Provider Forms & Resources

About Case Management and Care Coordination

When you as the provider and Blue Cross and Blue Shield of Vermont as the plan work together to help coordinate the care of our members, there are times when we may need to use members' Protected Health Information (PHI). Under these circumstances, the members do not need to provide authorization for this use of their PHI.

Blue Cross VT is committed to respecting the privacy of our members' PHI. As a Covered Entity under HIPAA, we do not use or disclose a member's PHI unless either HIPAA's Privacy Rule permits or requires such disclosure, or the member who is the subject of the PHI authorizes such use or disclosure in writing. The Privacy Rule specifically permits the use and disclosure of a member's PHI for the purpose of that member's case management and care coordination. This permitted use allows us to work together with providers in a safe way to help facilitate a member's case management and care coordination needs. (See 45 CFR §§ 164.501, 164.502(a)(1); see also https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html and https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/disclosures-treatment-payment-health-care-operations/index.html.)

How to Refer to Case Management

There are three options to refer to case management and either the member or provider can initiate:

1. Complete the following form on our website: https://secure.bcbsvt.com/referral.php
2. Send our team a secure email at IHMTriage@bcbsvt.com
   • ​​​​​​​At a minimum, the email will need to contain the member name, date of birth and phone number where they can be reached.
   • Emails should always be sent through a secure method.
3. Call (800) 922-8778, option 3.

• BlueCard Appeal Form
• CMS 1500 Form Instructions
• CMS 1500 Sample Form
• Late Charges - Institutional Submission Requirements
• Medicare Advantage Private Fee-for-Service (PFFS) Terms and Conditions Web Finder Tool
• Notice of Open Negotiation
• Prefix Listing
• Outpatient Revenue Codes Requiring a CPT or HCPCS
• UB-04 Paper Claim Billing Instructions

Coding Tip Sheets

• Column Two Procedure with Column One Procedure Code
• Evaluation & Management with Chiropractic Manipulation Therapy
• Evaluation & Management with Modifier -25 and Surgical Procedure on the Same Day
• Evaluation & Management with Osteopathic Manipulation Treatment
• Modifier -25
• Modifier -59 (including XE, XS, XP and XU)
• Physical Medicine Codes with Chiropractic Manipulative Treatment (97112, 97124, 97140 with 98940-98942)
• Physical Therapy Re-Evaluation

Webinars

• Modifer -25 and Modifer -59 Webinar Recording (Note: you will need the passcode: 4%FxdHNc to view the webinar)
• Modifier -25 and Modifier -59 Slide Deck
• Modifier -25 and Modifier -59 Q & A from the Webinar

• 835 Enrollment/Change Form
• 835 Enrollment Status (check enrollment status)
• Clearinghouse Vendor List
• 835 Companion Guide for Electronic Remittance Advice
• 837 Professional Claims Submissions Companion Guide
• 837 Institutional Claims Submissions Companion Guide
• Medicare Advantage Claims Guide
• Electronic Data Interchange User Guide

Administrative

• BlueCard Appeal Form
• Coordination of Benefits Questionnaire for BlueCard Members
• Coordination of Benefits Questionnaire
• Payment Inquiry Form
• Provider Overpayment Form

Institutional/Facility

• Census Reporting for Facilities 
• Census Reporting Template 
• Emergency Room Census Reporting Template

• Academic Detailing and Prescription Support for Vermont Blue Rx
• Contact Information for Providers
• Employer Group Number for Blueprint for Health PCP Prior Authorization Waiver
• Member Preventive Benefits Overview
• Pediatric Patient Transition Template
• Prevent Hospital Readmission
• Provider Handbook
• Provider Resource Center Reference Guide
• Vision Service Overview for Federally Qualified Health Plans
• Unit Designation

Laboratory Services

• Independent Laboratory List

Mental Health and Substance Use Disorder (MHSUD) Treatment – Additional Resources

• Valera Health provides virtual care for members, and in addition to treating conditions ranging from depression to schizophrenia, they also treat children and adolescents staring at six years of age, maternal health, and serious mental illness.
• For members with access to Amwell, Blue Cross VT's 24/7 telemedicine partner, Amwell therapists treat a wide range of MHSUD diagnoses.

Find out how to refer members either to a Valera provider or to Amwell.

Provider Orientation

• Mental Health and Substance Use Disorder Treatment Clinicians
• All other provider types (MD, DO, ND, PA, NP, etc)
• Vermont Blue Advantage