Policies

The policies below summarize BMC HealthNet Plan's medical coverage criteria and claims payment guidelines for specific services. You will also find policies related to administrative services.

The policies are used as a guide by the Plan to make clinical determinations regarding health care coverage and reimbursement. The Plan's policies undergo regular updates; check back often for the most up-to-date information. Providers are reminded that member eligibility is determined before medical coverage policies and reimbursement guidelines are applied to any claim. As a result, the Plan cannot guarantee payment when a member is ineligible or a non-covered benefit is rendered.

Type Title
Actigraphy Testing (Policy 3.712), Effective 10/01/18
Administratively Necessary Days (Policy 3.102), Effective 11/01/18
Ambulance and Transportation Services (Policy 3.191), Effective 04/01/19
Ambulatory Cardiac Monitors (Excluding Holter Monitors) (Policy 3.35), Effective 01/01/19
Autism Spectrum Disorders Medical Diagnosis and Treatment (Policy 3.724), Effective 06/01/18
Balloon Sinus Ostial Dilation (Policy 3.706), Effective 12/01/18
Biofeedback in an Outpatient Setting to Treat Bladder and/or Bowel Dysfunction (Including Incontinence) (Policy 3.969), Effective 01/01/19
Breast Reconstruction (Policy 3.43), Effective 06/01/18 and Retired 06/30/19
Breast Reconstruction (Policy 3.43), Effective 07/01/19
Breast Reduction Mammoplasty (Policy 3.44), Effective 05/01/19
Breast Reduction Mammoplasty (Policy 3.44), Effective 06/01/18 and Retired 04/30/19
Cardiac Rehabilitation, Outpatient (Policy 3.61), Effective 03/01/19 Used in Conjunction with InterQual Criteria Adopted 03/01/19
Car T-Cell Therapy with KYMRIAH or YESCARTA to Treat Hematological Malignancies (Policy 3.22), Effective 01/01/19
Central Auditory Function Evaluation to Diagnose Central Auditory Processing Disorder (Policy 3.82), Effective 07/01/18
Cervical Artificial Disc Replacement (Policy 3.421), Effective 03/01/18 and Retired 05/31/19
Cervical Artificial Disc Replacement (Policy 3.421), Effective 06/01/19 used in conjunction with InterQual criteria adopted 06/01/19
Chromosomal Microarray Analysis for Intellectual Disabilities and/or Multiple Congenital Anomalies (Policy 3.573), Effective 04/01/19
Clinical Review Criteria (Policy 3.201), Effective 12/01/18
Clinical Technology Evaluation (Policy 3.13), Effective 12/01/18
Clinical Trials (Policy 3.192), Effective 07/01/18
Cochlear Implants (Policy 3.301), Effective 06/01/18
Complementary and Alternative Medicine Including Acupuncture (Policy 3.194), Effective 05/01/19
Complementary and Alternative Medicine Including Acupuncture (Policy 3.194), Effective 04/01/19 and Retired 04/01/19
Contact Lens and Scleral Lens (Policy 3.28), Effective 05/01/18 and Retired 05/31/19
Contact Lens and Scleral Lens (Policy 3.28), Effective 06/01/19
Continuous Glucose Monitoring Systems and Insulin Delivery Devices (Policy 3.966), Effective 01/01/19
Cosmetic Reconstructive, and Restorative Services (Policy 3.69), Effective 07/01/18
Denervation of Facet Joints or Sacroiliac Joints (Policy 3.70), Effective 03/01/19
DNA Testing of Stool Samples with Cologuard to Screen for Colorectal Cancer (Policy 3.63), Policy Retired as of 07/01/19
DNA Testing of Stool Samples with Cologuard to Screen for Colorectal Cancer (Policy 3.63), Effective 06/01/18 and Retired 06/30/19
Drug Screening/Testing for Drugs of Abuse and/or Controlled Substances (Policy 3.98), Effective 06/01/19
Drug Screening/Testing for Drugs of Abuse and/or Controlled Substances (Policy 3.98), Effective 10/01/18 and Retired 05/31/19
Endoscopic Treatments for GERD in the Outpatient Setting (Including Transoral Incisionless Fundoplication) (Policy 3.46), Effective 12/01/18
Experimental and Investigational Treatment (Policy 3.12), Effective 07/01/18
Facet Joint Nerve Injections (Policy 3.9641), Effective 05/01/18 and Retired 04/30/19
Facet Joint Nerve Injections (Policy 3.9641), Effective 05/01/19
Gender Affirmation Surgeries (Policy 3.11), Effective 06/01/18
Gene Expression Profiling of Tumor Tissue to Predict Cancer Recurrence with Risk Stratification (Including Oncotype DX and Other Tests) (Policy 3.572), Effective 03/01/19
Genetic/Genomic Testing and Pharmacogenetics (Policy 3.727), Effective 04/01/19 and Retired 04/30/19
Genetic/Genomic Testing and Pharmacogenetics (Policy 3.727), Effective 05/01/19 and Retired 05/31/19
Genetic/Genomic Testing and Pharmacogenetics (Policy 3.727), Effective 06/01/19
Genetic Testing for Familial Malignant Melanoma (Policy 3.78), Effective 01/01/19
Genetic Testing for Fragile X-Associated Disorders (Policy 3.571), Effective 04/01/19
Genetic Testing for Hereditary Breast and Ovarian Cancer Syndrome (Policy 3.57), Effective 03/01/19
Genetic Testing for Hereditary Colorectal Cancer (Policy 3.64), Effective 04/01/19
Genetic Testing for Hereditary Thrombophilia (Policy 3.728), Effective 04/01/19
Gynecomastia Surgery (Policy 3.48), Effective 05/01/19
Gynecomastia Surgery (Policy 3.48), Effective 06/01/18 and Retired 04/30/19
Home Health Care (Policy 3.719), Effective 09/01/18
Home Prothrombin Time Monitoring Devices (Policy 3.27), Effective 02/01/19
Hyperbaric Oxygen Therapy (HBOT) or Topical Oxygen Therapy (TOT) (Policy 3.75) Effective 03/01/19 Used in Conjunction with InterQual Criteria Adopted 03/01/19
Implantable Bone-Conduction (Bone-Anchored) Hearing Aids (Policy 3.30), Effective 08/01/18
Infertility Services (Policy 3.725), Effective 09/01/18
Intensity Modulated Radiation Therapy, Outpatient (Policy 3.81), Effective 10/01/18
Lumbar Artificial Disc Replacement (Policy 3.42), Effective 03/01/18 and Retired 07/01/19 and Interqual Criteria Adopted 07/01/19
Lumbar Artificial Disc Replacement (Policy 3.42), Effective 07/01/19 used in conjunction with InterQual Criteria Adopted 07/01/19
Mastopexy (Policy 3.717), Effective 05/01/19
Mastopexy (Policy 3.717), Effective 06/01/18 and Retired 04/30/19
Mechanized Spinal Distraction Therapy (Policy 3.84), Effective 03/01/19
Medically Necessary Facility/Hospital Services to Provide Dental Services (Due to a Serious Medical Condition) (Policy 3.723), Effective 05/01/18 and Retired 04/30/19
Medically Necessary Facility/Hospital Services to Provide Dental Services (Due to a Serious Medical Condition) (Policy 3.723), Effective 05/01/19
Medically Necessary (Policy 3.14), Effective 11/1/18
Medical Nutrition Therapy in the Outpatient Setting or Office Setting (Policy 3.66) Effective 12/01/18
Minimally Invasive Procedures and Associated Devices used to Treat Back Pain (Including Thermal Intradiscal Procedures, Interspinous Spacers, Interlaminar Stabilization Devices, and Minimally Invasive Surgical Procedures for Spinal Fusion and/or to Remove Disc Material) (Policy 3.713), Effective 03/01/19
Nerve Repairs for Peripheral Nerve Injuries Using Allografts, Autografts, and Conduits (Policy 3.701), Effective 02/01/19
Occipital Nerve Stimulation (Policy 3.501), Effective 03/01/19
Occupational Therapy in the Outpatient Setting (Policy 3.53), Effective 12/01/18
Osteochondral Treatments for Defects of the Knee (Policy 3.965), Effective 03/01/18 and Retired 05/31/19
Osteochondral Treatments for Defects of the Knee, Talus, and Other Joints (Policy 3.965), Effective 06/01/19
Panniculectomy and Related Redundant Skin Surgery (Policy 3.722), Effective 02/01/19
Pelvic Floor Stimulation for the Treatment of Incontinence and/or Overactive Bladder (Policy 3.561), Effective 03/01/19
Photochemotherapy and Phototherapy for Dermatological Conditions in the Outpatient Setting (Policy 3.39), Effective 02/01/19
Physical Therapy in the Outpatient Setting (Policy 3.54), Effective 12/01/18 nd Retired 05/31/19
Physical Therapy in the Outpatient Setting (Policy 3.54), Effective 06/01/19
Posterior Tibial Nerve Stimulation (Percutaneous or Transcutaneous) (Policy 3.562), Effective 03/01/19
Preimplantation Genetic Testing (Preimplantation Genetic Diagnosis and Pregenetic Testing) (Policy 3.726), Effective 09/01/18
Private Duty Nursing Services (Policy 3.715), Effective 01/01/19
Prolotherapy (Policy 3.707), Effective 10/01/18
Pulmonary Rehabilitation, Outpatient (Policy 3.62), Effective 02/01/19
Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions (Policy 3.563), Effective 01/01/19
Sacroiliac Joint Injections (Policy 3.9642), Effective 03/01/19
Skin Substitutes in the Outpatient Setting (Policy 3.710), Effective 02/01/19
Speech Therapy, Language Therapy, Voice Therapy, or Auditory Rehabilitation for a Member Age 20 or Younger in the Outpatient Setting (Policy 3.55), Effective 02/01/19
Speech Therapy, Language Therapy, Voice Therapy, or Auditory Rehabilitation for a Member Age 21 or Older in the Outpatient Setting (Policy 3.551), Effective 02/01/19
Temporomandibular Joint Disorder Treatment (Policy 3.968), Effective 01/01/19
Transplantation Administrative (Policy 3.10), Effective 04/01/19
Transplantation of Lung or Lobar Lung (Policy 3.24), Effective 04/01/19
Transplantation of Pancreas or Pancreas-Kidney (Policy 3.25), Effective 04/01/18 and Retired 05/31/19
Transplantation of Pancreas or Pancreas-Kidney (Policy 3.25), Effective 06/01/19
Transplantation of Small Bowel, Small Bowel-Liver, or Multivisceral Organs (Policy 3.26), Effective 04/01/18 and Retired 05/31/19
Transplantation of Small Bowel, Small Bowel-Liver, or Multivisceral Organs (Policy 3.26), Effective 06/01/19
Tube Fed Enteral Nutrition Products (Supplied and Billed by Home Infusion Providers) and Digestive Enzyme Cartridges (Policy 3.37), Effective 01/01/19
Video Electroencephalography (EEG) Monitoring (Policy 3.38), Effective 07/01/19
Video Electroencephalography (EEG) Monitoring (Policy 3.38), Effective 05/01/18 and Retired 06/30/19
Vision Therapy (Policy 3.40), Effective 04/01/18 and Retired 05/31/19
Vision Therapy (Policy 3.40), Effective 06/01/19
Whole Body Integumentary Photography (Policy 3.702), Effective 10/01/18
Type Title Plan Type
Acupuncture Services (Policy 4.4), Effective 04/01/15
MassHealth or QHP
Anesthesia (Policy 4.103), Effective 01/01/17
MassHealth or QHP
Bilateral and Multiple Procedure Reduction (Policy 4.607), Effective 04/01/15
MassHealth or QHP
Chemotherapy (Policy 4.11), Effective 07/01/16
MassHealth or QHP
Chiropractic Services (Spinal Manipulation) (Policy 4.116), Effective 01/01/16
MassHealth or QHP
Chronic Maintenance Dialysis performed in Freestanding Dialysis Clinics (Policy 4.95), Effective 12/22/14
MassHealth or QHP
Clinical Trials (Policy 4.134), Effective 07/01/15, Retired 6/30/2019
MassHealth or QHP
Clinical Trials (Policy 4.134), Effective 07/01/2019
MassHealth or QHP
Community Health Centers and Federally Qualified Health Centers (Policy 4.107), Effective 08/01/18
MassHealth or QHP
Dental Services (Policy 4.15), Effective 07/01/15
MassHealth or QHP
Diabetes Self-Management Training / Medical Nutrition Therapy (Policy 4.32), Effective 05/01/18
MassHealth or QHP
Drug Screening/Testing (DS/T): Drugs of Abuse (Policy 4.94), Effective 01/01/18
MassHealth or QHP
Early Intervention (Policy 4.3), Effective 10/01/16
MassHealth or QHP
Family Planning, Sterilization and Abortion Services (Policy 4.115), Effective 01/01/18
MassHealth or QHP
Free Standing Surgical Facility (Policy 4.114), Effective 04/01/16
MassHealth or QHP
General Billing and Coding Guidelines (Policy 4.31), Effective 06/01/18
MassHealth or QHP
General Clinical Editing and Payment Accuracy Review Guidelines (Policy 4.108), Effective 11/01/18
MassHealth or QHP
Hearing Aid Dispensing and Repairs (Policy 4.111), Effective 01/01/19
MassHealth or QHP
Home Health (Policy 4.7), Effective 05/01/18
MassHealth or QHP
Home Infusion including Parenteral/Tube Fed Enteral Nutritional Therapy (Policy 4.121), Effective 01/01/19
MassHealth or QHP
Hospice (Policy 4.8), Effective 06/01/18
MassHealth or QHP
Immunization Services (Policy 4.117), Effective 05/01/18
MassHealth or QHP
Infertility Services (Policy 4.34), Effective 07/01/15
MassHealth or QHP
Inpatient Hospital (Policy 4.110), Effective 04/01/19
MassHealth or QHP
Modifiers (Policy 4.23), Effective 05/15/19
MassHealth or QHP
Newborn and Neonatal Intensive Care Unit (NICU) Services (Policy 4.106), Effective 09/01/15
MassHealth or QHP
Non-Priced Codes (Policy 4.37), Effective 10/01/17
MassHealth or QHP
Non-Reimbursed Codes (Policy 4.48), Effective 04/01/19
MassHealth or QHP
Observation Services (Policy 4.36), Effective 12/30/16
MassHealth or QHP
Obstetrical (Policy 4.105), Effective 04/17/17
MassHealth or QHP
Outpatient Hospital (Policy 4.17), Effective 12/30/16
MassHealth or QHP
Physical, Occupational and Speech Rehabilitation Modalities and Therapeutic Procedures (Policy 4.609), Effective 01/01/19
MassHealth or QHP
Physician and Non-Physician Practitioner Services (Policy 4.608), Effective 01/01/19
MassHealth or QHP
Private Duty Nursing (Policy 4.39), Effective 03/01/18
MassHealth or QHP
Provider Preventable Conditions and Serious Reportable Events (Policy 4.610), Effective 04/01/15
MassHealth or QHP
Sleep Studies (Policy 4.5), Effective 08/01/19
MassHealth or QHP
Sleep Studies (Policy 4.5), Retired 07/31/19
MassHealth or QHP
Telemedicine Services (Policy 4.33)), Effective 01/01/19
MassHealth or QHP
Transportation (Policy 4.113), Effective 03/01/18
MassHealth or QHP
Urgent Care (Policy 4.96), Effective 10/01/18
MassHealth or QHP
Vision Services (Policy 4.38), Effective 04/01/19
MassHealth or QHP
Adult and Group Foster Care (SCO 4.21), Effective 04/01/19
SCO
Adult Day Health (SCO 4.20), Effective 01/01/16
SCO
Aging Service Access Points (ASAP) (SCO 4.24), Effective 04/01/19
SCO
Ambulance (SCO 4.113), Effective 01/01/16
SCO
Ambulatory Surgical Center - Facility (SCO 4.114), Effective 01/01/16
SCO
Anesthesia (SCO 4.103), Effective 01/01/17
SCO
Bilateral and Multiple Procedure Reductions (SCO 4.607), Effective 03/01/18
SCO
Chiropractic Services (Spinal Manipulation) (SCO 4.116), Effective 01/01/16
SCO
Clinical Trials, (SCO 4.134), Effective 07/01/2019
SCO
Clinical Trials (SCO 4.134), Effective 01/01/16, Retired 06/30/2019
SCO
Day Habilitation (SCO 4.22), Effective 01/01/16
SCO
End-Stage Renal Disease -Dialysis (SCO 4.95), Effective 01/01/16
SCO
General Billing and Coding Guidelines (SCO 4.31), Effective 01/01/18
SCO
General Clinical Editing and Payment Accuracy Review Guidelines (SCO 4.108), Effective 11/01/18
SCO
Hearing Aid Dispensing and Repairs (SCO 4.111), Effective 01/01/19
SCO
Medicare Certified Home Health Agency Services, (SCO 4.7), Effective 05/01/2019
SCO
Hospice (SCO 4.8), Effective 06/01/18
SCO
Inpatient Rehabilitation Hospital (SCO 4.71), Effective 01/01/16
SCO
Inpatient (SCO 4.110), Effective 10/01/18
SCO
Modifiers (SCO 4.23), Effective 01/01/16
SCO
Non-Medicare Certified Home Health Agency Services (SCO 4.6), Effective 05/01/2019
SCO
Outpatient Hospital (SCO 4.17), Effective 01/01/16
SCO
Outpatient Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST) (SCO 4.609), Effective 01/01/19
SCO
Personal Care Attendant (SCO 4.25), Effective 04/01/19
SCO
Personal Care Management Services (SCO 4.26), Effective 04/01/19
SCO
Physician / Non-Physician Practitioner Services (SCO 4.608), Effective 01/01/16
SCO
Podiatry Services (SCO 4.72), Effective 01/01/16
SCO
Private Duty Nursing (SCO 4.27), Effective 01/01/16
SCO
Provider Preventable Conditions (PPC) and Serious Reportable Events (SRE) (SCO 4.610), Effective 01/01/16
SCO

We're Here to Help

Contact Us