NC Medicaid Medicaid
Special Services: After Hours Clinical Coverage Policy No: 1A-38
Amended Date: August 15, 2023
23G17 i
To all beneficiaries enrolled in a Prepaid Health Plan (PHP): for questions about benefits and
services available on or after November 1, 2019, please contact your PHP.
Table of Contents
1.0 Description of the Procedure, Product, or Service ........................................................................... 1
1.1 Definitions .......................................................................................................................... 1
2.0 Eligibility Requirements .................................................................................................................. 1
2.1 Provisions............................................................................................................................ 1
2.1.1 General ................................................................................................................... 1
2.1.2 Specific .................................................................................................................. 1
2.2 Special Provisions ............................................................................................................... 2
2.2.1 EPSDT Special Provision: Exception to Policy Limitations for a Medicaid
Beneficiary under 21 Years of Age ....................................................................... 2
3.0 When the Procedure, Product, or Service Is Covered ...................................................................... 3
3.1 General Criteria Covered .................................................................................................... 3
3.2 Specific Criteria Covered .................................................................................................... 3
3.2.1 Specific criteria covered by Medicaid ................................................................... 3
3.2.2 Medicaid Additional Criteria Covered ................................................................... 3
4.0 When the Procedure, Product, or Service Is Not Covered ............................................................... 4
4.1 General Criteria Not Covered ............................................................................................. 4
4.2 Specific Criteria Not Covered ............................................................................................. 4
4.2.1 Specific Criteria Not Covered by Medicaid ........................................................... 4
4.2.2 Medicaid Additional Criteria Not Covered ............................................................ 4
5.0 Requirements for and Limitations on Coverage .............................................................................. 4
5.1 Prior Approval .................................................................................................................... 4
5.2 Limitations or Requirements............................................................................................... 5
6.0 Provider(s) Eligible to Bill for the Procedure, Product, or Service ................................................. 5
6.1 Provider Qualifications and Occupational Licensing Entity Regulations ........................... 5
6.2 Provider Certifications ........................................................................................................ 5
7.0 Additional Requirements ................................................................................................................. 5
7.1 Compliance ......................................................................................................................... 5
8.0 Policy Implementation/Revision Information .................................................................................. 6
Attachment A: Claims-Related Information ................................................................................................. 7
A. Claim Type ......................................................................................................................... 7
B. International Classification of Diseases and Related Health Problems, Tenth Revisions,
Clinical Modification (ICD-10-CM) and Procedural Coding System (PCS) ..................... 7
C. Code(s) ................................................................................................................................ 7
D. Modifiers ............................................................................................................................. 7
E. Billing Units ........................................................................................................................ 7
NC Medicaid Medicaid
Special Services: After Hours Clinical Coverage Policy No: 1A-38
Amended Date: August 15, 2023
23G17 ii
F. Place of Service .................................................................................................................. 8
G. Co-payments ....................................................................................................................... 8
H. Reimbursement ................................................................................................................... 8
NC Medicaid Medicaid
Special Services: After Hours Clinical Coverage Policy No: 1A-38
Amended Date: August 15, 2023
CPT codes, descriptors, and other data only are copyright 2018 American Medical Association.
All rights reserved. Applicable FARS/DFARS apply.
23G17 1
1.0 Description of the Procedure, Product, or Service
Special service (or miscellaneous office services) CPT codes represent urgent or emergent
services that are provided under special circumstances. Special service CPT codes are adjunct
services to outpatient evaluation and management services.
1.1 Definitions
None Apply.
2.0 Eligibility Requirements
2.1 Provisions
2.1.1 General
(The term “General” found throughout this policy applies to all Medicaid
policies)
a. An eligible beneficiary shall be enrolled in the NC Medicaid Program
(Medicaid is NC Medicaid program, unless context clearly indicates
otherwise).
b. Provider(s) shall verify each Medicaid beneficiary’s eligibility each time a
service is rendered.
c. The Medicaid beneficiary may have service restrictions due to their
eligibility category that would make them ineligible for this service.
2.1.2 Specific
(The term “Specific” found throughout this policy only applies to this policy)
a. Medicaid
None Apply.
NC Division of Medical Assistance Medicaid
Special Services: After Hours Clinical Coverage Policy No: 1A-38
Amended Date: August 15, 2023
23G17 2
2.2 Special Provisions
2.2.1 EPSDT Special Provision: Exception to Policy Limitations for a
Medicaid Beneficiary under 21 Years of Age
a. 42 U.S.C. § 1396d(r) [1905(r) of the Social Security Act]
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a
federal Medicaid requirement that requires the state Medicaid agency to
cover services, products, or procedures for Medicaid beneficiary under 21
years of age if the service is medically necessary health care to correct or
ameliorate a defect, physical or mental illness, or a condition [health
problem] identified through a screening examination (includes any
evaluation by a physician or other licensed practitioner).
This means EPSDT covers most of the medical or remedial care a child
needs to improve or maintain his or her health in the best condition possible,
compensate for a health problem, prevent it from worsening, or prevent the
development of additional health problems.
Medically necessary services will be provided in the most economic mode,
as long as the treatment made available is similarly efficacious to the service
requested by the beneficiary’s physician, therapist, or other licensed
practitioner; the determination process does not delay the delivery of the
needed service; and the determination does not limit the beneficiary’s right to
a free choice of providers.
EPSDT does not require the state Medicaid agency to provide any service,
product or procedure:
1. that is unsafe, ineffective, or experimental or investigational.
2. that is not medical in nature or not generally recognized as an accepted
method of medical practice or treatment.
Service limitations on scope, amount, duration, frequency, location of
service, and other specific criteria described in clinical coverage policies may
be exceeded or may not apply as long as the provider’s documentation shows
that the requested service is medically necessary “to correct or ameliorate a
defect, physical or mental illness, or a condition” [health problem]; that is,
provider documentation shows how the service, product, or procedure meets
all EPSDT criteria, including to correct or improve or maintain the
beneficiary’s health in the best condition possible, compensate for a health
problem, prevent it from worsening, or prevent the development of additional
health problems.
b. EPSDT and Prior Approval Requirements
1. If the service, product, or procedure requires prior approval, the fact that
the beneficiary is under 21 years of age does NOT eliminate the
requirement for prior approval.
2. IMPORTANT ADDITIONAL INFORMATION about EPSDT and
prior approval is found in the NCTracks Provider Claims and Billing
NC Division of Medical Assistance Medicaid
Special Services: After Hours Clinical Coverage Policy No: 1A-38
Amended Date: August 15, 2023
23G17 3
Assistance Guide, and on the EPSDT provider page. The Web addresses
are specified below.
NCTracks Provider Claims and Billing Assistance Guide:
https://www.nctracks.nc.gov/content/public/providers/provider-
manuals.html
EPSDT provider page: https://medicaid.ncdhhs.gov/
3.0 When the Procedure, Product, or Service Is Covered
Note: Refer to Subsection 2.2.1 regarding EPSDT Exception to Policy Limitations for a
Medicaid Beneficiary under 21 Years of Age.
3.1 General Criteria Covered
Medicaid shall cover the procedure, product, or service related to this policy when
medically necessary, and:
a. the procedure, product, or service is individualized, specific, and consistent with
symptoms or confirmed diagnosis of the illness or injury under treatment, and not in
excess of the beneficiary’s needs;
b. the procedure, product, or service can be safely furnished, and no equally effective
and more conservative or less costly treatment is available statewide; and
c. the procedure, product, or service is furnished in a manner not primarily intended for
the convenience of the beneficiary, the beneficiary’s caretaker, or the provider.
3.2 Specific Criteria Covered
3.2.1 Specific criteria covered by Medicaid
Special services codes are covered as follows:
a. When it is necessary for the physician to go into the office at times other
than regularly scheduled office hours or days when the office is normally
closed as on Saturday, Sunday or holidays to provide urgent or emergent
medical services to a beneficiary who may otherwise seek medical care in
a hospital emergency department.
b. When urgent or emergent care is provided in the office during regularly
scheduled evening, weekend or holiday hours, in addition to basic
service.
c. When urgent or emergent services are provided between the hours of
10:00 PM and 8:00 AM in a 24 hour facility, in addition to basic service.
d. When services are provided on an emergency basis in the office which
disrupts other scheduled office services, in addition to basic service.
e. When services are provided on an emergency basis out of the office,
which disrupts other scheduled office services, in addition to basic
service.
3.2.2 Medicaid Additional Criteria Covered
None Apply.
NC Division of Medical Assistance Medicaid
Special Services: After Hours Clinical Coverage Policy No: 1A-38
Amended Date: August 15, 2023
23G17 4
4.0 When the Procedure, Product, or Service Is Not Covered
Note: Refer to Subsection 2.2.1 regarding EPSDT Exception to Policy Limitations for a
Medicaid Beneficiary under 21 Years of Age.
4.1 General Criteria Not Covered
Medicaid shall not cover the procedure, product, or service related to this policy when:
a. the beneficiary does not meet the eligibility requirements listed in Section 2.0;
b. the beneficiary does not meet the criteria listed in Section 3.0;
c. the procedure, product, or service duplicates another provider’s procedure, product,
or service; or
d. the procedure, product, or service is experimental, investigational, or part of a clinical
trial.
4.2 Specific Criteria Not Covered
4.2.1 Specific Criteria Not Covered by Medicaid
a. Special services codes are not covered when routine medically necessary
services or health maintenance services are provided to beneficiaries.
Examples of some routine medical services and health maintenance services
are:
1. Scheduled appointments for medically necessary non-emergent and
non-urgent medical care.
2. Appointments scheduled outside of posted office hours for the
convenience of the provider.
b. Special Services CPT codes are not covered when the service is provided in
a hospital emergency department by physicians assigned to cover the
emergency department.
c. Special Services CPT codes are not covered when the service is provided in
the inpatient setting.
4.2.2 Medicaid Additional Criteria Not Covered
Special services codes are not covered when routine medically necessary services
or health maintenance services are provided to beneficiaries. Examples of some
routine medical services and health maintenance services are:
a. Adult preventive medicine health assessments for Medicaid beneficiaries
21 years of age and older.
b. Health Check screenings for Medicaid beneficiaries up to 21 years of age.
1. Dental services shall be provided on a restricted basis in accordance with
criteria adopted by the Department to implement this subsection.”
5.0 Requirements for and Limitations on Coverage
Note: Refer to Subsection 2.2.1 regarding EPSDT Exception to Policy Limitations for
Medicaid Beneficiaries under 21 Years of Age.
5.1 Prior Approval
Medicaid shall not require prior approval for special services after hours.
NC Division of Medical Assistance Medicaid
Special Services: After Hours Clinical Coverage Policy No: 1A-38
Amended Date: August 15, 2023
23G17 5
5.2 Limitations or Requirements
a. Documentation in the medical record must substantiate that the service was provided
in accordance with this policy.
b. Special services cannot be billed when a scheduled appointment begins during posted
office hours and ends after posted office hours are over.
c. One special service is billable per beneficiary per date of service.
6.0 Provider(s) Eligible to Bill for the Procedure, Product, or Service
To be eligible to bill for the procedure, product, or service related to this policy, the provider(s)
shall:
a. meet Medicaid qualifications for participation;
b. have a current and signed Department of Health and Human Services (DHHS) Provider
Administrative Participation Agreement; and
c. bill only for procedures, products, and services that are within the scope of their clinical
practice, as defined by the appropriate licensing entity.
6.1 Provider Qualifications and Occupational Licensing Entity Regulations
None Apply.
6.2 Provider Certifications
None Apply.
7.0 Additional Requirements
Note: Refer to Subsection 2.2.1 regarding EPSDT Exception to Policy Limitations for a
Medicaid Beneficiary under 21 Years of Age.
7.1 Compliance
Provider(s) shall comply with the following in effect at the time the service is rendered:
a. All applicable agreements, federal, state and local laws and regulations including the
Health Insurance Portability and Accountability Act (HIPAA) and record retention
requirements; and
b. All NC Medicaid’s clinical (medical) coverage policies, guidelines, policies, provider
manuals, implementation updates, and bulletins published by the Centers for
Medicare and Medicaid Services (CMS), DHHS, DHHS division(s) or fiscal
contractor(s).
NC Division of Medical Assistance Medicaid
Special Services: After Hours Clinical Coverage Policy No: 1A-38
Amended Date: August 15, 2023
23G17 6
8.0 Policy Implementation/Revision Information
Original Effective Date: November 1, 2003
Revision Information:
Date
Section Revised
Change
1/1/06
Section 1.0
The policy statement was revised to indicate that
special services represent urgent or emergent
services; the definition of posted office hours
was deleted.
1/1/06
Section 2.0
CPT codes 99052 and 99054 were end-dated
and deleted from the policy. The descriptions
for CPT codes 99050 and 99058 were revised.
CPT codes 99051, 99053, and 99060 were
added to the policy.
7/1/2010
Throughout
Policy Conversion: Implementation of Session
Law 2009-451, Section 10.32 “NC HEALTH
CHOICE/PROCEDURES FOR CHANGING
MEDICAL POLICY.”
3/12/12
Throughout
To be equivalent where applicable to NC
DMA’s General Policy # A1-under Session Law
2011-145 § 10.41.(b)
3/12/12
Throughout
Technical changes to merge Medicaid and
NCHC current coverage into one policy.
7/1/12
Attachment A: C
Technical change correcting wording in
description for CPT code 99050
10/01/2015
All Sections and
Attachments
Updated policy template language and added
ICD-10 codes to comply with federally
mandated 10/1/2015 implementation where
applicable.
03/15/2019
Table of Contents
Added, “To all beneficiaries enrolled in a
Prepaid Health Plan (PHP): for questions about
benefits and services available on or after
November 1, 2019, please contact your PHP.”
03/15/2019
All Sections and
Attachments
Updated policy template language.
08/15/2023
All Sections and
Attachments
Updated policy template language due to North
Carolina Health Choice Program’s move to
Medicaid. Policy posted 08/15/2023 with an
effective date of 4/1/2023.
NC Division of Medical Assistance Medicaid
Special Services: After Hours Clinical Coverage Policy No: 1A-38
Amended Date: August 15, 2023
23G17 7
Attachment A: Claims-Related Information
Provider(s) shall comply with the, NCTracks Provider Claims and Billing Assistance Guide, Medicaid
bulletins, fee schedules, NC Medicaid’s clinical coverage policies and any other relevant documents for
specific coverage and reimbursement for Medicaid:
A. Claim Type
Professional (CMS-1500/837P transaction)
B. International Classification of Diseases and Related Health Problems, Tenth
Revisions, Clinical Modification (ICD-10-CM) and Procedural Coding System (PCS)
Provider(s) shall report the ICD-10-CM and Procedural Coding System (PCS) to the highest level
of specificity that supports medical necessity. Provider(s) shall use the current ICD-10 edition and
any subsequent editions in effect at the time of service. Provider(s) shall refer to the applicable
edition for code description, as it is no longer documented in the policy.
C. Code(s)
Provider(s) shall report the most specific billing code that accurately and completely describes the
procedure, product or service provided. Provider(s) shall use the Current Procedural Terminology
(CPT), Health Care Procedure Coding System (HCPCS), and UB-04 Data Specifications Manual
(for a complete listing of valid revenue codes) and any subsequent editions in effect at the time of
service. Provider(s) shall refer to the applicable edition for the code description, as it is no longer
documented in the policy.
If no such specific CPT or HCPCS code exists, then the provider(s) shall report the procedure,
product or service using the appropriate unlisted procedure or service code.
CPT Code(s)
99050
99051
99053
99058
99060
Unlisted Procedure or Service
CPT: The provider(s) shall refer to and comply with the Instructions for Use of the CPT
Codebook, Unlisted Procedure or Service, and Special Report as documented in the current CPT in
effect at the time of service.
HCPCS: The provider(s) shall refer to and comply with the Instructions For Use of HCPCS
National Level II codes, Unlisted Procedure or Service and Special Report as documented in the
current HCPCS edition in effect at the time of service.
D. Modifiers
Provider(s) shall follow applicable modifier guidelines.
E. Billing Units
Provider(s) shall report the appropriate code(s) used which determines the billing unit(s).
NC Division of Medical Assistance Medicaid
Special Services: After Hours Clinical Coverage Policy No: 1A-38
Amended Date: August 15, 2023
23G17 8
F. Place of Service
Outpatient, Office.
G. Co-payments
For Medicaid refer to the NC Medicaid State Plan:
https://medicaid.ncdhhs.gov/meetings-notices/medicaid-state-plan-public-notices
H. Reimbursement
Provider(s) shall bill their usual and customary charges.
For a schedule of rates, refer to: https://medicaid.ncdhhs.gov/
