivered from 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service
99056:Service(s) usually delivered in the office, or delivered out of the office at patient request, in addition to basic service
99058: Service(s) delivered in the office on an emergency basis, disrupting other scheduled office services, in addition to basic service
99060: Service(s) delivered on an emergency basis, out of the office, disrupting other scheduled office services, in addition to basic service

POLICY:
Horizon BCBSNJ shall not reimburse separately for after hour and weekend care in an office setting, except for CPT Code 99050. Reimbursement shall be considered included in the allowance of other services and shall be denied.

The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association.  In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure:
Procedure codes 99051, 999053, 99056, 99058, 99060 shall be denied as inclusive when billed with the appropriate evaluation and management procedure code.

In denied instances where the provider is participating, there shall be no member liability.

In denied instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge

LIMITATIONS AND EXCLUSIONS:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

CPT® is a registered trademark of the American Medical Association.

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