Provider Policies

We’re committed to supporting you in providing quality care and services to our members. Here you will find information on our medical policies, quality improvement program standards, and billing guidelines. The Provider Resource Center provides access to many of our forms, policies, and updates.

Access our Out-of-Area Medical Policy router.

Provider Policies

These documents are provided for informational purposes only and are not an authorization, certification, explanation of benefits or a contract. Benefits and eligibility are determined before medical guidelines and payment guidelines are applied.  Benefits are determined by the subscriber certificate that is in effect at the time services are rendered. Medical practices and knowledge are constantly changing, and we reserve the right to review and revise medical policies periodically and without notice.

When available, we may utilize Blue Cross and Blue Shield of Vermont approved medical policies or those specific to plans as outlined below.  When an appropriate policy does not exist we may utilize the medical policies of the national Blue Cross & Blue Shield Association as guidance to determine medical necessity. These policies are available on request.

BlueCard Members: To look up out-of-area member's medical policies, please use the Out-of-Area Network Policy option at the bottom of this page.

Updated: 05.25.2023

Archived medical policies are inactive and no longer updated. Archived policies will remain available for a period of one year. Policies may be archived due to the technology being obsolete or discarded, the technology becoming standard of care and details about its use are well known, and/or Blue Cross and Blue Shield of Vermont is no longer implementing the policy.

The information in the archived policies is current through the last review date before the policy was archived. These policies may be useful for providing background information or for understanding benefit determinations made when the policy was active. However, because archived policies are not updated, providers should not rely on them as a source of information with respect to current requests for coverage.

View Blue Cross and Blue Shield of Vermont’s practice standards and how we monitor those as part of our quality program.

By accessing these policies, I acknowledge the following:

Blue Cross and Blue Shield of Vermont’s payment policies:

  • Serve as a reference to assist providers and facilities in submitting accurate claims.
  • Outline the basis for reimbursement for covered services.
  • Apply to services rendered by participating providers.
  • Are subject to changes in coding rules and guidelines, such as those established by CPT and HCPCS; there may be instances where coding changes are applied before the policies are amended.
  • May be revised from time to time based on state or federal requirements or changes to provider contracts.

BCBSVT payment policies do NOT:

  • Provide billing or coding advice.
  • Guarantee or determine benefits.
  • Control in the event of a conflict with member contracts, provider contracts, medical policies, or claim edits.
  • Dictate how other Blue Plans set allowances for care rendered by non-participating providers.
  • Constitute medical advice.

Permanent Payment Policy Name

In effect until July 1, 2023

    In effect until December 31, 2023

    Blue Cross and Blue Shield of Vermont is required to: “Maximize the number of members receiving care consistent with treatment protocols and practices that are informed by generally accepted medical and scientific evidence and practice parameters consistent with prevailing standards of medical practice as recognized by health care professions in the same specialties as typically provide the procedure or treatment, or diagnose or manage the medical condition, and that are developed with the appropriate clinical input.”

    Consistent with this requirement, Blue Cross and Blue Shield of Vermont's quality program has adopted the following guidelines for clinical practice:

    Center for Disease Control and Prevention (CDC)

    U.S. Preventive Services Task Force (USPST)

    American Psychiatric Association (APA)

    National Heart, Lung and Blood Institute (NHLBI)

    American College of Cardiology (ACC)

    American Academy of Child and Adolescent Psychology

    Global Initiative for Chronic Obstructive Lung Disease

    American Diabetes Association

    If you would like to receive any or all of these guidelines by mail, please call (800) 924-3494 or email customerservice@bcbsvt.com.

    Updated: 12-04-2019

    Out-of-Area Medical Policy Access

    To view the out-of-area Blue Plan's medical policies or general pre-certification/pre-authorization information, please select the type of information requested, enter the first three letters of the member's identification number on their Blue Cross Blue Shield ID card, and click "GO".
    Type of information being requested

    If you experience difficulties or need additional information, please contact (800) 676-BLUE or provider services at (800) 924-3494.

    Date modified : 09/08/2010

     

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