Provider News & Updates

August 3, 2026

Global Obstetrics/New Maternity Services Codes  

In anticipation of the transition from the global obstetric codes to the new 2027 maternity services codes, beginning on and for dates of service after September 1, 2026, claims for members presenting for their first prenatal visit after confirmation of pregnancy must be billed with: 

• An evaluation and management (E/M) code appended with modifier -TH to differentiate the visits as maternity care, and 
• The appropriate ICD-10-CM code(s), (Z34A Category [4th character required]), to verify the gestation of the pregnancy.

Subsequent antepartum visits are required to be billed with the appropriate E/M code appended with modifier -TH. 

These claims are subject to E/M coding rules, and medical record documentation must support medical decision making (MDM) or the time consistent with current CPT® guidelines for the billing of an E/M code.

Claims for prenatal care for dates of services prior to September 1, 2026, should be billed with the current antepartum codes, 59425 for 4-6 Visits or 59426 for 7 or more visits. 

All other services within this timeframe should continue to be reported in alignment with the global package as indicated by our current policies.

August 1, 2026

CMO Corner: An Extension of Your Care Team

Some patients need more support between office visits—and that's where our Clinical Case Management team of registered nurses (RN) and licensed behavioral health professionals (LICSW, LCMHC, LADC) can help.

Think of our clinical case managers as an extension of your care team.

As part of Blue Cross and Blue Shield of Vermont (Blue Cross VT), our team has valuable experience with medical and pharmacy claims, care utilization, and provider networks. Combined with their expertise in compassionate patient-centered case management, they can identify patterns that may not be visible to a single practice or health system.  

In their role as care connectors, our clinical case managers provide consistent, personalized support—making it easier for your patients to focus on their wellbeing. Our team can:  

• coordinate care
• reinforce treatment plans
• help members navigate their health plan benefits
• connect members with mental health services
• share community resources that address barriers, such as transportation, food insecurity, and housing

If you know a patient who could benefit from additional support, we encourage you to make a referral by calling (800) 922-8778, option 3, or by sending a secure email to healthsupport@bcbsvt.com. Members can also be encouraged to reach out on their own.

By working together to organize care and support for your patients, we can help Vermonters achieve better health outcomes.

Regards,
Dr. Tom Weigel
Chief Medical Officer

August 1, 2026

Important Updates to Policies and Codes

Starting October 1, 2026, updates to our medical and payment policies go into effect. Corrections have also been made to the Routine Code Maintenance Changes that were shared in the July 2026 newsletter. Please take a moment to review these updates, as they may impact your practice and patients.

Routine Code Maintenance Changes
Payment Policy Changes
Medical Policy Changes

August 1, 2026

Only 60 Days Left 

As of October 1, 2026, we will no longer issue paper checks. Sign up for Electronic Fund Transfer ( EFT ) before October 1, 2026, to ensure you receive payments.

Sign Up Now
Get more information on how to enroll

August 1, 2026

New Virtual Mental Health Program: Dialectal Behavior Therapy (DBT)

We are pleased to announce a new program available to your patients through our virtual provider partner, Valera Health.

DBT focuses on emotion dysregulation and behavioral dyscontrol, helping patients replace ineffective coping mechanisms with healthier skill practices. The program is 24 weeks long and available to patients as young as 12 years old.

If you believe you have patients who would benefit from DBT, they can contact Valera Health directly at (646) 450-7748.

August 1, 2026

Pharmacy Updates

Stay informed to ensure your patients' prescriptions are appropriate and timely.

New Generics and Formulary Additions

• New Tier 1 Generics for Diabetes medications
  • Januvia (sitagliptin)
  • Janumet (sitagliptin/metformin)
• Prior Authorizations are no longer required for the following preferred medications:
• Bimzelx
• Icotyde

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.

August 1, 2026

Changes to Global Maternity Care and Delivery Coding

In our June newsletter, we shared that the American Medical Association has adopted substantial revisions that will replace the current global maternity care and delivery codes with new CPT® codes, effective January 1, 2027.

The billing guidance for antepartum (prenatal) care, beginning on and after September 1, 2026, has been updated and added to our existing Global Maternity Obstetric Package and Home Births payment policies.

We will keep you informed over the coming months as we further evaluate these changes and update our claims processing system, payment policies and provider handbook.

Read more

August 1, 2026

Reminder: Updates to Carelon Guidelines Effective in September

Starting with services provided on or after September 19, 2026, updates to the Carelon Medical Benefits Management, Inc., Clinical Appropriateness Guidelines will be in effect.

See the updates

August 1, 2026

MD Rx and HIT Fee Schedule Change

Effective October 1, 2026, the community fee schedule payment for medications administered or supplied in a provider’s office (MD Rx) and Community Home Infusion Therapy will change.

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) in your outreach.

August 1, 2026

Member Rights and Responsibilities

To help members get the most from their health plan, providers are expected to adhere to the guidelines outlined in our Member Rights and Responsibilities. If you would like a paper copy, please contact our provider relations team at providerrelations@bcbsvt.com. 

August 1, 2026

Updated Worksheet for Prior Authorization

The Psychological/Neuropsychological Testing Clinical Information Worksheet is supplemental to the standard prior authorization form and has been updated with one new question to clarify if testing is being requested for educational evaluation or academic accommodations. If you have a supply of these forms, you will need to replace them with the updated version.

August 1, 2026

Provider Satisfaction Survey

We'd like to hear about your experience working with us. Our research partner, Press Ganey, is sending a provider satisfaction survey via email to a random sample of Blue Cross VT providers. They will then follow up with a call. The survey takes less than 10 minutes to complete and will help us improve the plan experience for you and our members. Thank you for sharing your feedback and helping make health care work better for Vermonters

July 13, 2026

Upcoming Maintenance: Prior Authorization Tool

The prior authorization tool in the Provider Resource Center will be unavailable from 6:00 p.m. on Friday, July 17, 2026, through 7:00 am Monday, July 20, 2026, for routine maintenance. If you have an urgent prior authorization request during this time, 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 in the Provider Resource Center, such as eligibility, claims, and provider vouchers will be available during this time.

July 13, 2026

Adaptive Maintenance (new and revised codes) Addition

After we released our Adaptive Maintenance enewsletter for July 1, 2026, CMS released more codes. The following codes were released by CMS on July 6, 2026 and are retroactive to January 1,2026: G0681, G0682, G0683 and G0684 and are considered informational by Blue Cross VT.

July 1, 2026

CMO Corner: Provider Directory Validation and Potential Claim Denials

Federal law requires all insurers to maintain an accurate provider network directory and all providers to verify or update their directory information every 90 days. We send Provider Directory Validation emails with important information and deadlines in January, April, July, and October.

Starting with this month's validation cycle, and every quarter thereafter, you must complete the validation within 30 days of the notification, or your claims will be denied until you complete the validation process. In this instance, providers will be required to resubmit denied claims.

Provider Directory Validation instructions are located on the Enrollment and Credentialing area of our website. If you have questions, please call (888) 449-0443 option 1 or email CAA@bcbsvt.com. 

Thank you for doing your part to help maintain an accurate provider directory. By completing each quarterly validation, you help members seeking care access your information in our find-a-doctor tool, as well as help other providers complete referrals for care to your practice.

Regards, 
Dr. Tom Weigel
Chief Medical Officer

July 1, 2026

Time Sensitive: Policies and Handbook

Updates to our medical policy and provider handbook go into effect August 1, 2026. Please take a moment to review these updates, as they may impact your practice and patients.

Provider Handbook Updates 
Medical Policy Changes

July 1, 2026

90 Days Left to Sign Up for Electronic Payments

As of October 1, 2026, we will no longer issue paper checks and will be transitioning to Electronic Fund Transfer (EFT), which is safe and free of charge. Sign up to receive EFT before October 1, 2026, to ensure you receive timely payments.

Here’s information on how to enroll:

• If you need help, please call the PayeeHub Customer Care team at (877) 882-0384, Monday through Friday, 9 a.m. to 8 p.m. EST.
• If you use vouchers (ERA/835), make sure you’re also signed up for our Provider Resource Center (PRC), where you can obtain vouchers going forward.
• If you have questions, please contact our Provider Relations team at providerrelations@bcbsvt.com or call (888) 449-0443, option 1.

July 1, 2026

Holiday Electronic Fund Transfer (EFT) Payment Schedule 

EFT payments are typically made on Fridays for provider voucher(s) submitted on Wednesdays, except for Friday holidays. Below is the holiday EFT payment schedule for the remainder of the year:

• Friday, July 3 (Independence Day) will occur on Monday, July 6, 2026
• Friday, December 25 (Christmas Day) will occur on Monday, December 28, 2026 
• Friday, January 1 (New Year’s Day) will occur on Monday, January 4, 2027

July 1, 2026

Preventive Care Reminder Sent to Members

We recently reached out to members who have not seen a doctor in the last two years to remind them to schedule their annual preventive care visit with their Primary Care Provider (PCP). Check out our Preventive Care Guide for more information about services available at no cost to members.

July 1, 2026

2025 QHP Risk Adjustment Data Validation Project

We have partnered with Reveleer again this year for the medical record retrieval of 2025 claims identified in the Risk Adjustment Data Validation (RADV) project by the Centers for Medicare & 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 Qualified Health Plan (QHP) Risk Adjustment Department by email at RiskAdjustment@bcbsvt.com or phone at (802) 371-3540.

July 1, 2026

Pharmacy Updates

Updates to the formulary or pharmacy policies may influence prescribing decisions. Stay informed to ensure your patients' prescriptions are appropriate and timely.

New Generics and Biosimilars

• Generic for the diabetes medication Farxiga, dapagliflozin, is now available as a Tier 1 generic.
• Generic for Atrovent, ipratropium inhaler, is now available as a Tier 1 generic.
• Prolia (denosumab) biosimilars are available on the formulary. Osenvelt, Xgeva, Stoboclo, and Prolia are all now preferred brand specialty medications.
• Ozempic Tablet (previously known as Rybelus) is a Tier 2 preferred brand and used for diabetes treatment.

View Full List of Changes

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, 2026

National Drug Code (NDC) Notice: Date Change

The enforcements for NDC requirements will not go into effect on July 3, 2026. We are working on this process and will provide you with a new effective date soon.

As a reminder, billing requirements for NDC, Unit of Measure, and Quantity have been in place since September 1, 2016—the only change will be in the enforcement. You can learn more about NDC on our website, where you can also find an FAQ to help answer any of your questions during this process.

Read more

June 26, 2026

Adaptive Maintenance (new and revised codes) Addition

After we released our Adaptive Maintenance enewsletter for July 1, 2026, CMS released another code. Code G0577 is effective on July 1, 2026, and will be considered investigational by Blue Cross VT.

June 3, 2026

Nutritional Therapy and Nutritional Counseling

Our June 2026 provider enewsletter provided notice that we are archiving our Nutritional Counseling Medical Policy, effective August 1, 2026. We have created two new policies that will go into effect on August 1, 2026 – Medical Nutrition Therapy and Nutritional Counseling Medical Policy and Medical Nutrition Therapy and Nutritional Counseling Payment Policy. Please review these new policies in their entirety to understand what, if any, impact this may have on your practice.

Note: Our monthly provider enewsletter should always be reviewed to understand changes and requirements that may impact your practice directly. We may not always provide direct notices on changes that have an impact on your practice.

May 29, 2026

CMO Corner: 2026 Appointment Access Survey

Each year, we conduct reviews of our Accessibility of Services and Provider Administrative Service Standards using member feedback, audits, and appointment access data. To support this process, we ask that you complete our brief, 2-minute provider survey that you’ll receive via email in early June. If you are not the appropriate contact, please forward the survey to the individual within your organization who manages appointment access information.

Why is this survey important? The survey results help us assess the availability for urgent and routine appointments across our network and provide valuable insight into current access challenges and operational realities. We recognize that many of you are facing significant staffing shortages and system pressures continue. While our standards reflect the level of access we aim to achieve, we understand they may not always align with current conditions. To ensure a more informed and collaborative review process, this year’s evaluation will place greater emphasis on direct provider feedback and perspective.

If you have any additional feedback to share or would like to join our annual analyses, please contact: Christina Filipowich, RN, Clinical Quality Consultant. Thank you in advance for your participation in the survey.  

Regards,  

Dr. Tom Weigel, Chief Medical Officer 
Blue Cross VT

May 29, 2026

Community Letter from Our CEO

On May 21, our President and CEO Beth Roberts sent a letter to our colleagues, community leaders, and members, reflecting on her first six months. In it, she discussed our premium rates and what we’re doing to address healthcare affordability.

Read the full letter

May 29, 2026

Important Updates to Policies and Handbook

Updates to our medical and payment policies and provider handbook go into effect August 1, 2026. We've also made routine coding updates that have added services to our prior approval list. Please take a moment to review these updates, as they may impact your practice and patients.

Routine Coding Updates
Provider Handbook Updates
Medical Policy Changes
Payment Policy Changes

May 29, 2026

Sign Up for Electronic Payments

As of October 1, 2026, we will no longer issue paper checks and will be transitioning to Electronic Fund Transfer (EFT), which is safe and free of charge. Sign up to receive EFT before October 1, 2026, to ensure you receive timely payments. Here’s information on how to enroll.

If you need help, please call the PayeeHub Customer Care team at (877) 882-0384, Monday through Friday, 9 a.m. to 8 p.m. EST.  

If you use vouchers (ERA/835), make sure you’re also signed up for our Provider Resource Center (PRC), where you can obtain vouchers going forward.

If you have questions, please contact our Provider Relations team at providerrelations@bcbsvt.com or call (888) 449-0443, option 1.

May 29, 2026

Holiday Electronic Fund Transfer (EFT) Payment Schedule

EFT payments are typically made on Fridays for provider voucher(s) submitted on Wednesdays, except for Friday holidays. Below is the holiday EFT payment schedule for the remainder of the year:

• Friday, June 19 (Juneteenth) will occur on Monday, June 22, 2026
• Friday, July 3 (Independence Day) will occur on Monday, July 6, 2026
• Friday, December 25 (Christmas Day) will occur on Monday, December 28, 2026
• Friday, January 1 (New Year’s Day) will occur on Monday, January 4, 2027

May 29, 2026

Changes to Carelon Clinical Practice Guidelines for Radiology Services

For radiology services provided on or after September 19, 2026, Carelon Medical Benefits Management, Inc. has updated its clinical appropriateness guidelines to promote clinically appropriate, safe, and affordable healthcare.

View all changes

May 29, 2026

BlueCard Claim Resubmissions

For an efficient BlueCard claim process, pended claims need to finish processing before submitting any corrections or adjustments.

• If we receive an updated claim to replace one that has not yet been fully processed, it will be immediately returned to the submitter through the U.S. Postal Service.
• If corrections are needed after the existing claim is processed through a provider voucher, it can then be resubmitted.

May 29, 2026

CAA Provider Directory Validation

CAA Provider Directory Validations are sent quarterly in January, April, July, and October, and they must be completed within 30 days of the notification.

• Starting September 1, 2026, providers or practices who did not validate their July 1, 2026, CAA Provider Directory Validation within the specified timeframe (as defined in the CAA Provider Directory Validation email) will have their claims under the non-confirmed NPI number denied, until the provider or practice goes through the process to complete the validation.
• Claims denied during the non-compliant period will have to be resubmitted by the provider or practice.

The best way to avoid claim denials and removal from our online provider directory is to complete the CAA Provider Directory Validation on time. The Third Quarter CAA Provider Directory Validation will be released on or around July 4, 2026.

This process, and your participation, is mandated by federal law. CAA Provider Directory Validation and instructions to complete the process are located on the Enrollment and Credentialing area of our website. If you have questions, please call (888) 449-0443 option 2 or email CAA@bcbsvt.com. 

May 29, 2026

Changes Coming in January to Global Maternity Care and Delivery Coding

Maternity care coding is currently reported under one global code, representing nine months of care as a single bundled service. Effective January 1, 2027, the AMA has mandated coding changes for maternity care. The global maternity code will be removed and replaced with new CPT codes. If you bill the global code on or after January 1, the claim will deny.

View all changes

May 29, 2026

National Drug Code (NDC) Notice

Claims for certain services with a processing date on or after July 3, 2026 must contain an NDC, Unit of Measure (UoM) and Quantity, in addition to the applicable HCPCS code and unit amount. See the full list of impacted services.

Services lines that require an NDC, UoM, and Quantity but do not report them will be denied. Members cannot be held liable (even with a signed waiver), but a corrected claim can be submitted for consideration. We encourage you to review your claim submissions for these services to avoid any denials.

You can learn more about NDC on our website, where you can also find an FAQ to help answer any of your questions during this process.

May 29, 2026

Monthly Coding Tip: Major Depressive Disorder (MDD)

Since May is Mental Health Awareness Month, we’re sharing a reminder for best practice documentation and coding guidelines for Major Depressive Disorder (MDD). When MDD is added to a claim, be sure it is supported in the medical record with descriptions that accurately reflect the patient’s health; consider the severity (mild, moderate, or severe), whether psychotic features are present, and remission status.

May 29, 2026

Change in Approach to Payment Policy Design and Content

Starting in August, our payment policies will have a new look that includes a comprehensive policy statement, related policies, policy implementation details, and reference to our new Payment Policy Guideline Document.

Please note that while we generally follow the Centers for Medicare and Medicaid Services (CMS) guidelines and industry standards, our new payment policies are designed to specify where we differ in billing or coding requirements and/or our reimbursement methodology.

Existing payment policies will be reviewed and updated to match the new format.

May 29, 206

Pharmacy Update: Infusion Therapy Options

There are several infusion therapy options for our members who receive infusion medications, such as independent clinics, hospital and office-based outpatient clinics, and home infusion companies. Our team is here to answer any questions about coverage and help members find in-network infusion providers.  

View the flyer

Monthly Newsletters

• February 2026
• March 2026
• April 2026
• May 2026
• June 2026
• July 2026

Adaptive Maintenance Newsletters

• December 2025
• March 2026
• June 2026

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. 
 

• 2026 Provider Required Annual Notice