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
September 1, 2026
CMO Corner: VT Affordable Care
At Blue Cross and Blue Shield of Vermont (Blue Cross VT), we’re committed to helping educate Vermonters on how to navigate the healthcare affordability challenges in our state. Like last year, we are collaborating with Northwestern Medical Center, Green Mountain Surgery Center, Vermont OPEN Imaging, and Vermont Diagnostic Imaging to help empower our community to make more informed decisions about their care.
The new VT Affordable Care website features resources like cost comparison tools, local viewpoints on affordable care, prescription drug savings opportunities, questions patients can ask at appointments, and more.
The overall goal is to provide a more complete picture of how prices vary by service and facility. For example, showing that while some hospitals may be among the most affordable for certain services, they may cost more for others.
Making high-quality affordable healthcare a reality requires collaboration across the entire healthcare system, and we’re committed to being a strong partner to Vermont’s providers. If you have questions or feedback, please don’t hesitate to reach out.
Regards,
Dr. Tom Weigel
Chief Medical Officer
September 1, 2026
Only 30 Days Left - Don't Miss Your Payments!
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
September 1, 2026
Important Updates to Policies, Provider Handbook, Preventive Guide, and Codes
Starting November 1, 2026, updates to our medical policies, provider handbook, preventive guide, and codes go into effect. Please take a moment to review all of these updates, as they may impact your practice and patients.
Code Maintenance Changes
Provider Handbook Updates
Preventive Guide Updates
Medical Policy Changes
September 1, 2026
Artificial Intelligence (AI) Inquiries
Blue Cross VT will not respond to AI generated, automated, or non-live inquiries or calls made to any area of the company. If your office or a third-party vendor is using AI, please make sure it does not contact us. Suspected AI calls will be disconnected. This decision has been made to protect our data and our members.
The Provider Resource Center (PRC) makes it easy to find the information you need, whenever you need it. If you need assistance, we're here to help. You, or a member of your practice, can reach out to the provider relations team by email at providerrelations@bcbsvt.com or by phone at (888) 449-0443, option 1.
September 1, 2026
Granting Access for Third-Party Billers
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.
September 1, 2026
Contraceptive Counseling Reminder
If you are working with a patient on contraceptive counseling or contraceptive management, the diagnosis in the first position needs to align with those eligible diagnoses in our preventive guide, under Preventive Gynecologic and Wellness Exam for Contraceptive Management. When you bill using one of the diagnoses listed in the preventive guide, the services are eligible for coverage without member cost-share.
September 1, 2026
National Drug Code (NDC) Notice: Live on October 30
NDC billing rules will be systematically enforced for claims processed on or after October 30, 2026. This may mean that claims previously accepted will be denied for failure to follow NDC billing rules.
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 billing rules on our website, where you can also find an FAQ to help answer any of your questions during this process.
We encourage you to review your claim submissions for these services and make sure they are correct and compliant now. Doing so will ensure you will not be impacted by denials going forward.
September 1, 2026
Vermont Blue Advantage (VBA) Claims Reminder
Claims for services rendered to VBA members in 2025 must be submitted by December 31, 2026.
- Claims, including corrected claims, and medical records can be faxed to (800) 479-8973.
- Claim denial appeals can be faxed to (800) 479-8938.
For VBA’s mailing address and other non-medical claim submission information, please refer to the Contact Us page or contact VBA Provider Services at (844) 839-5122, Monday through Friday, 8 a.m. to 5 p.m., EST., with any questions.
September 1, 2026
Timely Filing Reminder
All claims must be filed within 180 days of the date of service or they will be denied.
Providers can verify and review the receipt and status of a claim in the Provider Resource Center, or by contacting the appropriate customer service team. If contacting a customer service team, you must wait at least 30 days from the submission date before requesting a status.
If you would like assistance or instructions on using the Provider Resource Center, please contact the Provider Relations Team at (888) 449-0443 option 1.
September 1, 2026
Adaptive Maintenance for October 1, 2026
In a few weeks, we will be sharing a special newsletter that will provide details on the implementation of the new and revised codes for October 1, 2026.
September 1, 2026
Documentation and Coding Training Series
Provider groups have asked, and we have delivered! Check out our series of short documentation and coding video trainings. These resources are based on industry standard best practice guidelines and are designed to support coders, billers, and providers.
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.
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.
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.
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.
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.