Reimbursement

Plan Reimbursement Guidelines

The guidelines below summarize BMC HealthNet Plan's claims payment editing logic for specific services. These reimbursement guidelines were developed by the Plan and undergo regular updates to account for code additions and deletions, and clinical code edits based on current coding conventions.

Providers are reminded that benefits and eligibility are determined before medical guidelines and reimbursement guidelines are applied to any given claim. As a result, adherence to these reimbursement guidelines does not guarantee payment when a member is ineligible or a non-covered benefit is rendered.

The definitions used throughout these policy statements have been centralized into a single location. These may be accessed through the below link:

Reimbursement Policies

• Anesthesia Reimbursement Policy 
• Chemotherapy Reimbursement Policy 
• Chiropractic Services Reimbursement Policy 
• Clinical Trials  
• Dental Reimbursement Policy 
• Enterals Parenterals and Infusion Reimbursement Policy
• Family Planning Reimbursement Policy 
• Early Intervention Reimbursement Policy
• FQHC and CHC Reimbursement Policy
• Free Standing Surgical Facility Reimbursement Policy 
• General Billing and Coding Reimbursement Policy
• General Editing Guidelines 
• General Physician Reimbursement Policy  
• Hearing Aid Reimbursement 
• Home Health Reimbursement Policy 
• Hospice Reimbursement Policy 
• Infertility Services Reimbursement Policy 
• Immunization Reimbursement Policy
• Inpatient Hospital Reimbursement Policy 
• Multiple Procedure Reduction Reimbursement Policy 
• Obstetrical Reimbursement Policy
• Outpatient Hospital Reimbursement 
• Observation Reimbursement Policy 
• Physical Rehabilitation Modalities and Therapeutic Procedures Reimbursement Policy 
• Serious Reportable Events Reimbursement Policy
• Transportation Reimbursement Policy
• Urine Drug Screening Reimbursement Policy 
• Vision Reimbursement Policy