Provider Forms & Resources

About Case Management and Care Coordination

When you as the provider and Blue Cross and Blue Shield of Vermont as the plan work together to help coordinate the care of our members, there are times when we may need to use members' Protected Health Information (PHI). Under these circumstances, the members do not need to provide authorization for this use of their PHI.

Blue Cross VT is committed to respecting the privacy of our members' PHI. As a Covered Entity under HIPAA, we do not use or disclose a member's PHI unless either HIPAA's Privacy Rule permits or requires such disclosure, or the member who is the subject of the PHI authorizes such use or disclosure in writing. The Privacy Rule specifically permits the use and disclosure of a member's PHI for the purpose of that member's case management and care coordination. This permitted use allows us to work together with providers in a safe way to help facilitate a member's case management and care coordination needs. (See 45 CFR §§ 164.501, 164.502(a)(1); see also https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html and https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/disclosures-treatment-payment-health-care-operations/index.html.)

How to Refer to Case Management

There are three options to refer to case management and either the member or provider can initiate:

1. Complete the following form on our website: https://secure.bcbsvt.com/referral.php
2. Send our team a secure email at IHMTriage@bcbsvt.com
   • ​​​​​​​At a minimum, the email will need to contain the member name, date of birth and phone number where they can be reached.
   • Emails should always be sent through a secure method.
3. Call (800) 922-8778, option 3.

• CMS 1500 Form Instructions
• CMS 1500 Sample Form
• Late Charges - Institutional Submission Requirements
• Medicare Advantage Private Fee-for-Service (PFFS) Terms and Conditions Web Finder Tool
• Notice of Open Negotiation
• Prefix Listing
• Outpatient Revenue Codes Requiring a CPT or HCPCS
• UB-04 Paper Claim Billing Instructions

To make changes to an address, NPI, tax identification number, or a group name, complete the following:

• Online Group Enrollment Change Form
• W-9

To make a chance to a provider name, complete the following:

• If the provider is part of a group practice, complete an Provider Enrollment/Change Form and include a copy of the updated State licensure and any applicable board certificates
• If the provider is an independent provider (private practice), complete an Group Enrollment/Change Form and include a copy of the updated State licensure and any applicable board certificates

Mental health and substance abuse clinicians need to complete the Area of Expertise form to identify their area of expertise for marketing in the Blue national directories.

• 835 Enrollment/Change Form
• 835 Enrollment Status (check enrollment status)
• Clearinghouse Vendor List
• 834 Submissions Companion Guide
• 835 Companion Guide for Electronic Remittance Advice
• 837 Professional Claims Submissions Companion Guide
• 837 Institutional Claims Submissions Companion Guide
• Medicare Advantage Claims Guide
• Electronic Data Interchange User Guide

Administrative

• BlueCard Appeal Form
• Coordination of Benefits Questionnaire for BlueCard Members
• Coordination of Benefits Questionnaire
• Payment Inquiry Form
• Provider Overpayment Form

Institutional/Facility

• Census Reporting for Facilities 
• Census Reporting Template 
• Emergency Room Census Reporting Template

• Academic Detailing and Prescription Support for Vermont Blue Rx
• Contact Information for Providers
• Member Preventive Benefits Overview
• Pediatric Patient Transition Template
• Prevent Hospital Readmission
• Provider Handbook
• Provider Resource Center Reference Guide
• Vision Service Overview for Federally Qualified Health Plans
• Unit Designation

Laboratory Services

• Independent Laboratory List
• Lab Draw Stations

Provider Orientation

• Mental Health and Substance Use Disorder Clinicians 
• All other provider types (MD, DO, ND, PA, NP, etc)
• Vermont Blue Advantage