Provider News & Updates

May 1. 2026

CMO Corner: Supporting Mental Health in Vermont

May is Mental Health Awareness Month—a time to recognize the importance of timely, compassionate care, and the role we all play in supporting patients across Vermont.

I’d like to take a moment to highlight the new Mental Health Urgent Care in Burlington, which offers an alternative to the emergency department for individuals experiencing distress. Developed through a collaboration between UVM Medical Center, Howard Center, Pathways Vermont, Community Health Centers, and the Vermont Department of Mental Health, this setting is designed to be calm and welcoming, with same-day access to counseling, peer support, and connections to follow-up care—no referral, appointment, or payment required. The goal is simple but critical: help people earlier, before distress escalates into crisis.

At Blue Cross VT, we continue to strengthen how we support members navigating mental health needs and expand access to in-network care by:

• Certifying our clinical case managers in Mental Health First Aid, equipping them to recognize early signs of distress, engage with empathy, and connect members to appropriate resources quickly.
• Connecting members with general and specialty providers, such as virtual options including Amwell, Valera Health, and NOCD for OCD-specific care. For patients seeking support, we offer a simple guide to getting started.

As providers, your role remains central. Together, with expanded community resources and coordinated plan support, we can help patients access the right care at the right time, in the right setting.

Regards,  
Dr. Tom Weigel, Chief Medical Officer 

May 1, 2206

Important Policy, Preventive Grid, and Handbook Updates

Updates to our medical policy and preventive care grid go into effect July 1, 2026. Our provider handbook has been updated to reflect changes to claim guidelines, reimbursement, integrated health functions, and more. Please take a moment to review these updates, as they may impact your practice and patients.

Preventive Grid Updates
Provider Handbook Updates
Medical Policy Changes

May 1, 2026

Helpful Tips for Working with Us

Here are some helpful tips for how to work with our teams on claim submissions, appeals, and more.

Get the Tips

May 1, 2026

Vermont Blue Advantage (VBA) Claims Reminder

As a reminder, VBA is not selling products in 2026. Any claims for services rendered to VBA members in 2025 needing reconciliation can be done through one of the following: Claims, including corrected claims, and medical records can be faxed to (800) 479-8973. Claim denial appeals can be faxed to (800) 479-8938. Please see the contact us page for mailing address and other non-medical claim submission contacts, and contact VBA Provider Services at (844) 839-5122 with any questions.

May 1, 2026

Sign Up for Electronic Payment

We’re discontinuing paper checks and 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.

May 1, 2026

Pharmacy Updates

Updates to the formulary or pharmacy policies may influence prescribing decisions. Stay informed to support timely, appropriate therapy.

Update: Generic for Revlimid, lenalidomide, is currently on formulary. Generic supply restraints are resolving, and supply is expected to significantly increase over the next six months.

On 7/1/2026, formulary changes will occur such as exclusions, quantity limits, step therapy, and prior authorization additions. Member ID cards will note if a member has either the NPF or BCBSVT formulary. Most members use the NPF formulary. Changes with the most member impact are listed below.

• Moving to Excluded - Generic formulation available on formulary
  • Motegrity (prucalopride) tablet
  • Nuvaring (etonogestrel-ethinyl estradiol) vaginal ring (Excluded on NPF formulary; will remain Nonpreferred Brand on BCBSVT formulary with ST)
  • Premarin (conjugated estrogens) tablet
  • Rytary (carbidopa/levodopa ER) tablet
  • Spiriva (tiotropium) Handihaler inhalation capsules
  • Thalitone (chlorthalidone) tablet
• Moving to Excluded - Consider alternative product
  • Sertraline capsules (150mg; 200mg) – Alternative: Sertraline tablets
  • Sulfacetamide sodium with Sulfur Cleanser – Alternative: a covered, preferred acne product
  • Triamterine capsule - Alternative: amiloride tablet, eplerenone tablet, spironolactone tablet
  • Zegalogue (dasiglucagon) auto-injector – Alternative: Baqsimi or Fesnius Kabi manufacturer of Glucagon Emergency Kit
• Biosimilar Changes – Excluded and biosimilar product available
  • Basaglar - Alternative: Lantus or insulin glargine-ygfn
  • Prolia – Alternative: Stoboclo (Pharmacy benefit change only)
  • Rezvoglar - Alternative: Lantus or insulin glargine-ygfn
• Add Quantity Limit
  • Albendazole tablets
  • Emverm (mebendazole) tablets
  • Ivermectin tablets
  • Sodium hyaluronate products (e.g. Euflexxa, Gelsyn-3)
  • Xdemvy (lotilaner) solution
• Add Step Therapy
  • Zoryve (roflumilast) Foam

View the Full List

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.

May 1, 2026

Chart Retrieval Reminder

We understand that chart retrieval requests – particularly those tied to government-mandated projects with tight timelines – can place added stress on your practice. We appreciate your continued collaboration and ask that you submit records only for the dates during which the member was enrolled with us, as providing records outside of that coverage period may constitute a Health Insurance Portability and Accountability Act (HIPAA) violation.

May 1, 2026

Verisys for Re-credentialing

Verisys, a national credentials verification organization, is responsible for primary source verification for our credentialing and re-credentialing process. They may reach out to you if additional actions are required to complete your primary source verification. Please respond to them immediately to avoid interruption to your network status.

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 proview.caqh.org. Please review and verify:

• All information is current and that current copies of malpractice insurance, current licensure, DEA, etc. are successfully uploaded.
• Your provider status is 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 proview.caqh.org.

May 1, 2026

NDC Notice

Since November 1, 2025, we have been providing information related to the enforcement of the billing requirements for National Drug Codes (NDC). The next enforcement will be claims with a process date of July 3, 2026.  

Read More

May 1, 2026

What to Do with Requests for Medical Notes
 

Have you received a request for medical records from Blue Cross VT? If so, please make sure to follow the instructions in the letter and include a copy of it with the submission of the applicable medical records.  

Did you know? The medical request letter contains a bar code that assists us in routing the medical records to the appropriate department. Medical records returned without the letter create a delay in processing, as the information must be manually reviewed to determine where it needs to go.

Reminder: Please do not proactively send medical records with a claim unless requested to do so. Unsolicited claim attachments can cause payment delays.

Section 6.3 of our Provider Handbook, under “Submitting Attachments with Claims," provides details on which services require supporting documentation as well as how to submit.

May 1, 2026

Prefix Listing Update

The Prefix Listing can now be found in two different listings: Blue Cross VT and CBA Blue. They contain high-level information on benefits, eligibility, claims, and prior authorizations.

The listings can be found on our Provider Forms and Resources page, under Claim Forms and Information.

May 1, 2026

EIN/TIN Changes

Do you have a new Employer Identification Number (EIN) or Tax Identification Number (TIN)? If so, you must do the following:

• Submit an updated W-9 along with a Group Enrollment Change Form or Solo/Independent Provider Enrollment Change Form
  • You will be contacted if a contract change is required
• Enroll your new EIN/TIN for Electronic Fund Transfer
  • Note: You will not be able to request an EFT update until 72 hours after your update is processed in our provider files. Once processed, you will be notified.
• Contact Provider Relations at providerrelations@bcbsvt.com or (888) 449-0443, option 1 to have your Provider Resource Center profile updated to include your updated EIN/TIN.

If you do not take this step, any claims information under your updated EIN/TIN will not be available to you.

May 1, 2026

Prior Approvals

Visit our Prior Approval Authorization page for details on:

• What Needs Prior Approval
• Primary Care Provider Prior Authorization Waivers
• Who Manages Prior Approvals and Pre-Notifications
• Prior Approval and Pre-Notification Submission Methods
• Retrospective Prior Approval
• Members of Another Blue Cross and Blue Shield Plan (BlueCard Members)

Reminder: Approved prior approvals do not guarantee benefits or payment. If you have an approved prior approval request, it means that the proposed service(s) to be rendered meets expected medical criteria and is eligible for consideration of benefits. Approved prior approval requests, upon receipt of the claim, are subject to provider contract terms, provider payment policies, coding rules, and member benefits. If you have any questions related to this, please contact your provider relations consultant.

May 1, 2026

Lab Draw Stations

Independent, in-network lab draw stations can be used if you do not have in-office lab draw services. View our list of lab locations designed for patient convenience, including options with extended hours and lower costs. Hospital lab draw stations are also in-network, but not listed.

April 23, 2026

Enhanced Community Primary Care (ECPC) and Vermont Blue Integrated Care (VBIC) Payments

Due to a system error, the ECPC and VBIC payments for April (March attribution) were not issued this month. The error has been corrected, and the April payment will be made next month with your May payment. We apologize for any inconvenience this may cause your practice.

As a note, all other capitation payments were made on schedule.

April 1, 2026

CMO Corner: Meet Lori Bombardier, Manager of Provider Strategy Implementation

We value our relationship with our provider network and appreciate your feedback on how we can improve your experience working with Blue Cross and Blue Shield of Vermont (Blue Cross VT). To further our commitment to strengthening provider partnerships, I’m pleased to share that we have created a new role within our provider services team that is focused on coordinating the planning, communications, and implementation of activities that affect you and your practice.

Lori Bombardier has moved into this new position as Manager of Provider Strategy Implementation. Lori has been supporting our Medicare Advantage provider network, so many of you may already be familiar with her. In this role, Lori will work closely with you and your practices to gather feedback on initiatives, programs, and other activities that impact you, as well as coordinate with Blue Cross VT teams to promote a more consistent experience.

Collectively, we remain committed to ensuring you are represented, informed, and supported as we work together to advance affordability, sustainability, and quality in health care for Vermonters.

April 1, 2026

Important Policy, Preventive Grid, and Handbook Updates

Updates to our medical and payment policies as well as the preventive care grid go into effect June 1, 2026. Our provider handbook has also been updated to reflect changes to claim guidelines, durable medical equipment suppliers, and integrated health functions. Please take a moment to review these updates, as they may impact your practice and patients.

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

April 1, 2026

2026 Annual Provider Notice 

Please take a moment to review our 2026 Annual Provider Notice, containing important updates to our policies and processes. These updates will help improve how we work together and how you support our members. Highlights include:

• Helping your patients get the most out of their coverage
  • Our members’ rights and responsibilities statement
  • How to refer your patients to our free case management services
• Our utilization review process
  • How to get a copy of our utilization management criteria
  • How to discuss 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  
  • How to report suspected fraud, waste, and abuse

April 1, 2026

Update Your Practice Email Address

Important communications occur by email, so making sure we have the current email address on file is critical. If you or your practice has had a recent email change, contact providerfiles@bcbsvt.com. Please be sure to include your billing NPI number and a contact person. Note, additional documentation may be required to update an email address.

April 1, 2026

Tired of Waiting on Checks?

Electronic Fund Transfers (EFT) are safe, fast, and environmentally friendly. If you still receive paper checks, we strongly encourage you to switch to EFT. Sign up now.

If you have questions or would like to discuss EFT, please contact your provider relations consultant. If you are not sure who that is, email providerrelations@bcbsvt.com or call (888) 449-0443, option 1 for assistance.

April 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: Tiotropium capsules for inhalation, generic for Spiriva Handihaler, will be a Tier 1 Generic.  

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.

April 1, 2026

Billing Services for National Drug Codes

Since our last update, the following American Dental Association (ADA) claim submission instructions have been added to the Provider Handbook:

• Using the ADA forms, report the following information in the remark field: N4, 11-digit NDC (no hyphens), unit of measure and quantity (limited to 8 digits before the decimal point and 3 digits after the decimal point).
  • Example: N400023923201UN100.
• If the form does not have a remark field, report at the top of the claim.  

For your convenience, the National Drug Code (NDC) Tool can now be found in the following two locations:

• In the Provider Resource Center under the Tools and Resources link
• On our Provider Forms & Resources page under the Claim Forms and Information link

Read More

April 1, 2026

1099s Available on the Provider Resource Center (PRC) 

Your 2025 tax form(s) are available via the PRC. To access them:

• Go to Tools & Resources, then select Tax Documents.
• Select 2025, then your tax identification number
• Click Request Documents
• From there, you can view or print documents

If you need assistance, please contact provider relations at (888) 449-0443 option 1, or email providerrelations@bcbsvt.com. 

April 1, 2026

Member Rights and Responsibilities

Blue Cross VT and The Vermont Health Plan (TVHP) members must follow certain guidelines to ensure they get the most from their benefits. These guidelines can be found in our Member Rights and Responsibilities statement. If you require a paper copy, please contact provider relations at (888) 449-0443 option 1, or email providerrelations@bcbsvt.com. 

April 1, 2026

Second Quarter Provider Directory Validation 

The Second Quarter Provider Directory Validation will be released via email on or around April 4, 2026; the email comes from noreply@onbaseonline.com. Directory validation(s) must be completed by Tuesday, May 5, 2026. Failure to validate your contact information will result in removal of you from our provider directory. It could also include denial of claims or contract termination.

Provider Directory Validation and instructions to complete the process are located on the Enrollment and Credentialing area of our website.

Read More

April 1, 2026

Coding Tip: Malnutrition Documentation

Diagnosis: Specify type and severity (e.g., Severe protein-calorie malnutrition).

Clinical Indicators: Include unintentional weight loss percentage over time, low BMI or weight-for-height percentile, muscle/fat wasting, relevant labs, poor oral intake, or prolonged inadequate nutrition.

Etiology: State underlying cause (e.g., chronic illness, acute illness, socioeconomic factors).

Interventions: Document nutrition plan (e.g., enteral/parental feeding, supplements).

Response to treatment: Document on improvement or decline.

A partial list of the more common malnutrition ICD-10 codes:

• E43 – Unspecified severe protein-calorie malnutrition
• E44.0 – Moderate protein-calorie malnutrition
• E44.1 – Mild protein-calorie malnutrition
• E46 – Unspecified protein-calorie malnutrition

Hypothetical example: Patient meets ASPEN (American Society for Parental and Enteral Nutrition) criteria for severe protein-calorie malnutrition (E43) due to chronic heart failure. Noted 13% weight loss over 3 months, BMI 17.8, severe muscle wasting in temporal and clavicular regions. Initiated high-calorie, high protein oral supplements and will have patient follow-up with the dietician.

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.

Read More

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.

View Details and Examples

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.

Monthly Newsletters

• December 2025
• January 2026
• February 2026
• March 2026
• April 2026
• May 2026

Adaptive Maintenance Newsletters

• September 2025
• December 2025
• March 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