Provider News & Updates

September 30, 2026

CMO Corner: Important Changes to Global Maternity Care Coding and Billing

The American Medical Association has adopted substantial revisions that will replace the current global maternity care and delivery codes with new CPT® codes.

Starting January 1, 2027, these code changes affect how maternity care services are reported and include the introduction of new labor management codes and the deletion of several longstanding maternity package codes.  

We are here to help support you and your practice with these changes and will continue to keep you informed as we learn more and further update our claims processing system, payment policies, and provider handbook.

Read more

September 30, 2026

Important Updates to Policies, Provider Handbook, and Preventive Guide

Starting December 1, 2026, updates to our medical and payment policies, provider handbook, and preventive guide go into effect. Please take a moment to review these updates, as they may impact your practice and patients.

Payment Policy Changes
Preventive Guide Updates
Medical Policy Changes
Provider Handbook Updates

September 30, 2026

Adaptive Maintenance Reminder

Our quarterly adaptive maintenance email was sent on September 15 with new and revised codes effective October 1, 2026. Check your email or visit our Provider News & Updates webpage to view the notification.

September 30, 2026

Pharmacy Updates

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

New Generics and Formulary Additions for October 1, 2026

• New Tier 1 generics are available for Xeljanz and Xeljanz XR
• Breztri aerosphere inhaler is added as a Tier 2 medication with a quantity limit, but no prior authorization

January 1, 2027 Formulary Changes

Formulary changes occur on January 1 and July 1 of each year. Patients and providers will receive individualized letters in October about any changes.

• For most drugs where there is an available generic, this will be preferred, and the brand will be excluded. Examples include: Atrovent HFA, Farxiga, Januvia, Janumet, Lumigan, Motegrity, Revlimid, Saxenda, and Viibryd.
• Quantity limits will be added for diabetic test strips: 100 strips per 30 days without insulin use; or 300 strips per 30 days with insulin use.

See the full list

Medical Drug Changes for January 1, 2027

Changes for Infliximab (Remicade) products:

• Avsola (Q5121) will remain preferred and will not require prior authorization
• Renflexis (Q5104) will be preferred and will not require prior authorization
• Inflectra (Q5103) will become nonpreferred and will require prior authorization.
  • Note: Blue Cross and Blue Shield of Vermont (Blue Cross VT) members taking Inflectra will receive a letter notifying them of this change and providing them with guidance on next steps to ensure no gap in treatment.

Avsola and Renflexis are biosimilars of infliximab (Remicade), so patients can switch to these if previously prescribed a different infliximab product.

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.

September 30, 2026

Free Cultural Health Training for Your Practice 

The U.S. Department of Health and Human Services, Office of Minority Health has free virtual continuing education programs available to help healthcare professionals provide more inclusive care.

Here are a few benefits of participating in cultural health training:

• See Better Patient Outcomes: Culturally informed care increases treatment success and patient satisfaction.
• Reduce Disparities and Risk: Unconscious bias training builds providers’ capacity to address cultural barriers to health and improves access to care for people who speak or sign languages other than English.
• Meet Standards: Many regional networks and insurance panels require ongoing equity education.

Learn more

September 30, 2026

Fourth Quarter 2026 Provider Directory Validation 

The fourth quarter Provider Directory Validation will be released in early October.

Providers and practices who do not complete the validation within the specified timeframe (as defined in the directory validation email) will be removed from our online directory.

Instructions to complete the process are located on the Enrollment and Credentialing area of our website.

If you have questions, please call (802) 371-3745, option 2 or email CAA@bcbsvt.com. 

September 30, 2026

Keep Your Contact Information Current

We frequently send important communications (like this newsletter!) by email, so it is critical to make sure that we have your current email address on file.

If you need to make a change, you can reach out to providerfiles@bcbsvt.com with your new contact information and billing NPI number.

September 30, 2026

In-Network Laboratories

As outlined in our Use of Non-Network Providers Payment Policy, Blue Cross VT contracted providers are expected to direct members to use in-network providers when arranging care.

If you do not have in-office lab draw services, you can use the independent in-network lab draw stations listed below. Independent labs are lower cost alternatives that can offer extended hours and patient convenience. See a full list of Independent Laboratories contracted with Blue Cross VT.

September 30, 2026

Vermont Blue Advantage (VBA) Operations Ending

Claims for services rendered to VBA members in 2025 must be submitted prior to 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. The VBA Provider Services line will be open through December 31, 2026.

The VBA provider portal will be accessible through January 31, 2027. We recommend that you download Explanation of Payments (EOPs) or any other documents you may need from the portal before then.

September 4, 2026

Carelon Routine Maintenance

Our radiology management partner, Carelon’s prior authorization tool will be unavailable for the dates and times below.

• From 9:00 p.m. (CST) on Friday, September 11, 2026, through 6:00 p.m. (CST) on Sunday, September 13, 2026
• From 9:00 p.m. (CST) on Friday, October 9, 2026, through 6:00 p.m. (CST) on Sunday, October 11, 2026

If you have an urgent prior authorization request during this time, please contact the Blue Cross VT Care Management staff at (800) 922-8778.

September 4, 2026

Prenatal Care and New Obstetric Billing Codes Seminar

As you are preparing for the implementation of the new obstetric billing codes, we wanted to share this learning opportunity with you. 

On September 16, Dr. Alex Peahl and a panel of clinical leaders will present "Implementing Tailored Prenatal Care and New Obstetric Billing Codes". The webinar will explore the recently released tailored prenatal care clinical guidance, real-world implementation experiences, and the implications of the upcoming 2027 transition to unbundled obstetric payment codes.

• Implementing Tailored Prenatal Care and New Obstetric Billing Codes
• Date: September 16, 2026
• Time: 2:00 p.m. ET

Sign up for the webinar

We encourage all physicians and practitioners, coders, and billing professionals to evaluate the potential impact to clinical documentation and claims workflows to ensure readiness for these significant coding changes.

Here are resources on the coding changes:

• AMA CPT^® 2027 Maternity Care Services Code Changes 
• AMA CPT^® 2027 Maternity Care Services Code Guidelines
• AMA FAQs: CPT^® 2027 Maternity Care Services Code Changes

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.                

Read more

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.

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.

Monthly Newsletters

• May 2026
• June 2026
• July 2026
• August 2026
• September 2026
• October 2026

Adaptive Maintenance Newsletters

• December 2025
• March 2026
• June 2026
• September 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