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 10/01/19
Administratively Necessary Days (Policy 3.102), Effective 10/01/19
Ambulance and Transportation Services (Policy 3.191), Effective 01/01/20
Ambulatory Cardiac Monitors (Excluding Holter Monitors) (Policy 3.35), Effective 01/01/20
Autism Spectrum Disorders Medical Diagnosis and Treatment (Policy 3.724), Effective 06/01/19
Balloon Sinus Ostial Dilation (Policy 3.706), Effective 01/01/20
Biofeedback-in-OP-Setting-Effective-01_01_20
Biofeedback in an Outpatient Setting to Treat Incontinence or Constipation(Policy 3.969), Effective 01/01/20
Breast Reconstruction (Policy 3.43), Effective 02/01/20
Breast Reconstruction (Policy 3.43), Effective 07/01/19 and Retired 01/31/2020
Breast Reduction Mammoplasty (Policy 3.44), Effective 05/01/19
Cardiac Rehabilitation, Outpatient (Policy 3.61), Effective 12/01/19 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 12/01/19
Central Auditory Function Evaluation to Diagnose Central Auditory Processing Disorder (Policy 3.82), Effective 01/01/20
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 01/01/20 with InterQual Criteria Adopted 10/01/19 and Retired 01/31/20
Chromosomal Microarray Analysis for Intellectual Disabilities and/or Multiple Congenital Anomalies (Policy 3.573), Effective 02/01/20 with InterQual Criteria Adopted 10/01/19
Clinical Review Criteria (Policy 3.201), Effective 01/01/20
Clinical Technology Evaluation (Policy 3.13), Effective 01/01/20
Clinical Trials (Policy 3.192), Effective 08/01/19
Cochlear Implants (Policy 3.301), Effective 02/01/20
Cochlear Implants (Policy 3.301), Effective 08/01/19 and Retired 01/31/20
Complementary and Alternative Medicine, Including Acupuncture (Policy 3.194), Effective 01/01/20
Contact Lens and Scleral Lens (Policy 3.28), Effective 06/01/19
Continuous Glucose Monitoring Systems, Artificial Pancreas Devices and Insulin Delivery Devices (Policy 3.966), Effective 12/01/19
Cosmetic Reconstructive, and Restorative Services (Policy 3.69), Effective 02/01/20
Cosmetic Reconstructive, and Restorative Services (Policy 3.69), Effective 07/01/19 and Retired 01/31/20
Denervation of Facet Joints or Sacroiliac Joints (Policy 3.70), Effective 03/01/19
Drug Screening/Testing for Drugs of Abuse and/or Controlled Substances (Policy 3.98), Effective 10/01/19
Endoscopic Treatments for GERD in the Outpatient Setting (Policy 3.46), Effective 10/01/19
Experimental and Investigational Treatment (Policy 3.12), Effective 07/01/19
Facet Joint Nerve Injections (Policy 3.9641), Effective 05/01/19
Gender Affirmation Surgeries (Policy 3.11), Effective 01/01/20
Gene Expression Profiling of Tumor Tissue to Predict Cancer Recurrence with Risk Stratification (Including Oncotype DX and Other Tests) (Policy 3.572), Retire Medical Policy and Adopt InterQual Criteria as of 10/01/19
Genetic/Genomic Testing and Pharmacogenetics (Policy 3.727), Effective 01/01/20 and Retired 03/31/20 with InterQual Criteria Adopted to Coincide with Policy
Genetic/Genomic Testing and Pharmacogenetics (Policy 3.727), Effective 04/01/20 with InterQual Criteria Adopted to Coincide with Policy
Genetic Testing for Familial Malignant Melanoma (Policy 3.78), Retire Medical Policy and Adopt InterQual Criteria as of 10/01/19
Genetic Testing for Fragile X-Associated Disorders (Policy 3.571), Effective 02/01/20 with InterQual Criteria Adopted to Coincide with Policy
Genetic Testing for Fragile X-Associated Disorders (Policy 3.571), Effective 10/01/19 and Retired 01/31/20 with InterQual Criteria Adopted to Coincide with Policy
Genetic Testing for Hereditary Breast and Ovarian Cancer Syndrome (Policy 3.57), Retire Medical Policy and Adopt InterQual Criteria as of 10/01/19
Genetic Testing for Hereditary Colorectal Cancer (Policy 3.64), Retire Medical Policy and Adopt InterQual Criteria as of 10/01/19
Genetic Testing for Hereditary Thrombophilia (Policy 3.728), Effective 04/01/20
Genetic Testing for Hereditary Thrombophilia (Policy 3.728), Effective 10/01/19 and Retired 03/31/20
Gynecomastia Surgery (Policy 3.48), Effective 05/01/19
Home Health Care (Policy 3.719), Effective 02/01/2020
Home Health Care (Policy 3.719), Effective 07/01/19 and Retired 01/31/2020
Home Prothrombin Time Monitoring Devices (Policy 3.27), Effective 03/01/20
Home Prothrombin Time Monitoring Devices (Policy 3.27), Effective 02/01/19 and Retired 02/28/20
Hyperbaric Oxygen Therapy (HBOT) or Topical Oxygen Therapy (TOT) (Policy 3.75) Effective 12/01/19 Used in Conjunction with InterQual Criteria
Implantable Bone-Conduction (Bone-Anchored) Hearing Aids (Policy 3.30), Effective 08/01/19
Infertility Services (Policy 3.725), Effective 09/01/19
Intensity Modulated Radiation Therapy, Outpatient (Policy 3.81), Effective 10/01/19
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
Mechanized Spinal Distraction Therapy (Policy 3.84), Effective 03/01/19
Medically Necessary (Policy 3.14), Effective 01/01/20
Medically Necessary Facility/Hospital Services to Provide Dental Services (Due to a Serious Medical Condition) (Policy 3.723), Effective 07/01/19
Medical Nutrition Therapy in the Outpatient Setting or Office Setting (Policy 3.66) Effective 12/01/19
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 0/01/20
Occipital Nerve Stimulation (Policy 3.501), Effective 02/01/20
Occipital Nerve Stimulation (Policy 3.501), Effective 03/01/19 and Retired 01/31/20
Occupational Therapy in the Outpatient Setting (Policy 3.53), Effective 01/01/20 and Retired 01/31/20
Occupational Therapy in the Outpatient Setting (Policy 3.53), Effective 02/01/20 and Retired 02/29/20
Occupational Therapy in the Outpatient Setting (Policy 3.53), Effective 03/01/20
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 12/01/19
Pelvic Floor Stimulation for the Treatment of Incontinence and/or Overactive Bladder (Policy 3.561), Effective 10/01/19
Photochemotherapy and Phototherapy for Dermatological Conditions in the Outpatient Setting (Policy 3.39), Effective 02/01/20
Photochemotherapy and Phototherapy for Dermatological Conditions in the Outpatient Setting (Policy 3.39), Effective 02/01/19 and Retired 01/31/20
Physical Therapy in the Outpatient Setting (Policy 3.54), Effective 01/01/20 and Retired 01/31/20
Physical Therapy in the Outpatient Setting (Policy 3.54), Effective 02/01/20 and Retired 02/29/20
Physical Therapy in the Outpatient Setting (Policy 3.54), Effective 03/01/20 and Retired 03/31/20
Physical Therapy in the Outpatient Setting (Policy 3.54), Effective 04/01/20
Posterior Tibial Nerve Stimulation (Percutaneous or Transcutaneous) (Policy 3.562), Effective 12/01/19
Preimplantation Genetic Testing (Policy 3.726) Effective 09/01/19
Private Duty Nursing Services (Policy 3.715), Effective 09/01/19
Prolotherapy (Policy 3.707), Effective 10/01/19
Pulmonary Rehabilitation, Outpatient (Policy 3.62), Effective 02/01/19 and policy Retired 02/28/20, InterQual Criteria Adopted
Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions (Policy 3.563), Effective 10/01/19
Sacroiliac Joint Injections (Policy 3.9642), Effective 03/01/19
Skin Substitutes in the Outpatient Setting (Policy 3.710), Effective 01/01/20
Speech Therapy, Language Therapy, Voice Therapy, or Auditory Rehabilitation for a Member Age 20 or Younger in the Outpatient Setting (Policy 3.55), Effective 10/01/19
Speech Therapy, Language Therapy, Voice Therapy, or Auditory Rehabilitation for a Member Age 21 or Older in the Outpatient Setting (Policy 3.551), Effective 01/01/20 and Retired 01/31/20
Speech Therapy, Language Therapy, Voice Therapy, or Auditory Rehabilitation for a Member Age 21 or Older in the Outpatient Setting (Policy 3.551), Effective 02/01/20
Temporomandibular Joint Disorder Treatment (Policy 3.968), Effective 12/01/19
Transplant Administration (Policy 3.10), Effective 04/01/19
Transplantation of Lung or Lobar Lung (Policy 3.24), Effective 06/01/19
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 06/01/19
Tube Fed Enteral Nutrition Products (Supplied and Billed by Home Infusion Providers) and Digestive Enzyme Cartridges (Policy 3.37), Effective 08/01/19
Video Electroencephalography (EEG) Monitoring (Policy 3.38), Effective 01/01/20
Vision Therapy (Policy 3.40), Effective 02/01/20
Vision Therapy (Policy 3.40), Effective 06/01/19 and Retired 01/31/20
Whole Body Integumentary Photography (Policy 3.702), Effective 10/01/19
Type Title Plan Type
Acupuncture Services (Policy 4.4), Effective 10/01/19
MassHealth or QHP
Anesthesia (Policy 4.103), Effective 01/01/17
MassHealth or QHP
Bilateral and Multiple Procedure Reduction (Policy 4.607), Effective 10/01/19
MassHealth or QHP
Chemotherapy (Policy 4.11), Effective 07/01/16
MassHealth or QHP
Chiropractic Services (Spinal Manipulation) (Policy 4.116), Effective 01/01/20
MassHealth or QHP
Chronic Maintenance Dialysis performed in Freestanding Dialysis Clinics (Policy 4.95), Effective 07/01/19
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 01/01/20
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 04/15/2020
MassHealth or QHP
Drug Screening/Testing (DS/T): Drugs of Abuse (Policy 4.94), Effective 12/11/19
MassHealth or QHP
Early Intervention (Policy 4.3), Effective 01/01/20
MassHealth or QHP
Family Planning, Sterilization and Abortion Services (Policy 4.115), Effective 07/01/19
MassHealth or QHP
Free Standing Surgical Facility (Policy 4.114), Effective 01/01/20
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 07/01/19
MassHealth or QHP
Home Infusion including Parenteral/Tube Fed Enteral Nutritional Therapy (Policy 4.121), Effective 01/01/20
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 10/01/19
MassHealth or QHP
Inpatient Hospital (Policy 4.110), Effective 12/01/19
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 07/01/19
MassHealth or QHP
Non-Reimbursed Codes (Policy 4.48), Effective 01/01/20
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 01/01/20
MassHealth or QHP
Physician and Non-Physician Practitioner Services (Policy 4.608), Effective 10/01/19
MassHealth or QHP
Preventive Services (Policy 4.6), Effective 10/01/19
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 07/01/19
MassHealth or QHP
Sleep Studies (Policy 4.5), Effective 08/01/19
MassHealth or QHP
Telemedicine Services (Policy 4.33)), Effective 01/01/19
MassHealth or QHP
Transportation (Policy 4.113), Effective 01/01/20
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 01/01/20
SCO
Ambulatory Surgical Center - Facility (SCO 4.114), Effective 01/01/20
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 01/01/20
SCO
Clinical Trials, (SCO 4.134), Effective 07/01/2019
SCO
Day Habilitation (SCO 4.22), Effective 10/01/19
SCO
End-Stage Renal Disease -Dialysis (SCO 4.95), Effective 07/01/19
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
Home Health Agency Services: Medicare-Certified (SCO 4.7), Effective 01/01/20
SCO
Home Health Agency Services: Medicare-Certified (SCO 4.7), Effective 05/01/2019 and Retired: Episodes beginning on or before 12/31/2019
SCO
Home Health Agency Services: Non-Medicare Certified (SCO 4.6), Effective 05/01/2019
SCO
Hospice (SCO 4.8), Effective 06/01/18
SCO
Inpatient Rehabilitation Hospital (SCO 4.71), Effective 01/01/20
SCO
Inpatient (SCO 4.110), Effective 10/01/18
SCO
Modifiers (SCO 4.23), Effective 01/01/16
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 01/01/20
SCO
Personal Care Attendant (SCO 4.25), Effective 01/01/20
SCO
Personal Care Management Services (SCO 4.26), Effective 01/01/20
SCO
Physician / Non-Physician Practitioner Services (SCO 4.608), Effective 07/01/19
SCO
Podiatry Services (SCO 4.72), Effective 10/01/19
SCO
Private Duty Nursing (SCO 4.27), Effective 01/01/20
SCO
Provider Preventable Conditions (PPC) and Serious Reportable Events (SRE) (SCO 4.610), Effective 07/01/19
SCO

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