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
August 29, 2025
Supervised Billing Reminder
Supervised billing is generally not allowed. Providers who render care to our members must be licensed, credentialed, and enrolled with Blue Cross and Blue Shield of Vermont. Submitted claims must report the provider who rendered the care to the member, using their individual National Provider Identifier.
Exceptions to this are: Physical Therapy Assistants, Occupational Therapy Assistants, and Mental Health/Substance Use Disorder (MHSUD) Trainees. Details on the requirements for Therapy Assistants and MHSUD Trainees are in our Provider Handbook.
August 29, 2025
Medical and Payment Policy Updates
Review the payment and medical policy updates that go into effect November 1, 2025.
August 29, 2025
Quality Policy Update
The Accessibility of Services and Provider Administrative Service Standards policy has been updated. It includes best practice revisions to After-Hours Care Standards for PCP and Specialty Offices and a new Practitioner Access Enhancement section. Please review the changes to ensure alignment with the updated standards.
August 29, 2025
Telemedicine for College Students or Members Residing Outside of Vermont
If you have a current patient moving from Vermont, and you plan to continue care using telemedicine, you must possess appropriate licensure in all states where the patient receives the care. Full details related to the requirements of Telemedicine and billing for these services are available in our Telemedicine (CPP_03) Payment Policy.
August 29, 2025
Reminder: Use of Third-Party Billers/Vendors
Third-party billers (or vendors) are defined as those entities/persons who are:
- Not physically located at a provider or group office
- Not direct employees of the provider or group
- Those submitting claims or following up on accounts on behalf of the provider or group and have a business associate relationship with the provider or group. Please note that the provider or group should be prepared to provide proof of a business associate relationship with the biller/vendor upon request.
For information to be released, the provider or group must authorize third-party billers (or vendors) with us. Additional details, including the steps needed for granting access are located in our Provider Handbook, in Section 6.1 General Claim Information.
August 29, 2025
Provider Handbook Updates
The provider handbook has been updated in various sections, including Section 4 on Integrated Health Services, Section 6.7 for Claim Specific Guidelines, and Section 6 on Member Liabilities, among others.
August 29, 2025
Surcharges and Convenience Fee
Providers must have a fee-free way to collect member liabilities, regardless of whether a member is using a check, credit card, or debit card. Additionally, providers may not impose credit card surcharges or other fees on members using either a personal debit card or an HSA/HRA issued debit card. A member should never be responsible for any additional fees beyond their reported liability.
August 29, 2025
Operational Reminders for Working with Us
To work more effectively and efficiently together, we have outlined different operational reminders about claims, appeals, and inquiries. Check out our document for detailed information.
July 31, 2025
Medical and Payment Policy Updates
View the payment and medical policy updates that go into effect October 1, 2025.
July 31, 2025
Pharmacy Updates
Generic Qsymia (Topiramate/phentermine) is now available and added to formulary as a Tier 1 generic.
July 31, 2025
Mental Health & MHSUD Medication Management Support with Valera Health
Through our partnership with Valera Health, they will work with you to ensure your patients get the care they need sooner, as well as ensure the patient’s medications are working effectively. Learn more about Valera Health and how their services can support you and our members at www.valerahealth.com.
July 31, 2025
Upcoming Holiday Closure
We will be closed on Monday, September 1, 2025, in observance of Labor Day. We will reopen for normal business hours on Tuesday, September 2, 2025.
July 31, 2025
Provider Handbook Updates
The provider handbook has been updated to reflect changes in effect for the coding validation review process, as well as where to access our current clinical practice guidelines.
July 31, 2024
Prior Approval List Changes
Review the upcoming changes to our list of services, equipment, and supplies requiring prior approval.
July 1, 2025
2025 Annual Provider Notice
Please take a moment to review our 2025 Annual Provider Notice, which contains important updates to our policies and processes. These updates can help improve how we work together and how you support our members. Highlights include:
- Helping your patients get the most out of their coverage
- Locating our members’ rights and responsibilities statement
- Our case management process, including eligibility criteria and how to refer your patients
- Understanding our utilization review process
- How to get a copy of our utilization management criteria
- Discussing 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 and provider availability
- Reporting suspected fraud, waste and abuse to our Payment Integrity Department
July 1, 2025
Medical Policy Updates
On September 1, 2025, new medical policy updates go into effect. The updates include reinstating prior approval for non-urgent ambulance and medical transport services. Please note that non-urgent ambulance services are generally not covered and will not be paid for unless medically necessary, regardless of the need for prior approval. Review our notice for more details on this and all upcoming changes.
July 1, 2025
Pharmacy Updates
- Stelara (ustekinumab) will be excluded on the National Performance Formulary (NPF) and BCBSVT formulary starting July 1, 2025.
- Yesintek, an interchangeable biosimilar to Stelara, is another option and is a preferred Tier 1 drug. It is already on the formulary, along with another biosimilar, Wezlana. Both do not require prior authorization at this time, have the same tier, and have coupon cards that can be applied.
- These medications are biologics used for inflammatory conditions such as plaque psoriasis, psoriatic arthritis, Crohn's disease, and ulcerative colitis. Studies indicate they have comparable safety and effectiveness to Stelara.
- Quantity limits have been removed for buprenorphine tabs, buprenorphine/naloxone films, and Zubsolv. This assists patients and prescribers with providing individualized care and dosing plans, as these are commonly used for the indication of opioid use disorder (or medication assisted therapy, MAT).
- Other formulary changes occur on July 1, 2025, and have been provided in letters to providers and prior e-newsletters. View our Covered Medications webpage for the current formulary.
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.
July 1, 2025
Act 111 Prior Authorizations Reminder
Prior authorizations are not required for Blue Cross VT members (including New England Health Plan/Access Blue New England members who have selected a Vermont primary care provider) when the following criteria applies:
- The ordering provider is a Blueprint Primary Care Provider who is in the Blue Cross VT network.
- The member is eligible for prior authorization waiver under Act 111.
If these two requirements are met, prior authorization is waived, and you do not need to submit a request. If you submit a request for prior authorization, you will receive a letter indicating no prior authorization is required and no prior authorization will be given.
For an eligible claim to bypass prior authorization requirements, the claim must be billed correctly. The billing provider or facility must submit the claim for the service identifying the ordering Blueprint provider. Claim submission details are located in our Provider Handbook, in Section 12: Act 111 – Blueprint Primary Care Provider Waiver of Prior Authorization.
July 1, 2025
Third Quarter CAA Directory Validation
- Third Quarter Consolidated Appropriations Act (CAA) directory validations will be released on or around July 5, 2025.
- You must complete the directory validation by Tuesday, August 5, 2025, or you will be removed from our provider directory and risk possible contract termination.
- Be on the lookout for an email from noreply@onbaseonline.com.
- If you receive more than one email, please respond to all emails received. Some providers have multiple providers files and multiple verification needs to occur.
- If your practice was removed from the network directory due to non-response of the second quarter validation, this is your opportunity to be added back in.
Details about the CAA Directory Validation and instructions to complete the process are located on our Enrollment and Credentialing webpage, under the “CAA Directory Validation” section. If you have questions, please call (888) 449-0443, option 2, or email CAA@bcbsvt.com.
July 1, 2025
New In-Network Independent Laboratory
On June 1, 2025, Billion to One, Inc., a genetic testing laboratory, was added to our network on independent laboratories.
Reminder: Blue Cross VT providers must use in-network laboratories. In-network facilities that offer lab services can also be used.
View the list of in-network independent laboratories.
July 1, 2025
Preventive Care Guide Updates
The preventive care guide has been updated with an additional code in the Hepatitis B section. The change goes into effect September 1, 2025.
June 18, 2025
2024 QHP Risk Adjustment Data Validation Project
Our Qualified Health Plan (QHP) Risk Adjustment department has partnered with Reveleer again this year for the medical record retrieval of 2024 claims identified in the Risk Adjustment Data Validation (RADV) project by the Centers for Medicare and Medicaid Services (CMS). Outreach typically begins in July. If you receive a request from Reveleer, please respond promptly following the instructions provided.
If you have any questions on the RADV project, contact our Risk Adjustment Department by email at RiskAdjustment@bcbsvt.com or phone at (802) 371-3540.
June 1, 2025
Medical and Payment Policy Updates
On August 1, 2025, new payment and medical policy updates go into effect.
June 1, 2025
Pharmacy Updates
- Cabenuva, a long-acting antiretroviral for HIV-1, is on the formulary as a Tier 2 preferred brand with no prior authorization requirements.
- Namzaric, a medication for treating symptoms of moderate to severe Alzheimer’s, has a generic available, memantine/donepezil, that is a Tier 1 generic on the formulary.
- DPP4-inhibitor medications for diabetes, such as Saxagliptin (Tier 1), Januvia (Tier 2), and Tradjenta (Tier 2), no longer have Step Therapy requirements and can be initiated without trialing other medications.
- Twiist, insulin infusion pump kits, are available as a Tier 2 preferred brand with no prior authorization requirements.
- Humira biosimilars, Amjevita for Nuvaila, Simlandi, and Adalimumab-adbm continue to be the preferred biosimilars on the formulary. Simlandi 20 mg prefilled syringes and Simlandi 80 mg pens and pre-filled syringes are now available in addition to the 40 mg pens and syringes.
June 1, 2025
New In-Network Independent Laboratory Options
- LabCorp now offers a lab draw station at 185 Tilley Drive, South Burlington, VT. It is open Monday through Friday from 7:30 a.m. – 4:00 p.m. Appointments can be schedule by calling (802) 949-0966, or you can fax your lab orders to (833) 650-1037.
- Omniseq, Inc., an oncology lab service, has been added to our lab network as of May 2025.
- In the Rutland area, Quest has an in-network lab draw station. Quest is located at 11 Common Street, Rutland, VT. Quest can be reached via phone at (802) 774-8341, fax at (802) 747-0031, or you can schedule an appointment online.
View the complete list of in-network independent lab services.
June 1, 2025
Provider Handbook Updates
The provider handbook has been updated to reflect changes related to BlueCard modifier -GY and member billing.
June 1, 205
July 4, 2025 Electronic Fund Transfer Reminder
Due to the holiday on Friday, July 4, 2025, the weekly Electronic Fund Transfer (EFT) will occur on Monday, July 7, 2025.
June 1, 2025
Coding Corner: Cancer
Solid-tumor cancer diagnoses often result in coding errors. Accurate documentation of active versus historical cancer diagnoses ensures patients’ medical records reflect their current diagnoses status, supports public health efforts, and helps guarantee proper provider payment.
Cancer is considered active when:
- The patient is currently and actively being treated and managed for cancer, such as:
- Current chemotherapy, radiation, or anti-neoplasm drug therapy
- Current pathology revealing cancer
- A newly diagnosed patient awaiting treatment
- Affirmation of current disease management
- Refusal of therapeutic treatment by patient or watchful waiting
- The cancerous organ has been removed or partially removed, and the patient is still receiving ongoing treatment such as chemotherapy or radiation.
Cancer is considered historical when:
- The cancer was successfully treated, and the patient isn’t receiving treatment.
- The cancer was excised or eradicated, and there’s no evidence of recurrence and further treatment isn’t needed.
- The patient had cancer and is coming back for surveillance of recurrence.
- The patient is currently on adjuvant therapy (like Lupron or Tamoxifen) for prophylactic purposes.
For the latest coding information, view the ICD-10-CM Official Guidelines for Coding and Reporting.
June 1, 2025
Preventive Care Guide Updates
The preventive care guide has been updated with an additional code in the Colorectal Cancer Screening section. The changes go into effect August 1, 2025.
May 13, 2025
2026 Coverage Changes for GLP-1 Drugs FDA-Approved for Weight Management
Beginning January 1, 2026, Blue Cross Vermont will no longer cover prescription GLP-1 drugs that are FDA-approved for weight management, such as Wegovy®, Zepbound®, and Saxenda®, for our Qualified Health Plan (QHP) and Blue Edge Business members. For members with these plans, we will continue to cover GLP-1 drugs prescribed as a treatment for members with Type 2 diabetes.
Members who are affected by this coverage change will be notified by mail the week of May 12. If they choose to continue using GLP-1 medications for weight management on or after January 1, 2026, they will be responsible for the full cost. For additional information on this upcoming change in drug coverage, please contact our Customer Service team at (800) 924-3494 or view the FAQ document we developed for members.
Monthly 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)
We are working hard to understand the impacts and business needs of Act 111, also known as H.766. We have a group of individuals across our organization implementing the necessary changes as it relates to prior authorization, claims processing, step therapy, and provider contracting.
As changes and updates become available, we will be keeping our providers informed through this webpage, as well as regular emails and enewsletters. Be sure to keep an eye on your email for regular updates as the work progresses.
Contact us at providerrelations@bcbsvt.com to be added to our email list.
Blueprint Primary Care Provider Prior Authorization Waiver
Beginning January 1, 2025, prior authorizations will be waived for eligible primary care providers who order a qualifying service (imaging, clinical laboratory, durable medical equipment, etc.) for a qualifying member.
Provider Requirements for Prior Authorization Waiver
- Must participate in Vermont Blueprint for Health;
- Must be enrolled, credentialed, and contracted with Blue Cross and Blue Shield of Vermont
While the provider does not need to be the Blue Cross VT member's selected primary care provider, the ordering provider must have engaged in clinical decision making for the ordered service.
Please note, only in-network services are eligible for a prior authorization waiver. Out-of-network services and prescription drugs require prior authorization.
Member Requirements for Prior Authorization Waiver
- The member is enrolled in a Qualified Health Plan, a large group fully insured plan, New England Health Plan/Access Blue New England, or a governmental plan (State of Vermont, University of Vermont, Vermont Education Health Initiative).
Learn how you can identify if a member qualifies for a prior authorization with our online instructions.
Claims Submission Requirements
If you are submitting a claim for services ordered by a Vermont Blueprint for Health 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 automatically.
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.