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
July 1, 2025
Holiday Closure
We will be closed on Friday, July 4, 2025, for Independence Day. We will reopen for normal business hours on Monday, July 7, 2025.
July 1, 2025
July 4, 2025 EFT Reminder
Due to the holiday on Friday, July 4, 2025, the weekly Electronic Fund Transfer (EFT) will occur on Monday, July 7, 2025.
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.
May 1, 2025
Medical and Payment Policy Updates
Check out the payment and medical policy updates that go into effect July 1, 2025.
May 1, 2025
Change in Enrollment Process of Locum Tenens
Beginning July 1, 2025, all locum tenens must complete a provisional credentialing process. Locum tenens will not be eligible to render care to Blue Cross and Blue Shield members until the provisional credentialing process is complete.
View our notice for more information on the upcoming changes.
May 1, 2025
July 1, 2025 Pharmacy Updates
- In April, providers received patient-specific communications about any negative formulary changes effective July 1, 2025.
- Stelara (ustekinumab) will be excluded on the NPF and BCBSVT formulary.
- Currently, the interchangeable biosimilar, Wezlana is also on the formulary. It does not require prior authorization and will be the preferred option starting July 1, 2025. This medication is a biologic used for inflammatory conditions such as plaque psoriasis, psoriatic arthritis, Crohn's disease, and ulcerative colitis.
- View the full list of drug changes for July 1, 2025
May 1, 2025
Reminder: Unlisted Procedure, Service, or Supply Codes
Providers should always bill a defined procedure, service or supply code when one is available. If a defined code is not available, services can be billed using the unlisted code. For details on how to submit and request a review of unlisted codes, read our updated notice.
May 1, 2025
Preventive Care Guide Updates
The preventive care guide has been updated with additional codes. The changes go into effect July 1, 2025. Review our notice for more details.
May 1, 2025
Real-Time, Free Psychiatric Consultations for Child and Adolescent Primary Care Providers
The Vermont Consultation and Psychiatry Access Program (VTCPAP) offers real-time consultations for primary care providers treating children and adolescents. A team of licensed clinical social workers and board-certified child and adolescent psychiatrists are available to answer questions about assessments, screenings, treatment planning, or medication management. VTCPAP can help address your patients’ needs quickly and comprehensively, as well as aid in finding referrals to mental healthcare services. Visit their web site at www.vtcpap.com for more information and to access their services.
May 1, 2025
Updated BlueCard Appeal Form
We have updated the BlueCard Appeal form and posted it to the provider website. If you have printed a supply of this form, or have saved a version to your computer, please download and use the updated form.
Appeals for all BlueCard claims are handled through Blue Cross VT. We coordinate the appeal process with the member’s Blue Plan. Completed forms can be emailed to bluecard@bcbsvt.com or faxed to (802) 225-7698. You will be notified of the outcome of your appeal within 30 days of receipt.
Reminders:
- A BlueCard appeal form should only be used when there is a confirmed denial of benefits.
- Timely filing denials are not appealable and cannot be submitted on an appeal form.
- If you would like a timely filing reviewed, attach documentation supporting the filing to a payment inquiry form and send to bluecard@bcbsvt.com.
- Some Blue Plans may require members to sign an additional form specific to their Plan before they start an appeal process.
May 1, 2025
Provider Quality Policy Updates
The following provider quality policies have been updated, with changes effective July 1, 2025: practitioner credentialing, facility credentialing, and quality of care risk investigations.
May 1, 2025
CareCentrix Infusion Site of Care Program Begins in May
Blue Cross VT has partnered with CareCentrix to offer eligible members an alternate site for certain infusion therapies. This voluntary program applies to a specific group of drugs that have been approved by the health plan. Members will only transition to the home or infusion center if both the member and prescriber agree to the change.
Who is CareCentrix?
CareCentrix empowers health at home through whole-person care coordination and benefit management – helping payors and providers close gaps in care while helping lower costs and improving member outcomes. CareCentrix has 20+ years of experience coordinating infusion services for 500+ drugs and managing care transitions to an alternate site of care, including home and infusion centers. For more information about CareCentrix, visit https://www.carecentrix.com.
Questions about the program?
- If a member has questions about the Infusion Site of Care program, please direct them to call CareCentrix at (833) 592-1089.
- For providers with general questions about the program, contact Provider Customer Service at (800) 924-3494.
May 1, 2025
ClaimsXten-Select™ Upgrade
We have scheduled an update to ClaimsXten-Select™ for Tuesday, July 1, 2025. Review the notice to understand the upcoming changes.
May 1, 2025
Provider Handbook Changes
The provider handbook has been updated to reflect changes related to BlueCard appeals, provider credentialing, and claims guidelines and appeals.
April 1, 2025
eNewsletter CORRECTION
Our April 1, 2025, eNewsletter for Telemedicine Updates contained an error. CPT®code 99211 will remain eligible for telemedicine services after June 1, 2024.
We now send a monthly provider e-newsletter, which is our primary source for all notices and updates. It replaces the individual notices you used to receive. The e-newsletter comes out at the beginning of every month. If there are other 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.