Click on the following links for service specific coding information  

Chiropractic Code Set

This file contains the billable code set that applies to chiropractic services rendered by licensed chiropractors. Any procedure billed outside of this code set by a chiropractor will be denied by the plan. Download

DME Code Sets   DME Modifier Requirements   This file contains coding specific to DME products that must be billed with a modifier. Modifiers communicate to the Plan whether the item is being purchased, rented, or is an inhalation product. Failure to submit an appropriate modifier with any of these HCPCS codes will result in a claim denial requesting an appropriate modifier. Download    DME Authorization Code Set   This file contains general DME items that require a pre-authorization for payment. Any code in this listing that is submitted on a claim where no authorization is present in Facets will deny as not authorized. Please Note: this file does not contain HCPCS codes for Oxygen & Respiratory Therapy Equipment that require prior authorization, this listing will be published shortly. As a general rule, all liquid oxygen requires a prior authorization, and high end respiratory therapy equipment also requires pre-authorization. Download    DME Capped Rental Code Set   This file contains any DME item that is considered a "Capped Rental". These items require a rental period of at least 13 months before the item is considered purchased for the member. A member may decide to continue renting, which allows for up to 15 months of rental. Please reference the General DME Payment Policy for details on capped rentals and appropriate modfier usage. Also, please note that items on this listing may or may not require pre-authorization. Please reference the Authorization Listing to identify a code that requires pre-authorization. Download    DME Modifier Code Set   This file contains valid DME related modifiers. Use of a modifier not identified on this listing will result in claim denials. Download    DME Rental Only Code Set   This file contains those DME items that may be rented only. These items are considered either "Frequently Serviced" or are "Oxygen Related" and may be rented for as long as the member requires the equipment. This is not a pre-authorization listing. Download    DME Wheelchair Code Set   This file details the Plan's coverage and coding criteria for wheelchairs. Download

Medication Code Set

This file contains all CPT/HCPCS codes related to injectable medications/vaccines that have an established price and therefore do not require invoices for pricing. This listing also identifies all medications dispensed that require pre-authorization from the Plan for payment. Failure to seek authorization where indicated will result in claim denial. Any CPT/HCPCS not listed that corresponds to a medication requires documentation for pricing. Documentation must include NDC number, drug name, strength, and quantity dispensed. This file also contains a small number of medication codes that do not have pricing but do require pre-authorization. These codes must be submitted with the additional documentation previously stated. Download

Optometry Code Set

This file contains the billable code set that applies to optometry services rendered by a licensed optometrist. Any procedure billed outside of this code set by an optometrist will be denied by the plan. Download

Podiatry Code Set

This file contains the billable code set that applies to podiatry services rendered by a licensed podiatrist. Any procedure billed outside of this code set by a podiatrist will be denied by the Plan. Download

Oral Nutrition Dispensing Guide

This file contains information specific to dispensing oral nutrition products. This guide will allow you to determine the appropriate number of cans to dispense, as well as the corresponding units to bill the Plan. All authorizations will be approved according to the unit values and can dispensing methods identified in this guide. Failure to dispense the authorized quantity may result in claim denial. Download

Note: The use of any CPT/HCPCS identified in these documents is not a guarantee of payment. Payment will be made based on the member's eligibility, authorization status, and other clinical criteria that may apply to a specific code or code set. BMC HealthNet Plan will update CPT/HCPCS codes as soon as possible, and provide relevant information to assist providers with the use of codes that are being replaced. However, terminated codes cannot be accepted by the Plan regardless of their presence on a code listing published by the Plan. Effective and termination dates for CPT/HCPCS codes as published by AMA or CMS are the dates used by the Plan for claim processing.