Provider News & Updates
Below you will find the latest on important information that may impact your practice, as well as copies of letters and notices we have released.
News and Updates
April 1, 2026
CMO Corner: Meet Lori Bombardier, Manager of Provider Strategy Implementation
We value our relationship with our provider network and appreciate your feedback on how we can improve your experience working with Blue Cross and Blue Shield of Vermont (Blue Cross VT). To further our commitment to strengthening provider partnerships, I’m pleased to share that we have created a new role within our provider services team that is focused on coordinating the planning, communications, and implementation of activities that affect you and your practice.
Lori Bombardier has moved into this new position as Manager of Provider Strategy Implementation. Lori has been supporting our Medicare Advantage provider network, so many of you may already be familiar with her. In this role, Lori will work closely with you and your practices to gather feedback on initiatives, programs, and other activities that impact you, as well as coordinate with Blue Cross VT teams to promote a more consistent experience.
Collectively, we remain committed to ensuring you are represented, informed, and supported as we work together to advance affordability, sustainability, and quality in health care for Vermonters.
April 1, 2026
Important Policy, Preventive Grid, and Handbook Updates
Updates to our medical and payment policies as well as the preventive care grid go into effect June 1, 2026. Our provider handbook has also been updated to reflect changes to claim guidelines, durable medical equipment suppliers, and integrated health functions. Please take a moment to review these updates, as they may impact your practice and patients.
Medical Policy Changes
Payment Policy Changes
Provider Handbook Updates
Preventive Grid Updates
April 1, 2026
2026 Annual Provider Notice
Please take a moment to review our 2026 Annual Provider Notice, containing important updates to our policies and processes. These updates will help improve how we work together and how you support our members. Highlights include:
- Helping your patients get the most out of their coverage
- Our members’ rights and responsibilities statement
- How to refer your patients to our free case management services
- Our utilization review process
- How to get a copy of our utilization management criteria
- How to discuss a medical necessity denial with a Plan physician or pharmacist
- How we’re ensuring access for our members and tackling rising healthcare costs
- Our standards for appointment access
- How to report suspected fraud, waste, and abuse
April 1, 2026
Update Your Practice Email Address
Important communications occur by email, so making sure we have the current email address on file is critical. If you or your practice has had a recent email change, contact providerfiles@bcbsvt.com. Please be sure to include your billing NPI number and a contact person. Note, additional documentation may be required to update an email address.
April 1, 2026
Tired of Waiting on Checks?
Electronic Fund Transfers (EFT) are safe, fast, and environmentally friendly. If you still receive paper checks, we strongly encourage you to switch to EFT. Sign up now.
If you have questions or would like to discuss EFT, please contact your provider relations consultant. If you are not sure who that is, email providerrelations@bcbsvt.com or call (888) 449-0443, option 1 for assistance.
April 1, 2026
Pharmacy Updates
Updates to the formulary or pharmacy policies may influence prescribing decisions. Stay informed to support timely, appropriate therapy. This month, we're featuring newly available generics, which are generally preferred over brand-name medications.
New generics: Tiotropium capsules for inhalation, generic for Spiriva Handihaler, will be a Tier 1 Generic.
Questions? Reach out to our Clinical Pharmacist, Amy Stoll, PharmD at stolla@bcbsvt.com or 802-371-3657 to discuss drug coverage or clinical questions.
April 1, 2026
Billing Services for National Drug Codes
Since our last update, the following American Dental Association (ADA) claim submission instructions have been added to the Provider Handbook:
- Using the ADA forms, report the following information in the remark field: N4, 11-digit NDC (no hyphens), unit of measure and quantity (limited to 8 digits before the decimal point and 3 digits after the decimal point).
- Example: N400023923201UN100.
- If the form does not have a remark field, report at the top of the claim.
For your convenience, the National Drug Code (NDC) Tool can now be found in the following two locations:
- In the Provider Resource Center under the Tools and Resources link
- On our Provider Forms & Resources page under the Claim Forms and Information link
April 1, 2026
1099s Available on the Provider Resource Center (PRC)
Your 2025 tax form(s) are available via the PRC. To access them:
- Go to Tools & Resources, then select Tax Documents.
- Select 2025, then your tax identification number
- Click Request Documents
- From there, you can view or print documents
If you need assistance, please contact provider relations at (888) 449-0443 option 1, or email providerrelations@bcbsvt.com.
April 1, 2026
Member Rights and Responsibilities
Blue Cross VT and The Vermont Health Plan (TVHP) members must follow certain guidelines to ensure they get the most from their benefits. These guidelines can be found in our Member Rights and Responsibilities statement. If you require a paper copy, please contact provider relations at (888) 449-0443 option 1, or email providerrelations@bcbsvt.com.
April 1, 2026
Second Quarter Provider Directory Validation
The Second Quarter Provider Directory Validation will be released via email on or around April 4, 2026; the email comes from noreply@onbaseonline.com. Directory validation(s) must be completed by Tuesday, May 5, 2026. Failure to validate your contact information will result in removal of you from our provider directory. It could also include denial of claims or contract termination.
Provider Directory Validation and instructions to complete the process are located on the Enrollment and Credentialing area of our website.
April 1, 2026
Coding Tip: Malnutrition Documentation
Diagnosis: Specify type and severity (e.g., Severe protein-calorie malnutrition).
Clinical Indicators: Include unintentional weight loss percentage over time, low BMI or weight-for-height percentile, muscle/fat wasting, relevant labs, poor oral intake, or prolonged inadequate nutrition.
Etiology: State underlying cause (e.g., chronic illness, acute illness, socioeconomic factors).
Interventions: Document nutrition plan (e.g., enteral/parental feeding, supplements).
Response to treatment: Document on improvement or decline.
A partial list of the more common malnutrition ICD-10 codes:
- E43 – Unspecified severe protein-calorie malnutrition
- E44.0 – Moderate protein-calorie malnutrition
- E44.1 – Mild protein-calorie malnutrition
- E46 – Unspecified protein-calorie malnutrition
Hypothetical example: Patient meets ASPEN (American Society for Parental and Enteral Nutrition) criteria for severe protein-calorie malnutrition (E43) due to chronic heart failure. Noted 13% weight loss over 3 months, BMI 17.8, severe muscle wasting in temporal and clavicular regions. Initiated high-calorie, high protein oral supplements and will have patient follow-up with the dietician.
March 17, 2026
Adaptive Maintenance Reminder
On March 17, we sent our quarterly adaptive maintenance email, outlining the new and revised codes for April 1, 2026. Be sure to check your email to view the notification.
March 1, 2026
Virtual OCD Treatment
At Blue Cross and Blue Shield of Vermont, one of our goals this year is to continue evolving the tools and services that support your work and improve patient outcomes. This month, we are highlighting a new health service available for patients with obsessive compulsive disorder (OCD). We have partnered with NOCD to offer virtual, evidence-based treatment. This ensures members have access to Exposure and Response Prevention (ERP)-trained specialists, who can deliver the most effective, first-line, clinical standard for reducing OCD symptoms and improving daily functioning. This service is available to patients through a secure, convenient virtual platform. We’re excited about the benefits this partnership will bring to you and your patients and thank you for your continued partnership and the care you provide every day.
March 1, 2026
Important Policy, Code, and Handbook Updates
Effective May 1, 2026, updates go into effect for payment and medical policies and routine code maintenance. Our provider handbook also includes updates regarding cost-share, modifiers, and claim guidelines. Please be sure to review the upcoming changes that may impact your practice and patients.
Medical Policy Changes
Payment Policy Changes
Provider Handbook Updates
Routine Code Maintenance
March 1, 2026
2026 Prefix Listing
The Prefix Listing has been updated for 2026. It is available on the Provider Forms and Resources page under Claim Forms and Information.
March 1, 2026
Underway: Medical Records Retrieval Project
Our annual Healthcare Effectiveness Data and Information Set (HEDIS®) medical records data collection is currently underway. We appreciate your participation in this process as it helps your peers and our members understand the quality of care your clinical team provides every day.
For an overview of when a bulk of medical records may be requested from Blue Cross VT, check out our updated 2026 Medical Record Activity Timeline.
March 1, 2026
Pharmacy Updates
Updates to the formulary or pharmacy policies may influence prescribing decisions. Stay informed to support timely, appropriate therapy. This month, we're featuring newly available generics, which are generally preferred over brand-name medications.
New generics
- Ciprofloxacin hydrocortisone otic suspension, generic for Cipro HC, is a Tier 1 Generic.
- Amphetamine ER Orally Disintegrating Tablet, generic for Adzenys XR, is a Tier 1 Generic and may be appropriate for patients needing a drug formulation that does not need to be swallowed. It is bioequivalent to Adderall XR and indicated for patients age 6 and older.
Questions? Reach out to our Clinical Pharmacist, Amy Stoll, PharmD at stolla@bcbsvt.com or 802-371-3657 to discuss drug coverage or clinical questions.
March 1, 2026
Contraceptive Counseling
In order for a visit to be considered a preventive visit without cost share, an eligible diagnosis must be in the first position on the claim line. Please see our preventive grid for a list of eligible diagnosis located under Preventive Gynecologic and Wellness Exam for Contraceptive Management.
Contraceptive encounters are eligible for first dollar coverage (without cost share) when billed using one of the diagnoses listed in our Preventive Grid in the first position on the claim line.
March 1, 2026
Billing Services for National Drug Codes
As a follow-up to the information we shared with you on January 1, we are enforcing the requirements for professional claims (billed on a CMS 1500) to include the reporting of a National Drug Code (NDC.) Professional claim service lines that require and do not include an NDC will be denied. Members cannot be held liable (even with a signed waiver), and a corrected claim can be submitted for consideration of benefits. This is a first step in the enforcement of our reporting requirements. Please click the button below to learn more.
To date, we have addressed the following:
- The reporting of an NDC.
- The reporting of Unit of Measure (UoM) and quantity.
- The requirements for the applicable Current Procedural Terminology (CPT®) or Health Care Procedure Coding System (HCPCS) for professional and outpatient facilities for specific drugs.
March 1, 2026
Modifier -HN
Modifier -HN represents that a service is being rendered by a bachelor level provider. Per our Payment Policy for Supervised Practice of Mental Health and Substance Use Disorder, this is not allowed,
Only providers with a master level degree working toward licensure are eligible to bill for seeing patients as a trainee and must be billed with a modifier -HO. Details are in the payment policy.
March 1, 2026
Correct HCPCS Level II Drug Billing
Correct reimbursement of HCPCS Level II Drugs is dependent on the correct billing of units. A common mistake involves billing by the number of units administered rather than reporting the number of units represented by the HCPCS Level II code descriptor. Invalid units will result in claims denial or reversal.
March 1, 2026
2026 ICD-10 Coding Guidelines
The 2026 ICD-10 Coding Guidelines for acute myocardial infarction (AMI) offer the following rules for proper coding of the condition:
- Subcategories I21.0-I21.2 and code I21.3 are used for type 1 ST elevation myocardial infarction (STEMI).
- Code I21.4, Non-ST elevation (NSTEMI) myocardial infarction, is used for type 1 non-ST elevation myocardial infarction (NSTEMI) and non-transmural MIs.
- Code I21.9, Acute myocardial infarction, unspecified, is the default for unspecified acute myocardial infarction or unspecified type.
- The site of the MI must be identified to most correctly code the MI; examples include anterolateral wall or true posterior wall.
- If only type 1 STEMI or transmural MI without the site is documented, assign code I21.3, ST elevation (STEMI) myocardial infarction of unspecified site.
Points to consider:
- If a type 1 NSTEMI evolves to STEMI, assign the STEMI code. If a type 1 STEMI converts to NSTEMI due to thrombolytic therapy, it is still coded as STEMI.
- For encounters occurring while the myocardial infarction is equal to or less than four weeks old, including transfers to another acute setting or a post-acute setting, codes from category I21 may continue to be reported.
- For encounters after the 4-week time frame where the patient is still receiving care related to the myocardial infarction, the appropriate aftercare code should be assigned, rather than a code from category I21.
- For old or healed myocardial infarctions not requiring further care, code I25.2, Old myocardial infarction, may be assigned. Acute myocardial infarction can be billed up to 28 days from the date of the acute infarction. The date of the acute infarction is based on inpatient testing. If there was no inpatient testing, an acute infarction can’t and shouldn’t be billed.
February 1, 2026
Member Rights and Responsibilities
To help members get the most from their benefit plan, providers are expected to adhere to the guidelines outlined in our Member Rights and Responsibilities. If you prefer a paper copy, please contact our provider relations team at providerrelations@bcbsvt.com.
February 1, 2026
Community MD Rx and HIT Reimbursement
Effective April 1, 2026, there are changes to the community reimbursement for drugs administered/supplied in a provider’s office (MD Rx) and Community Home Infusion Therapy.
If you would like a copy of the updated fee schedule, please contact the provider relations team by email at providerrelations@bcbsvt.com or phone (888) 449-0443 option 1. Please include your billing NPI number(s).
February 1, 2026
Routine Code Maintenance Changes
Review our notice for details on the implementation of new and revised codes, effective April 1, 2026.
February 1, 2026
Diabetes Coding Reminder
The ICD-10 classification identifies six distinct types of diabetes, including the commonly recognized type 1, type 2, and gestational diabetes, which is coded both when a member has diabetes and becomes pregnant, or if a member develops diabetes due to pregnancy. In addition, there are three types of secondary diabetes: diabetes due to an underlying condition, drug or chemical-induced diabetes, and other specified diabetes which includes conditions such as post-surgical diabetes. Gestational diabetes must always be coded using the appropriate gestational diabetes code (O24.____). However, if the member had diabetes prior to pregnancy, the applicable diabetes type code should also be reported (E08.____ – E13.____). This is the only circumstance in which two different types of diabetes may be used.
Additionally, because a member cannot have both type 1 and type 2 diabetes, it is important to ensure the correct diabetes type is coded. Use of insulin alone does not indicate type 1 diabetes. Care should always be taken not to assign a diagnosis based solely on a member’s medication list.
February 1, 2026
2026 Holiday Observance Schedule Update
We’ve updated our holiday observance schedule for your reference. Please note that the Juneteenth Holiday on Thursday, June 19, 2026 will be observed by Carelon only, Blue Cross VT will remain open for business.
January 28, 2026
2026 Prefix Listing
The Prefix listing has been updated for 2026. It is posted on the Provider Forms and Resources page under the Claim Forms and Information link.
January 12, 2026
Prior Authorization Tool unavailable January 18, 2026
The Prior Authorization tool will be unavailable on Sunday, January 18, 2026 for routine maintenance. If you have a prior authorization request during this time, that cannot wait until the tool is operational on Monday, January 19, 2026, you will need to submit a State of Vermont Uniform Medical Prior Authorization Form with supporting medical documentation (if applicable) by fax to (866) 387-7914.
All other functions on the Provider Resource Center such as eligibility, claims, and provider vouchers will be available during this time.
Monthly Newsletters
Adaptive Maintenance Newsletters
Our monthly provider e-newsletter is our primary source for all notices and updates. It replaces the individual notices you used to receive. If there are staff in your office that would like to be on our distribution list, please contact Provider Relations at providerrelations@bcbsvt.com.
Act 111 (H.766)
Primary Care Provider Prior Authorization Waiver
Beginning January 1, 2026, prior authorizations for medically necessary services (excluding prescription drugs or out-of-network services) are waived if a member is covered by a Vermont state regulated plan and the ordering provider is enrolled, credentialed, and contracted with Blue Cross and Blue Shield of Vermont.
There are specific claim submission requirements that must be followed for the claim to bypass the prior authorization requirements. Details are in Section 12 of our Provider Handbook.
Claims Submission Requirements
If you are submitting a claim for services ordered by a primary care provider for a qualifying service and member, there are specific claim submission requirements that must be followed for the claim to bypass the prior authorization requirements. Details are in Section 12 of our Provider Handbook.
Working with our Pharmacy Benefit Manager (PBM), we are updating our policies and processes related to step therapy.
As we implement the requirements of Act 111, we will be sharing the ongoing updates to our policies and processes with you. Updates will be shared via email.
Provider Handbook
Access our Provider Handbook for a comprehensive reference of resources and requirements for Blue Cross providers.
Academic Detailing and Prescription Support for Vermont Blue Rx
Our Clinical Pharmacist, Amy Stoll, PharmD, works with our providers on specific prescription questions, drug authorizations, and patient panel projects. Amy is a board-certified ambulatory care pharmacist, certified diabetes educator and has a master's degree in public health. Learn more about the services our team can provide to you.