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
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.
January 1, 2026
Welcome to 2026
The new year means the renewal of member benefits and liabilities. Be sure to check eligibility and benefits prior to providing care by using a 27X transaction, the Provider Resource Center, or contacting the appropriate customer service team. If you need assistance with accessing the Provider Resource Center, contact the Provider Relations team at (888) 449-0443, option 1.
Copayments, deductibles, and coinsurance can be billed to the member at the point of service, prior to providing the service(s). To bill for these liabilities, you must verify the correct collection amount. In the case of a deductible, providers may bill members up to the allowed amount, or the member’s outstanding deductible balance, whichever is less. For example:
- If the allowance is $80 and the member has a $60 outstanding balance to complete their deductible, you collect $60 from the member.
- If the allowance is $80 and the member has a $100 outstanding balance to complete their deductible, you collect $80 from the member.
- If a member’s liability is reduced after the provider voucher is received, the member must be refunded promptly.
Note: Federal Employee Program (FEP) members who have Original Medicare as their primary payer have some cost shares waived. Contact the FEP customer service team at (800) 328-0365 for specific details.
January 1, 2026
Medical and Payment Policy Updates
Effective March 1, 2026, updates to some of our medical and payment policies take effect. A new payment policy has been created for Scalp Coding to Prevent Hair Loss During Chemotherapy. A new medical policy has been created for Intraosseous Basivertebral Nerve Ablation; other medical policies were reviewed with minor updates.
Medical Policy Updates
January 1, 2026
Pharmacy Updates
Pharmacist-led Medication Therapy Management
Our Medication Therapy Management vendor, Arine, has resumed outreach to members and providers to identify opportunities to improve the members’ overall health. Opportunities are identified using claims and diagnosis data and reviewed by clinical pharmacists.
Members may receive letters and phone calls inviting them to participate in the Medication Therapy Management program. If they choose to participate, a clinical pharmacist will review the member’s current health and medications, complete a comprehensive medication review, and work with them to create a personalized action plan.
You will be provided with a summary of the action plan to help patients achieve their goals. In addition, you may receive guideline-driven, evidence-based recommendations to help close gaps in care and prevent adverse outcomes for members. Communications will be sent via fax and may be followed by a phone call from the pharmacist.
The 2026 BCBSVT and NPF formularies are available on our Lists of Covered Medications webpage.
January 1, 2026
Updates on Billing Requirements for National Drug Codes
Since our last provider notice, we have made updates to the billing requirements for reporting a National Drug Code (NDC). Additional details can be found in the Provider Handbook:
- New Addition: Exception to Skin Substitutes/Bioengineered Skin – NDC is not required on code description(s) that indicate add-on list separately in addition to primary procedure OR list separately to primary procedure.
- New Addition: “The Requirement Does Not Apply to” services where Medicare is the primary carrier.
Time-sensitive reminder: Effective January 1, 2026, the billing requirement for reporting a National Drug Code (NDC) on professional claims will be fully enforced. It is required to report an NDC along with the unit of measure and quantity on the claim submission. Incomplete or inaccurate claims submissions not meeting the requirements will be denied.
January 1, 2026
CAA Provider Directory Validation
First Quarter Validation Timeline
- January 3, 2026: On or around January 3, the first quarter CAA directory validation emails will be released.
- February 3, 2026: Directory validation must be completed, or you will be removed from our provider directory and risk possible contract termination.
- The CAA directory validation is sent by email from noreply@onbaseonline.com
- If you receive more than one email, please make sure you respond to each email. Some providers have multiple providers files, and therefore, multiple verification needs to occur.
- If your practice was removed from the network due to non-response of the fourth quarter validation, this is your opportunity to be added back into the network directory.
Additional details about Provider Directory Validation and claims processing are located on our Enrollment and Credentialing webpage. For questions, please call (888) 449-0443, option 2 or email CAA@bcbsvt.com.
January 1, 2026
University of Vermont Health Network Employee Group
Effective January 1, 2026, University of Vermont Health Network employee group members no longer have coverage through Blue Cross and Blue Shield of South Carolina (National Alliance) or any Blue Cross and Blue Shield plan. Claims with dates of service on or before December 31, 2025, can continue to be submitted as usual:
- Non-University of Vermont Health Network providers submit to Blue Cross VT for processing through the BlueCard Program for consideration of benefits.
- University of Vermont Health Network providers submit to Blue Cross and Blue Shield of South Carolina (National Alliance) for consideration of benefits.
Claims will have a one-year runout claim processing period (until December 31, 2026); however, claims are subject to timely filing guidelines.
University of Vermont Health Network employee group (prefix “UNS) includes Central Vermont Medical Center, Porter Medical Center, University of Vermont Medical Center, and University of Vermont Medical Center Home Health and Hospice.
January 1, 2026
Mental Health Provider Reimbursement
Our sincere thanks to those who attended our recent listening sessions regarding reimbursement for mental health providers. Your thoughtful feedback was valuable and heard. We understand how essential supervisees are in ensuring access to care across the state and have made the decision to maintain the current reimbursement for supervisee-delivered services without change. Given the challenges facing Vermont’s health system, we’ll continue to collaborate with DVHA and the Office of Professional Regulation to identify a solution that supports our responsibility to our members while preserving their access to affordable, quality care.
January 1, 2026
Preventive Care Guide Changes
The preventive care guide has been updated with the adaptive maintenance code changes, as well as the addition of codes in the Vaccine Administration, COVID-19 Vaccine Administration, Chlamydia Screening, and Contraceptive Methods sections. Review our notice for more details.
January 1, 2026
Provider Handbook Updates
Multiple sections of the provider handbook have been updated, including Blue Cross VT Provider Website and the Provider Resource Center, Modifiers, Claim Specific Guidelines, and Blue Cross VT Marketing of Providers in Member Directories.
January 1, 2026
Reminder: Use of Third-Party Billers/Vendors
To ensure our files are up to date, please file any Third-Party Billers or Vendors. If you have a recent change in billing services, be sure to notify us.
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.
January 1, 2026
Prior Authorization Reminder (Act 111)
There are specific claim submission requirements that must be followed for the claim to bypass the prior authorization requirements. Details can be found in Section 12 of our Provider Handbook.
January 1, 2026
1099's
We will mail all 1099 forms by January 31, 2026. Please allow normal USPS processing time to receive the mailing. If you do not receive your 1099 by Monday, February 16, 2026, contact our Provider Relations team at (888) 449-0443, option 1.
November 30, 2025
Reminder: Prior Authorization Changes Effective January 1, 2026
- Beginning January 1, 2026, prior authorizations for medically necessary services, excluding prescription drugs or out of network services, will be waived for eligible members when ordered by any primary care provider that has a contract with us. Review our notice for information on the changes and submitting claims.
- The Provider Passport Program for Advanced Imaging will be paused. Beginning January 1, 2026, qualifying providers will be required to submit prior authorization requests for applicable imaging services. Practices/Facilities with qualifying providers were notified of this pause in September.
- Note: Qualifying primary care providers are not required to submit prior authorization requests for eligible members (for more information, see Section 12 of our Provider Handbook).
- Group numbers 426 and 802 have been added to our Employer Group Primary Care Provider Prior Authorization Waiver list.
November 30, 2025
Medical Policy Updates
Effective February 1, 2026, updates to our medical policies take effect. The policies updated include External Insulin Pumps, Sleep Disorders Diagnosis, Gene Expression Profiling, Charged-Particle Radiotherapy, Ambulatory Cardiac Monitors, and Minimally Invasive Treatments for BPH. Please review the upcoming changes.
November 30, 2025
Pharmacy Updates for January 1, 2026
- Infliximab product medical benefit drug changes:
- Prior Authorization Not Required
- Inflectra (Q5103) becomes preferred and no longer requires prior authorization.
- Avsola (Q5121) remains the preferred and does not require prior authorization.
- Prior Authorization Required
- Remicade/infliximab (J1745)
- Prior Authorization Not Required
- NPF Formulary changes
- All members and providers affected by formulary changes received a letter in October 2025.
- GLP-1 medications reminder: The GLP-1 medications Zepbound, Wegovy, and Saxenda are excluded for the indication of weight loss for members on Qualified Health Plans, Blue Edge Business, and most employer plans as of January 1, 2026. Members who continue to use these medications will be responsible for the full cost. To verify a member's coverage, please check their benefits.
Wegovy will be covered for the prevention for Major Adverse Cardiovascular Events (MACE) in those having had a prior heart attack, stroke, or symptomatic peripheral arterial disease. If a patient is on Wegovy for weight loss, a prior authorization can be completed for the MACE indication after December 1, 2025.
- Brand medications excluded on the formulary (must use generic equivalent)
- Adderall XR
- Aldactone
- Aptiom
- Brilinta
- Copaxone 40mg/mL
- Dymista
- Entresto
- Medications excluded with alternatives
- Adalimumab-adbm and Amjevita (biosimilars to Humira) will be excluded. The alternative is Simlandi, which is currently on formulary. Patients can be switched prior to January 1,2026.
- Wezlana (biosimilar to Stelara) will be excluded. The alternative is Yesintek, which is currently on formulary. Patients can be switched prior to January 1, 2026.
- Ajovy will be excluded. Emgality is moving to preferred on January 1, 2026. Aimovig, Nurtec, and Qulipta will continue to be on formulary.
- Candesartan
- Dayvigo
- Doxycycline 40mg (Rosacea)
- Estrogel 0.06%
- Omeclamox Pak
- Up Tier
- OneTouch Meter and Test Strips (Lifescan mftr) will move to nonpreferred. Patients can switch to Contour (currently a preferred option) or Freestyle/Precision, which will be preferred on January 1, 2026.
- Wegovy for the indication of Major Adverse Cardiovascular Events (MACE)
- Depen Titra
- Supprelin LA
For the most up to date information on BCBSVT and NPF formularies, visit our Lists of Covered Medications.
November 30, 2025
Reminder: Billing Requirements for National Drug Code
Beginning January 1, 2026, the billing requirement for reporting a National Drug Code (NDC) on professional claims will be fully enforced. It is required to report an NDC along with the unit of measure and quantity on the claim submission. Incomplete or inaccurate claims submissions not meeting the requirements will be denied. We encourage you to review your claim submissions for these services and ensure they are compliant.
November 30, 2025
Mental Health Substance Use Disorder Service Codes
Our members have access to certain mental health and substance use services for the same copay as a primary care provider visit. Services included: 90785, 90791, 90792, 90832, 90834, 90837, 90846, 90847, 90853, 90863, H0015 and H0020.
Effective January 1, 2026, the following codes have been added for mental health and substance use services: 99446, 99447, 99448, 9949, 99451, 90839 and 90840.
November 30, 2025
Important Update for BlueCard Members with Arkansas Blue Cross and Blue Shield
Arkansas Blue Cross and Blue Shield has a new brand for their National Account Members – Skai Blue Cross Blue Shield. Beginning in 2026, the Skai Blue Cross Blue Shield branding will be on member identification cards, and members presenting these identification cards are considered BlueCard members.
November 30, 2025
2026 FEP Prior Approval
The 2026 Federal Employee Program (FEP) Prior Approval lists are now posted to our Prior Authorization webpage.
November 30, 2025
Preventive Care Guide Changes
The preventive care guide is updated with the removal of codes in the applicable syphilis screening sections, effective February 1, 2026. Review our notice for more details.
November 30, 2025
Provider Handbook Updates
The provider handbook is updated in various sections: The BlueCard® Program, Claim Specific Guidelines, Enrollment of Providers, General Claim Information, Mammogram Screening, and Member Liabilities.
November 30, 2025
ICD-10 Code Updates
The 2026 ICD-10-CM Official Guidelines for Coding and Reporting are valid for services provided after October 1, 2025. The Guidelines have been updated to clarify code assignment for patients with HIV and AIDS, along with other changes. If you have questions about proper coding for these conditions, refer to the Guidelines (available online or in your 2026 ICD-10-CM book), reach out to your Provider Engagement Consultant, or email our team at riskadjustment@bcbsvt.com.
November 30, 2025
You're Invited: Monthly Virtual Workgroup
Do you want to learn more about the impacts of documentation, coding, and billing, and how it relates to the qualified health plan patients that you treat? The Risk Adjustment Department hosts a monthly virtual provider workgroup that is open to all providers. It’s a great opportunity to connect with your colleagues and discuss how you and your peers are managing different risk adjustment and quality requests from payors.
The workgroup meetings are held the second Tuesday of every month from 11:30 a.m. – 12:30 p.m. We invite you to join the meeting for any length of time that fits your schedule. For a meeting invite, please email riskadjustment@bcbsvt.com.
November 30, 2025
Educating Vermonters About Affordable Care in Vermont
Over the past year, we've been intentionally vocal about our advocacy for healthcare affordability and the work required of providers, payers, hospital leaders, and legislators to create change. Recently, we had the opportunity to partner with several providers to educate Vermonters on how cost differs by facility and that there are multiple options for receiving care that is accessible and more affordable.
The partnership includes Northwestern Medical Center, Green Mountain Surgery Center, Vermont OPEN Imaging, Vermont Diagnostic Imaging, and Blue Cross VT. You can learn more on the campaign webpage VTAffordableCare.com.
November 1, 2025
Wegovy Coverage for the Prevention of Major Adverse Cardiovascular Outcomes
As a reminder from our previous notification, GLP-1 medications that are FDA-approved for weight loss will no longer be covered effective January 1, 2026, for most Blue Cross VT plans. We will continue to cover GLP-1 medications that are FDA-approved for Type 2 diabetes, with prior authorization. In addition, Wegovy may be covered for the prevention of certain obesity-related major adverse cardiovascular events (MACE). The criteria for MACE prevention are based on the SELECT trial.
For more information on coverage of GLP-1 medications for MACE, view our notice.
November 1, 2025
Medical and Payment Policy Updates
Effective January 1, 2026, payment and medical policy updates take effect. Please be sure to review the upcoming changes.
November 1, 2025
Free Provider Psychiatric Consultations
The Vermont Consultation & Psychiatry Access Program (VTCPAP) provides free, fast psychiatric consultations to registered practices that care for pediatric and perinatal patients. Providers can receive peer-to-peer support on screening, diagnosis, and treatment planning from licensed social workers or psychiatrists. Calls are returned within 30 minutes during business hours. Learn more about the service at vtcpap.com.
November 1, 2025
Identification Card Change
The Blue Cross and Blue Shield Association has begun making changes to member ID cards. While the health plan product type (EPO, PPO, HMO) will remain, the suitcase logo will be phased out, along with additional small changes. We’ll provide more details in the coming months.
November 1, 2025
Claims Xten-Select Upgrade
An update to ClaimsXten-Select™ is scheduled for Thursday, January 1, 2026. Review the notice to understand the upcoming changes.
November 1, 2025
Verisys Reminder
Verisys, a national credentials verification organization, is responsible for primary source verification for our credentialing and re-credentialing process.
Verisys may outreach to you directly if additional actions are required to complete the primary source verification. To ensure your network status isn't interrupted, please respond immediately if they reach out to you.
One way to avoid outreach from Verisys is to ensure your Council for Affordable Quality Healthcare (CAQH) information is current and attested. You can set up, view, and update your CAQH ProView™ account at https://proview.caqh.org/. Check your CAQH account to ensure:
- All information is current and that current copies of malpractice insurance, current licensure, DEA, etc. are successfully uploaded.
- Your provider status is at Re-Attestation.
- Blue Cross and Blue Shield of Vermont is authorized to receive your provider data from CAQH.
If you are unable to access CAQH or have questions regarding the primary source verification process, contact Verisys Customer Service at (855) 743-6161, Monday-Friday from 8 a.m. to 8 p.m. ET. If you are a first-time user, you can find an online demonstration of the application process at https://proview.caqh.org/.
November 1, 2025
Prior Approval List Updates
The prior approval list has been updated to reflect the addition and removal of codes, effective January 1, 2026. Review our notice for details on the updated codes.
November 1, 2025
Routine Code Maintenance
Review our notice for details on the implementation of new and revised codes, effective January 1, 2026.
November 1, 2025
Preventive Care Guide Updates
The preventive care guide is updated with additional codes. Review our notice for more details on the added codes.
November 1, 2025
Provider Handbook Updates
Updates to the provider handbook have been made to the following sections: Claim Specific Guidelines, Act 111 Primary Care Provider Waiver of Prior Authorization, Modifiers, Blue Cross VT/The Vermont Health Plan Contracts, Provider Voucher, and 835 Transactions.
November 1, 2025
2026-2027 Electronic Fund Transfer Payment Schedule
Electronic Fund Transfer (EFT) payments are made on Fridays for that Tuesday’s provider voucher(s). When a holiday falls on a Friday, the EFT will occur on the following Monday. EFT payments will be made on Mondays for the following holidays next year:
- Juneteenth
- Independence Day
- Christmas Day
- New Year's Day
November 1, 2025
2026 Holiday Schedule
Blue Cross VT and Carelon are closed January 1 and January 19. Please review our 2026 holiday schedule, including information for our partners.
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.