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 OCA 3.712), Effective 08/01/20
Administratively Necessary Days (Policy OCA 3.102), Effective 10/01/20
Ambulance and Transportation Services (Policy OCA 3.191), Effective 06/01/20
Ambulatory Cardiac Monitors (Excluding Holter Monitors) (Policy OCA 3.35), Effective 10/01/20
Autism Spectrum Disorders Medical Diagnosis and Treatment (Policy OCA 3.724), Effective 08/01/20
Balloon Sinus Ostial Dilation (Policy OCA 3.706), Effective 08/01/20
Biofeedback in an Outpatient Setting to Treat Incontinence or Constipation (Policy OCA 3.969), Effective 10/01/20
Breast Reconstruction (Policy OCA 3.43), Effective 05/01/20
Breast Reduction Mammoplasty (Policy OCA 3.44), Effective 07/01/19
Cardiac Rehabilitation, Outpatient (Policy OCA 3.61), Effective 12/01/20 Used in Conjunction with InterQual Criteria Adopted 03/01/19
Cardiac Rehabilitation, Outpatient (Policy OCA 3.61), Effective 12/01/19 and Retired 11/30/20 Used in Conjunction with InterQual Criteria Adopted 03/01/19
Car T-Cell Therapy with KYMRIAH or YESCARTA to Treat Hematological Malignancies (Policy OCA 3.22), Effective 08/01/20 and Retired 11/30/20
Car T-Cell Therapy with KYMRIAH or YESCARTA to Treat Hematological Malignancies (Policy OCA 3.22), Effective 12/01/20
Central Auditory Function Evaluation to Diagnose Central Auditory Processing Disorder (Policy OCA 3.82), Effective 01/01/20
Chromosomal Microarray Analysis for Intellectual Disabilities and/or Multiple Congenital Anomalies (Policy OCA 3.573), Effective 02/01/20 with InterQual Criteria Adopted 10/01/19
Clinical Review Criteria (Policy OCA 3.201), Effective 07/01/20
Clinical Technology Evaluation (Policy OCA 3.13), Effective 07/01/20
Clinical Trials (Policy OCA 3.192), Effective 09/01/20
Cochlear Implants (Policy OCA 3.301), Effective 10/01/20
Complementary and Alternative Medicine, Including Acupuncture (Policy OCA 3.194), Effective 07/01/20
Contact Lens and Scleral Lens (Policy OCA 3.28), Effective 10/01/20
Continuous Glucose Monitoring Systems, Artificial Pancreas Devices and Insulin Delivery Devices (Policy OCA 3.966), Effective 10/01/20 and Retired 11/30/20
Continuous Glucose Monitoring Systems, Artificial Pancreas Devices and Insulin Delivery Devices (Policy OCA 3.966), Effective 12/01/20
Cosmetic Reconstructive, and Restorative Services (Policy OCA 3.69), Effective 07/01/20
Denervation of Facet Joints or Sacroiliac Joints (Policy OCA 3.70), Effective 02/01/21
Denervation of Facet Joints or Sacroiliac Joints (Policy OCA 3.70), Effective 03/01/20 and Retired 01/31/21
Drug Screening/Testing for Drugs of Abuse and/or Controlled Substances (Policy OCA 3.98), Effective 08/01/20
Endoscopic Procedures or Magnetic Esophageal Sphincter Augmentation to Treat Gastrointestinal Reflux Disease (GERD) in the Outpatient Setting(Policy OCA 3.46), Effective 10/01/20
Enteral Nutrition(Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges(Policy OCA 3.37), Effective 10/01/20
Experimental and Investigational Treatment (Policy OCA 3.12), Effective 07/01/20
Facet Joint Nerve Injections (Policy OCA 3.9641), Effective 03/01/20 and Retired 11/30/20
Facet Joint Nerve Injections (Policy OCA 3.9641), Effective 12/01/20
Gender Affirmation Surgeries (Policy OCA 3.11), Effective 08/01/20
Gene Expression Profiling of Tumor Tissue to Predict Cancer Recurrence with Risk Stratification (Including Oncotype DX and Other Tests) (Policy OCA 3.572), Retire Medical Policy and Adopt InterQual Criteria as of 10/01/19
Genetic/Genomic Testing and Pharmacogenetics (Policy OCA 3.727), Effective 07/01/20 and Retired 11/30/20 with InterQual Criteria Adopted to Coincide with Policy
Genetic/Genomic Testing and Pharmacogenetics (Policy OCA 3.727), Effective 12/01/20 with InterQual Criteria Adopted to Coincide with Policy
Genetic Testing for Familial Malignant Melanoma (Policy OCA 3.78), Retire Medical Policy and Adopt InterQual Criteria as of 10/01/19
Genetic Testing for Fragile X-Associated Disorders (Policy OCA 3.571), Effective 02/01/20 with InterQual Criteria Adopted to Coincide with Policy
Genetic Testing for Hereditary Breast and Ovarian Cancer Syndrome (Policy OCA 3.57), Retire Medical Policy and Adopt InterQual Criteria as of 10/01/19
Genetic Testing for Hereditary Colorectal Cancer (Policy OCA 3.64), Retire Medical Policy and Adopt InterQual Criteria as of 10/01/19
Genetic Testing for Hereditary Thrombophilia (Policy OCA 3.728), Effective 04/01/20
Gynecomastia Surgery (Policy OCA 3.48), Effective 05/01/20
Home Health Care (Policy OCA 3.719), Effective 09/01/20
Home Health Care (Policy OCA 3.729 QHP), Effective 09/01/20
Home Prothrombin Time Monitoring Devices (Policy OCA 3.27), Effective 10/01/20
Hyperbaric Oxygen Therapy (HBOT) or Topical Oxygen Therapy (TOT) (Policy OCA 3.75) Effective 12/01/19 and Retired 11/30/20 Used in Conjunction with InterQual Criteria
Hyperbaric Oxygen Therapy (HBOT) or Topical Oxygen Therapy (TOT) (Policy OCA 3.75) Effective 12/01/20 Used in Conjunction with InterQual Criteria
Implantable Bone-Conduction (Bone-Anchored) Hearing Aids (Policy OCA 3.30), Effective 06/01/20
Infertility Services (Policy OCA 3.725), Effective 10/01/20
Intensity Modulated Radiation Therapy, Outpatient (Policy OCA 3.81), Effective 07/01/20
Mastopexy (Policy OCA 3.717), Effective 05/01/20
Mechanized Spinal Distraction Therapy (Policy OCA 3.84), Effective 03/01/20
Medically Necessary (Policy OCA 3.14), Effective 07/01/20
Medically Necessary Facility/Hospital Services for Non-Covered Dental Services (Due to a Serious Medical Condition) (Policy OCA 3.723), Effective 05/01/20
Medical Nutrition Therapy in the Outpatient Setting or Office Setting (Policy OCA 3.66) Effective 08/01/20
Minimally Invasive Procedures and Associated Devices used to Treat Back Pain (Policy OCA 3.713), Effective 05/01/20
Nerve Repairs for Peripheral Nerve Injuries Using Allografts, Autografts, and Conduits (Policy OCA 3.701), Effective 0/01/20
Occipital Nerve Stimulation (Policy OCA 3.501), Effective 02/01/20
Occupational Therapy in the Outpatient Setting (Policy OCA 3.53), Effective 03/01/20 and Retired 11/30/20
Occupational Therapy in the Outpatient Setting (Policy OCA 3.53), Effective 12/01/20
Osteochondral Treatments for Defects of the Knee, Talus, and Other Joints (Policy OCA 3.965), Effective 05/01/20
Panniculectomy and Related Redundant Skin Surgery (Policy OCA 3.722), Effective 12/01/19
Pelvic Floor Stimulation for the Treatment of Incontinence and/or Overactive Bladder (Policy OCA 3.561), Effective 10/01/20
Photochemotherapy and Phototherapy for Dermatological Conditions in the Outpatient Setting (Policy OCA 3.39), Effective 02/01/20 and Retired 01/31/21
Photochemotherapy, Phototherapy or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting (Policy OCA 3.39), Effective 02/01/21
Physical Therapy in the Outpatient Setting (Policy OCA 3.54), Effective 04/01/20 and Retired 11/30/20
Physical Therapy in the Outpatient Setting (Policy OCA 3.54), Effective 12/01/20
Posterior Tibial Nerve Stimulation (Percutaneous or Transcutaneous) (Policy OCA 3.562), Effective 10/01/20
Preimplantation Genetic Testing (Policy OCA 3.726) Effective 07/01/20 and Retired 11/30/20
Preimplantation Genetic Testing (Policy OCA 3.726) Effective 12/01/20
Private Duty Nursing Services (Policy OCA 3.715), Effective 09/01/19
Prolotherapy (Policy OCA 3.707), Effective 08/01/20
Pulmonary Rehabilitation, Outpatient (Policy OCA 3.62) Retired Medical Policy and Adopt InterQual Criteria as of 03/01/20
Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions (Policy OCA 3.563), Effective 10/01/20
Sacroiliac Joint Injections (Policy OCA 3.9642), Effective 03/01/20
Skin Substitutes in the Outpatient Setting (Policy OCA 3.710), Effective 10/01/20
Speech Therapy, Language Therapy, Voice Therapy, or Auditory Rehabilitation for a Member Age 20 or Younger in the Outpatient Setting (Policy OCA 3.55), Effective 06/01/20 and Retired 11/30/20
Speech Therapy, Language Therapy, Voice Therapy, or Auditory Rehabilitation for a Member Age 20 or Younger in the Outpatient Setting (Policy OCA 3.55), Effective 12/01/20
Speech Therapy, Language Therapy, Voice Therapy, or Auditory Rehabilitation for a Member Age 21 or Older in the Outpatient Setting (Policy OCA 3.551), Effective 02/01/21
Speech Therapy, Language Therapy, Voice Therapy, or Auditory Rehabilitation for a Member Age 21 or Older in the Outpatient Setting (Policy OCA 3.551), Effective 06/01/20 and Retired 11/30/20
Speech Therapy, Language Therapy, Voice Therapy, or Auditory Rehabilitation for a Member Age 21 or Older in the Outpatient Setting (Policy OCA 3.551), Effective 12/01/20 and Retired 01/31/21
Temporomandibular Joint Disorder Treatment (Policy OCA 3.968), Effective 10/01/20
Transplant Administration (Policy OCA 3.10), Effective 04/01/20
Transplantation of Lung or Lobar Lung (Policy OCA 3.24), Effective 06/01/20
Transplantation of Pancreas or Pancreas-Kidney (Policy OCA 3.25), Effective 06/01/20
Transplantation of Small Bowel, Small Bowel-Liver, or Multivisceral Organs (Policy OCA 3.26), Effective 04/01/20
Video Electroencephalography (EEG) Monitoring (Policy OCA 3.38), Effective 05/01/20
Vision Therapy (Policy OCA 3.40), Effective 02/01/20
Whole Body Integumentary Photography (Policy OCA 3.702), Effective 08/01/20
Type Title Plan Type
Acupuncture Services (Policy 4.4), Effective 10/01/19
MassHealth or QHP
Anesthesia (Policy 4.103), Effective 04/01/20
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
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 04/01/20
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 04/01/20
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 04/01/20
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 04/01/2020
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 06/01/20
SCO
Aging Service Access Points (ASAP) (SCO 4.24), Effective 04/01/19
SCO
Ambulance (SCO 4.113), Effective 06/01/20
SCO
Ambulatory Surgical Center - Facility (SCO 4.114), Effective 01/01/20
SCO
Anesthesia (SCO 4.103), Effective 04/01/20
SCO
Bilateral and Multiple Procedure Reductions (SCO 4.607), Effective 04/01/20
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 04/01/20
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 04/01/20
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 10/1/20
SCO
Non-Participating Provider, (SCO 4.5) Effective 10/1/20
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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