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
Bariatric Surgery (Policy 3.49) Retired 02/01/18 and InterQual Criteria Adopted 02/01/18
Intensity Modulated Radiation Therapy, Outpatient (Policy 3.81), Effective 10/01/18
Central Auditory Function Evaluation to Diagnose Central Auditory Processing Disorder (Policy 3.82), Effective 07/01/18
Clinical Review Criteria (Policy 3.201), Effective 07/01/18
Clinical Technology Evaluation (Policy 3.13), Effective 07/01/18
Clinical Trials (Policy 3.192), Effective 07/01/18
Cosmetic Reconstructive, and Restorative Services (Policy 3.69), Effective 07/01/18
Experimental and Investigational Treatment (Policy 3.12), Effective 07/01/18
Genetic Testing Guidelines and Pharmacogenetics (Policy 3.727), Effective 09/01/18
Home Health Care (Policy 3.719), Effective 09/01/18
Infertility Services (Policy 3.725), Effective 09/01/18
Intensity Modulated Radiation Therapy, Outpatient (Policy 3.81), Effective 07/01/18 and Retired 09/30/18
Medically Necessary (Policy 3.14), Effective 07/01/18
Preimplantation Genetic Testing (Preimplantation Genetic Diagnosis and Pregenetic Testing) (Policy 3.726), Effective 09/01/18
Tube Fed Enteral Nutrition Products Supplied and Billed by Home Infusion Provider (Policy 3.37), Effective 07/01/18
Actigraphy Testing (Policy 3.712), Effective 10/01/17
Administratively Necessary Days (Policy 3.102), Effective 11/15/17
Ambulance and Transportation Services (Policy 3.191), Effective 05/01/18
Ambulatory Cardiac Monitors (Excluding Holter Monitors) (Policy 3.35), Effective 03/01/18
Autism Spectrum Disorders Medical Diagnosis and Treatment (Policy 3.724), Effective 06/01/18
Balloon Sinus Ostial Dilation (Policy 3.706), Effective 01/01/18
Biofeedback in an Outpatient Setting to Treat Bladder and/or Bowel Dysfunction (Including Incontinence) (Policy 3.969), Effective 11/01/17
Breast Reconstruction (Policy 3.43), Effective 06/01/18
Breast Reduction Mammoplasty (Policy 3.44), Effective 06/01/18
Cardiac Rehabilitation, Outpatient (Policy 3.61), Effective 03/01/18
Cervical Artificial Disc Replacement (Policy 3.421), Effective 03/01/18
Chromosomal Microarray Analysis for Intellectual Disabilities and/or Multiple Congenital Anomalies (Policy 3.573), Effective 02/01/18
Cochlear Implants (Policy 3.301), Effective 06/01/18
Complementary and Alternative Medicine Including Acupuncture Treatment (Policy 3.194), Effective 06/01/18
Contact Lens and Scleral Lens (Policy 3.28), Effective 05/01/18
Continuous Glucose Monitoring Systems and Insulin Delivery Devices (Policy 3.966), Effective 06/01/18
Denervation of Facet Joints or Sacroiliac Joints (Policy 3.70), Effective 05/01/18
DNA Testing of Stool Samples with Cologuard to Screen for Colorectal Cancer (Policy 3.63), Effective 06/01/18
Drug Screening/Testing for Drugs of Abuse and/or Controlled Substances (Policy 3.98), Effective 07/01/18
Endoscopic Treatments for GERD in the Outpatient Setting (Including Transoral Incisionless Fundoplication) (Policy 3.46), Effective 03/01/18
Facet Joint Nerve Injections (Policy 3.9641), Effective 05/01/18
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 03/09/18
Genetic Testing for Familial Malignant Melanoma (Policy 3.78), Effective 01/01/18
Genetic Testing for Fragile X-Associated Disorders (Policy 3.571), Effective 02/01/18
Genetic Testing Guidelines and Pharmacogenetics (Policy 3.727), Effective 04/01/18 and Retired 08/31/18
Genetic Testing for Hereditary Breast and Ovarian Cancer Syndrome (Policy 3.57), Effective 03/09/18
Genetic Testing for Hereditary Colorectal Cancer (Policy 3.64), Effective 03/09/18
Genetic Testing for Hereditary Thrombophilia (Policy 3.728), Effective 04/01/18
Gynecomastia Surgery (Policy 3.48), Effective 06/01/18
Home Health Care (Policy 3.719), Effective 07/01/18 and Retired 08/31/18
Home Prothrombin Time Monitoring Devices (Policy 3.27), Effective 02/01/18
Hyperbaric Oxygen Therapy (HBOT) in the Outpatient Setting (Policy 3.75), Effective 02/01/18
Implantable Bone-Conduction (Bone-Anchored) Hearing Aids (Policy 3.30), Effective 01/01/18 and Retired 07/31/18
Implantable Bone-Conduction (Bone-Anchored) Hearing Aids (Policy 3.30), Effective 08/01/18
Infertility Services (Policy 3.725), Effective 03/01/18 and Retired 08/31/18
Lumbar Artificial Disc Replacement (Policy 3.42), Effective 03/01/18
Mastopexy (Policy 3.717), Effective 06/01/18
Mechanized Spinal Distraction Therapy (Policy 3.84), Effective 03/01/18
Medically Necessary Facility/Hospital Services to Provide Dental Services (Due to a Serious Medical Condition) (Policy 3.723), Effective 05/01/18
Medical Nutrition Therapy in the Outpatient Setting or Office Setting (Policy 3.66) Effective 05/01/18
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 03/01/18
Nerve Repairs for Peripheral Nerve Injuries Using Allografts, Autografts, and Conduits (Policy 3.701), Effective 02/01/18
Occipital Nerve Stimulation (Policy 3.501), Effective 03/01/18
Occupational Therapy in the Outpatient Setting (Policy 3.53), Effective 01/01/18
Osteochondral Treatments for Defects of the Knee (Policy 3.965), Effective 03/01/18
Panniculectomy and Related Redundant Skin Surgery (Policy 3.722), Effective 02/01/18
Pelvic Floor Stimulation for the Treatment of Incontinence (Policy 3.561), Effective 01/01/18
Photochemotherapy and Phototherapy for Dermatological Conditions in the Outpatient Setting (Policy 3.39), Effective 02/01/18
Physical Therapy in the Outpatient Setting (Policy 3.54), Effective 01/01/18
Posterior Tibial Nerve Stimulation (Policy 3.562), Effective 11/01/17
Preimplantation Genetic Testing (Preimplantation Genetic Diagnosis and Pregenetic Testing) (Policy 3.726), Effective 09/01/17 and Retired 08/31/18
Private Duty Nursing Services (Policy 3.715), Effective 05/01/18
Prolotherapy (Policy 3.707), Effective 10/01/17
Pulmonary Rehabilitation, Outpatient (Policy 3.62), Effective 03/01/18
Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions (Policy 3.563), Effective 01/01/18
Sacroiliac Joint Injections (Policy 3.9642), Effective 05/01/18
Skin Substitutes in the Outpatient Setting (Policy 3.710), Effective 02/01/18
Speech Therapy, Language Therapy, Voice Therapy, or Auditory Rehabilitation for a Member Age 20 or Younger in the Outpatient Setting (Policy 3.55), Effective 01/01/18
Speech Therapy, Language Therapy, Voice Therapy, or Auditory Rehabilitation for a Member Age 21 or Older in the Outpatient Setting (Policy 3.551), Effective 01/01/18
Temporomandibular Joint Disorder (Policy 3.968), Effective 12/01/17
Transplantation Administrative (Policy 3.10), Effective 04/01/18
Transplantation of Lung or Lobar Lung (Policy 3.24), Effective 04/01/18
Transplantation of Pancreas or Pancreas-Kidney (Policy 3.25), Effective 04/01/18
Transplantation of Small Bowel, Small Bowel-Liver, or Multivisceral Organs (Policy 3.26), Effective 04/01/18
Video Electroencephalography (EEG) Monitoring (Policy 3.38), Effective 05/01/18
Vision Therapy (Policy 3.40), Effective 04/01/18
Whole Body Integumentary Photography (Policy 3.702), Effective 10/01/17
Type Title Plan Type
Community Health Centers and Federally Qualified Health Centers (Policy 4.107), Effective 08/01/18
MassHealth or QHP
Non-Reimbursed Codes (Policy 4.38), Effective 10/01/18
MassHealth or QHP
Community Health Centers and Federally Qualified Health Centers (Policy 4.107), Retired 07/31/18
MassHealth or QHP
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
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 Clinical Editing and Payment Accuracy Review Guidelines (Policy 4.108), Effective 01/01/17
MassHealth or QHP
General Billing and Coding Guidelines (Policy 4.31), Effective 01/01/18
MassHealth or QHP
General Billing and Coding Guidelines (Policy 4.31), Effective 06/01/18
MassHealth or QHP
Hearing Aid Dispensing and Repairs (Policy 4.111), Effective 07/01/15
MassHealth or QHP
Home Health (Policy 4.7), Effective 05/01/18
MassHealth or QHP
Home Health (Policy 4.7), Retired 04/30/18
MassHealth or QHP
Hospice (Policy 4.8), Effective 04/01/16
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
Immunization Services (Policy 4.117), Retired 04/30/18
MassHealth or QHP
Infertility Services (Policy 4.34), Effective 07/01/15
MassHealth or QHP
Infusion/Parental/Tube Fed Enteral Nutritional Therapy (Policy 4.121), Effective 12/02/13
MassHealth or QHP
Inpatient Hospital (Policy 4.110), Effective 01/01/17
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
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 01/01/18
MassHealth or QHP
Physician and Non Physician Practitioner Services (Policy 4.608), Effective 05/01/18
MassHealth or QHP
Physician and Non Physician Practitioner Services (Policy 4.608), Retired 04/30/18
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 10/01/16
MassHealth or QHP
Telemedicine Services (Policy 4.33), Effective 05/01/18
MassHealth or QHP
Transportation (Policy 4.113), Effective 03/01/18
MassHealth or QHP
Urgent Care (Policy 4.96), Effective 01/01/16
MassHealth or QHP
Vision Services (Policy 4.38), Effective 01/01/17
MassHealth or QHP
Adult Day Health (SCO 4.20), Effective 01/01/16
SCO
Adult Foster Care (SCO 4.21), Effective 05/05/17
SCO
Aging Services Access Points (ASAP) (SCO 4.24), Effective 01/01/16
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 01/01/16
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 01/01/16
SCO
Hearing Aid Dispensing and Repairs (SCO 4.111), Effective 01/01/16
SCO
Home Health Agency Services (SCO 4.7), Effective 08/01/18 and Retired 08/31/18
SCO
Home Health Agency Services (SCO 4.7), Effective 09/01/2018
SCO
Home Health Agency Services (SCO 4.7), Effective 11/01/17
SCO
Hospice (SCO 4.8), Effective 06/01/18
SCO
Hospice (SCO 4.8), Effective 04/01/16
SCO
Inpatient Hospital (SCO 4.110), Effective 01/01/16
SCO
Inpatient Rehabilitation Hospital (SCO 4.71), Effective 01/01/16
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 01/01/18
SCO
Personal Care Attendant (SCO 4.25), Effective 01/01/16
SCO
Personal Care Management Services (SCO 4.26), Effective 01/01/16
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

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