Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE:04|01|2010 POLICY LAST REVIEWED: 02|19|2025

OVERVIEW: Special services, procedures, and reports codes provide the reporting physician (or other qualified healthcare professional) with the means of identifying the completion of these special reports and services as an adjunct to the basic services rendered. The specific CPT code number assigned indicates the special circumstances under which a basic procedure is performed.

MEDICAL CRITERIA:
Not applicable.

PRIOR AUTHORIZATION:
Not applicable

POLICY: Medicare Advantage Plans and Commercial Products Any urgently scheduled evaluation and management visit (E&M) rendered outside of a provider’s routine hours e.g. 8AM-5PM*, Monday through Friday (except holidays), may be filed with CPT 99050 added. CPT 99050 may not be reported for routine or preventative services. "Urgently scheduled" would typically be the same day or within 24 hours of the request for an acute problem or acute exacerbation of chronic illness.

• Note: While physician offices have varying hours, BCBSRI considers normal office hours to be between 8:00 a.m. and 5:00 p.m., Monday through Friday.

  Claims for services requested after regularly scheduled office hours, in addition to basic services (e.g., services requested on Sundays and holidays, 99050), are limited to the following specialties: • Pediatricians
  • Family practitioners
  • Internal medicine
  • Advanced Practice Providers (PCP specialties) • OB/GYN physicians functioning as PCPs

  When filing code 99050, advanced practice providers (PCP Specialties) will be reimbursed according to their appropriate fee schedule for this service.

  Urgent care centers, emergency room providers, and others not listed above are excluded from receiving the additional reimbursement.

  COVERAGE: Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage or Subscriber Agreement for applicable benefits/coverage.

  CODING: The following service is covered and separately reimbursed when filed with 99201-99215 only
  99050: Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g., holidays, Sundays, or Saturdays), in addition to basic service Payment Policy | After Hours: Special Services, Procedures and Reports

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

The following services are covered but not separately reimbursed: 99051: Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service
99053: Service(s) provided between 10:00pm and 8:00AM at 24-hour facility; in addition to basic service
99056: Service(s) typically provided in the office, provided out of the office at the request of the patient, in addition to basic service
99058: Service(s) provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service (as of May 1, 2008) 99060: Service(s) provided on an emergency basis, out of the office, which disrupts other scheduled office services, in addition to basic service

RELATED POLICIES: None

PUBLISHED: Provider Update, March 2025 Provider Update, April 2023 Provider Update, May 2020 Provider Update, July 2018 Provider Update, August 2017 Provider Update, Feb 2003

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This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM