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
March 17, 2026
Adaptive Maintenance Reminder
On March 17, we sent our quarterly adaptive maintenance email, outlining the new and revised codes for April 1, 2026. Be sure to check your email to view the notification.
March 1, 2026
Virtual OCD Treatment
At Blue Cross and Blue Shield of Vermont, one of our goals this year is to continue evolving the tools and services that support your work and improve patient outcomes. This month, we are highlighting a new health service available for patients with obsessive compulsive disorder (OCD). We have partnered with NOCD to offer virtual, evidence-based treatment. This ensures members have access to Exposure and Response Prevention (ERP)-trained specialists, who can deliver the most effective, first-line, clinical standard for reducing OCD symptoms and improving daily functioning. This service is available to patients through a secure, convenient virtual platform. We’re excited about the benefits this partnership will bring to you and your patients and thank you for your continued partnership and the care you provide every day.
March 1, 2026
Important Policy, Code, and Handbook Updates
Effective May 1, 2026, updates go into effect for payment and medical policies and routine code maintenance. Our provider handbook also includes updates regarding cost-share, modifiers, and claim guidelines. Please be sure to review the upcoming changes that may impact your practice and patients.
Medical Policy Changes
Payment Policy Changes
Provider Handbook Updates
Routine Code Maintenance
March 1, 2026
2026 Prefix Listing
The Prefix Listing has been updated for 2026. It is available on the Provider Forms and Resources page under Claim Forms and Information.
March 1, 2026
Underway: Medical Records Retrieval Project
Our annual Healthcare Effectiveness Data and Information Set (HEDIS®) medical records data collection is currently underway. We appreciate your participation in this process as it helps your peers and our members understand the quality of care your clinical team provides every day.
For an overview of when a bulk of medical records may be requested from Blue Cross VT, check out our updated 2026 Medical Record Activity Timeline.
March 1, 2026
Pharmacy Updates
Updates to the formulary or pharmacy policies may influence prescribing decisions. Stay informed to support timely, appropriate therapy. This month, we're featuring newly available generics, which are generally preferred over brand-name medications.
New generics
- Ciprofloxacin hydrocortisone otic suspension, generic for Cipro HC, is a Tier 1 Generic.
- Amphetamine ER Orally Disintegrating Tablet, generic for Adzenys XR, is a Tier 1 Generic and may be appropriate for patients needing a drug formulation that does not need to be swallowed. It is bioequivalent to Adderall XR and indicated for patients age 6 and older.
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.
March 1, 2026
Contraceptive Counseling
In order for a visit to be considered a preventive visit without cost share, an eligible diagnosis must be in the first position on the claim line. Please see our preventive grid for a list of eligible diagnosis located under Preventive Gynecologic and Wellness Exam for Contraceptive Management.
Contraceptive encounters are eligible for first dollar coverage (without cost share) when billed using one of the diagnoses listed in our Preventive Grid in the first position on the claim line.
March 1, 2026
Billing Services for National Drug Codes
As a follow-up to the information we shared with you on January 1, we are enforcing the requirements for professional claims (billed on a CMS 1500) to include the reporting of a National Drug Code (NDC.) Professional claim service lines that require and do not include an NDC will be denied. Members cannot be held liable (even with a signed waiver), and a corrected claim can be submitted for consideration of benefits. This is a first step in the enforcement of our reporting requirements. Please click the button below to learn more.
To date, we have addressed the following:
- The reporting of an NDC.
- The reporting of Unit of Measure (UoM) and quantity.
- The requirements for the applicable Current Procedural Terminology (CPT®) or Health Care Procedure Coding System (HCPCS) for professional and outpatient facilities for specific drugs.
March 1, 2026
Modifier -HN
Modifier -HN represents that a service is being rendered by a bachelor level provider. Per our Payment Policy for Supervised Practice of Mental Health and Substance Use Disorder, this is not allowed,
Only providers with a master level degree working toward licensure are eligible to bill for seeing patients as a trainee and must be billed with a modifier -HO. Details are in the payment policy.
March 1, 2026
Correct HCPCS Level II Drug Billing
Correct reimbursement of HCPCS Level II Drugs is dependent on the correct billing of units. A common mistake involves billing by the number of units administered rather than reporting the number of units represented by the HCPCS Level II code descriptor. Invalid units will result in claims denial or reversal.
March 1, 2026
2026 ICD-10 Coding Guidelines
The 2026 ICD-10 Coding Guidelines for acute myocardial infarction (AMI) offer the following rules for proper coding of the condition:
- Subcategories I21.0-I21.2 and code I21.3 are used for type 1 ST elevation myocardial infarction (STEMI).
- Code I21.4, Non-ST elevation (NSTEMI) myocardial infarction, is used for type 1 non-ST elevation myocardial infarction (NSTEMI) and non-transmural MIs.
- Code I21.9, Acute myocardial infarction, unspecified, is the default for unspecified acute myocardial infarction or unspecified type.
- The site of the MI must be identified to most correctly code the MI; examples include anterolateral wall or true posterior wall.
- If only type 1 STEMI or transmural MI without the site is documented, assign code I21.3, ST elevation (STEMI) myocardial infarction of unspecified site.
Points to consider:
- If a type 1 NSTEMI evolves to STEMI, assign the STEMI code. If a type 1 STEMI converts to NSTEMI due to thrombolytic therapy, it is still coded as STEMI.
- For encounters occurring while the myocardial infarction is equal to or less than four weeks old, including transfers to another acute setting or a post-acute setting, codes from category I21 may continue to be reported.
- For encounters after the 4-week time frame where the patient is still receiving care related to the myocardial infarction, the appropriate aftercare code should be assigned, rather than a code from category I21.
- For old or healed myocardial infarctions not requiring further care, code I25.2, Old myocardial infarction, may be assigned. Acute myocardial infarction can be billed up to 28 days from the date of the acute infarction. The date of the acute infarction is based on inpatient testing. If there was no inpatient testing, an acute infarction can’t and shouldn’t be billed.
February 1, 2026
Member Rights and Responsibilities
To help members get the most from their benefit plan, providers are expected to adhere to the guidelines outlined in our Member Rights and Responsibilities. If you prefer a paper copy, please contact our provider relations team at providerrelations@bcbsvt.com.
February 1, 2026
Community MD Rx and HIT Reimbursement
Effective April 1, 2026, there are changes to the community reimbursement for drugs administered/supplied in a provider’s office (MD Rx) and Community Home Infusion Therapy.
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).
February 1, 2026
Routine Code Maintenance Changes
Review our notice for details on the implementation of new and revised codes, effective April 1, 2026.
February 1, 2026
Diabetes Coding Reminder
The ICD-10 classification identifies six distinct types of diabetes, including the commonly recognized type 1, type 2, and gestational diabetes, which is coded both when a member has diabetes and becomes pregnant, or if a member develops diabetes due to pregnancy. In addition, there are three types of secondary diabetes: diabetes due to an underlying condition, drug or chemical-induced diabetes, and other specified diabetes which includes conditions such as post-surgical diabetes. Gestational diabetes must always be coded using the appropriate gestational diabetes code (O24.____). However, if the member had diabetes prior to pregnancy, the applicable diabetes type code should also be reported (E08.____ – E13.____). This is the only circumstance in which two different types of diabetes may be used.
Additionally, because a member cannot have both type 1 and type 2 diabetes, it is important to ensure the correct diabetes type is coded. Use of insulin alone does not indicate type 1 diabetes. Care should always be taken not to assign a diagnosis based solely on a member’s medication list.
February 1, 2026
2026 Holiday Observance Schedule Update
We’ve updated our holiday observance schedule for your reference. Please note that the Juneteenth Holiday on Thursday, June 19, 2026 will be observed by Carelon only, Blue Cross VT will remain open for business.
January 28, 2026
2026 Prefix Listing
The Prefix listing has been updated for 2026. It is posted on the Provider Forms and Resources page under the Claim Forms and Information link.
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.
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.