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:

Standard Definitions

• Absorbent Products
  
• Durable Medical Equipment Reimbursement Policy
  
• Enterals, Parenterals, and Infusion Reimbursement Policy
  
• Hearing Aid Reimbursement Policy
  
• Home Health Reimbursement Policy
  
• Hospice Reimbursement Policy
  
• Medical & Surgical Supply Reimbursement Policy
  
• Oral Nutrition Reimbursement Policy
  
• Oxygen & Respiratory Therapy Equipment and Supplies Reimbursement Policy
  
• Transportation Reimbursement Policy
  
• Wheelchairs, Accessories and Mobility Systems Reimbursement Policy
  

• Appropriate Billing of Modifier 50
  
• ICD-9-CM Volumes 1 and 2 Coding Requirements
  
• Immunization Reimbursement Policy
  
• Medication Codes Reimbursement Policy
  
• Unclassified Codes Reimbursement
  

• Abortion Sterilization Family Planning Reimbursement
  
• Clinical Trials
  
• FQHC and CHC Reimbursement Policy
  
• Free Standing Surgical Facility Reimbursement
  
• Inpatient Hospital Reimbursement
  
• Outpatient Hospital Reimbursement
  

• Anesthesia Reimbursement Policy
  
• Chemotherapy Reimbursement Policy
  
• Clinical Trials
  
• General Physician Reimbursement Policy
  
• Mid-Level Practitioner Reimbursement Policy
  
• Obstetrical Reimbursement Policy
  
• Oximetry Policy
  
• Paravertebral Facet Joint and Transforaminal Procedures
  
• Venipuncture Policy
  

• Physical Rehabilitation Modalites and Therapeutic Procedures