After-Hours Availability Incentive

Expanding access to timely care is a priority that Sunshine Health and our provider partners share. To support this effort, Sunshine Health offers incentives to providers who deliver care for members after their regular office hours. This initiative encourages greater availability beyond standard office hours, helping ensure members can access care at unexpected times when they need it most.

Note: Providers with capitated agreements are not eligible for incentive programs.

How Much is the Incentive?

Incentive: Sunshine Health offers payments for different specialty areas who provide services after-hours.

• $40 per member per appointment for:
  • Medical Doctors (MDs)
  • Doctor of Osteopathic Medicine (DOs)
  • Physician Assistants (PAs)
  • Psychologists (PhDs)
  • Nurse Practitioners (NPs)
    
• $15 per member per appointment for:
  • Occupational Therapist (OT)
  • Physical Therapist (PT)
  • Speech Therapist (ST)
  • Therapy Assistants

What is Considered After Hours?

• Healthcare services rendered from 5 p.m. to 8 a.m. local time
• All weekends
• All federally recognized holidays
• After-hours telehealth services are included
  

Which Providers are Eligible?

• Medical Doctors (MDs)
• Doctor of Osteopathic Medicine (DOs)
• Physician Assistants (PAs)
• Psychologists (PhDs)
• Nurse Practitioners (NPs)
• Therapists (Physical, Speech and Occupational Therapy/PT, ST, OT only)
  • Therapy Assistants included

This Guidance Applies to These Products

• Sunshine Health Medicaid (MMA)
• Comprehensive Long Term Care (LTC)
• Sunshine Health Pathway to Shine Child Welfare Specialty Plan (CWSP)
• Sunshine Health Mindful Pathways Serious Mental Illness Specialty Plan (SMI)
• Sunshine Health Power to Thrive HIV/AIDS Specialty Plan (HIV)
  

How to Indicate After-Hours Services?

Providers must use one of these procedure codes in addition to an Evaluation and Management (E/M) service code for services scheduled outside regularly scheduled hours:

• 99050: After-hours care provided in provider’s office outside of regular office hours.
• 99051: After-hours care provided during regularly scheduled evening, weekend or holiday office hours.
• 99060: After-hours emergency care.

Note: Modifiers are not needed when reporting after-hours services.

Important Notes

• Modifiers are not required when reporting after-hours services.
• After-hours reimbursement is limited to one payment per member, per date of service, per participating practice Taxpayer Identification Number (TIN).
  • If multiple after-hours eligible services are provided to the same member on the same date of service by practitioners billing under the same TIN, only one after-hours reimbursement will be issued
  • Example: If two providers within the same practice/TIN render after-hours eligible services to the same member on the same date of service, Sunshine Health will reimburse only one after-hours service for that member on that date.
• Eligible services must be rendered in an approved office-based setting that meets after-hours program requirements. Claims billed outside this setting, such as POS 03 (School), POS 12 (Home), or POS 99 (Other Place of Service) are not eligible for the after-hours reimbursement.
• Physical, occupational and speech therapy (PT, OT, and ST) services that are included within the authorized Prescribed Pediatric Extended Care (PPEC) program are not separately reimbursable.
• Providers must avoid duplicate billing for services already encompassed within the authorized PPEC service.

How is Sunshine Health Capturing this Information?

Sunshine Health will utilize claims data to verify when after-hours services were rendered, which indicates they occurred outside of regularly scheduled hours.

Please remember to indicate both the E&M code and after-hours code.

Corrected Claims

Providers who need to rebill with a corrected claim, please ensure to include both the E&M code and after-hours code.

Standards for Appointment Scheduling

Find the appointment standards for Sunshine Health (MMA).

2026 Federal Holidays

After-Hours Incentive Tips

• Visits that start during regular office hours but end after hours are not eligible for the incentive.
• Please ensure that your practice informs members about regular office hours and after-hours availability.
• Your website should be updated with your most current office hours and after-hours availability.

Note: Providers must have an updated W-9 tax form on file with the health plan to ensure no disruptions in payment. To update your W-9, utilize the Provider Demographics Updates tool.

Questions?

Contact your Sunshine Health Provider Engagement Account Manager (PEAM) or call Provider Services at 1-844-477-8313.