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

January 31, 2025

Carelon Prior Authorizations

Carelon letters authorizing services indicate that the prior approval is only valid for two months. However, prior approvals are valid for up to 365 days. Blue Cross and Blue Shield of Vermont will send a corrected letter with the proper prior approval expiration date until Carelon has updated its approval letters. Carelon anticipates a correction no later than the second quarter of 2025.

Reminder – if you are a primary care provider participating in Vermont's Blueprint for Health ordering a radiology service that requires prior authorization, you may not need a prior authorization if the member qualifies for a prior authorization waiver. Details are located in Section 12 of our online Provider Handbook.

January 31, 2025

Provider Policies Updates

Effective April 1, 2025, updates are available for certain medical and payment policies. Use the links below to view changes to impacted documents.

Medical Policy Updates

Payment Policy Updates

January 31, 2025

Pharmacy Updates

HIV PrEP: In addition to Tier 1 generic Truvada (emtricitabine and tenofovir disoproxil fumarate), both Descovy (Tier 3 nonpreferred) and injectable Apretude (Tier 3 nonpreferred) have $0 member cost share for HIV pre-exposure prophylaxis. 

Please note: Descovy still requires prior authorization to determine if it's being used for treatment or prophylaxis, but it does not require step through of generic Truvada.

January 31, 2025

Preventive Care Guide Updates

Effective April 1, 2025, our preventive care guide has updates for changes for Vision Screening and Tuberculosis, and a new section for Dual-Energy X-Ray Absorptiometry Scan for Bone Density.

January 31, 2025

Provider Handbook Updates

Check out the updates to our Provider Handbook, including changes for the Claims Editing Payment Policy and references to CMS 1500.

January 31, 2025

Prior Approval List Changes

Review upcoming changes to our list of services, equipment, and supplies requiring prior approval. Find the changes that are effective April 1, 2025.

January 31, 2025

Review Your 1099

Our 1099 tax forms have been released. With 2024 having had an increase in claims volume, as well as a record breaking number of healthcare cyber breaches, be sure to thoroughly review your 1099 and compare it to your payment records. This can help ensure the accuracy of claims submitted and payment received prior to filing the tax forms.

January 31, 2025

Yearly Physical Exams

With the New Year, it's a great time to ensure all patients schedule their annual physical exams. Seeing patients at least once a year is proven to be a best practice to help your patients identify health issues early and for you to establish a relationship with them. These visits enable you to:

  • Review your patient’s conditions, both acute and chronic.
  • Detect health issues before they become more serious.
  • Review and update medications.
  • Confirm if your patient is being managed by a specialist for a chronic condition. If so, document the condition and specialist to allow for better continuity of care.

If you would like assistance in determining which patients weren't seen in 2024, please email your Provider Engagement Consultant at RiskAdjustment@bcbsvt.com. They can provide you with a comprehensive list of your Qualified Health Plan (QHP) patients that did not have a Primary Care office visit in 2024.

January 31, 2025

Verisys Reminder

Verisys, a national credentials verification organization, is responsible for primary source verification for our credentialing and re-credentialing process. Verisys may outreach to you directly if additional actions are required to complete the primary source verification. To ensure your network status isn't interrupted, please respond immediately if they reach out to you.

One way to avoid outreach from Verisys is to ensure your Council for Affordable Quality Healthcare (CAQH) information is current and attested to. You can set up, view, and update your CAQH ProView™ account at https://proview.caqh.org/. Check your CAQH account to ensure:

  • All information is current and that current copies of malpractice insurance, current licensure, DEA, etc. are successfully uploaded.
  • Your provider status is at 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 any questions regarding the primary source verification process, contact Verisys Customer Service at (855) 743-6161. If you are a first-time user, you can find an online demonstration of the application process at https://proview.caqh.org/. 

January 31, 2025

Members Rights and Responsibilities

In order for Blue Cross and Blue Shield of Vermont and The Vermont Health Plan members to get the most from their benefit plan, certain guidelines must be followed, known as our Member Rights and Responsibilities statement. A copy can be found on our website, and a paper copy can be requested by contacting the provider relations team.

January 30, 2025

Independent Laboratory Listing

The Independent Lab listing has been updated for January 2025 and is posted here.

January 28, 2025

Prefix Listing

The Prefix Listing has been updated for 2025 and is posted here.

January 1, 2025

Updated Policies

Review a summary of all the medical and payment policies updates, effective March 1, 2025. The documents outline all impacted medical and payment policies.

Medical Policies

Payment Policies

January 1, 2025

Section 6.1 Provider Handbook Updates

Section 6.1: “Audits, Overpayment and Outcomes-Based and Coding Programs” of the Provider Handbook has been updated to reflect that Claris Health will be doing high dollar payment reviews, effective March 1, 2025.

View details

January 1, 2025

Reminder: CAA Directory Validation

January 2025 CAA Directory validation begins soon. Complete your validation to avoid being removed from the online provider directory, as well as possible contract termination. A reminder that federal law requires your quarterly responses.

Get instructions

January 1, 2025

Risk Coding Project

We have partnered with Reveleer again for the medical record retrieval of 2024 claims identified in the Risk Coding Project. Outreach begins in late December. If you receive a request from Reveleer, please respond promptly, following the instructions provided.

For questions on the Risk Coding Project, contact our Risk Adjustment Department by email at RiskAdjustment@bcbsvt.com or phone at (802) 371-3540.

January 1, 2025

2025 Pharmacy Updates

Effective January 1, 2025, some preferred specialty products no longer require prior authorization. There are also formulary changes for the National Performance Formulary (NPF) list.

Pharmacy updates

January 1, 2025

Act 111: Blueprint PCP Prior Authorization Waiver

As of January 1, 2025, prior authorizations are waived for services for eligible primary care providers who order a qualifying service for a qualifying member. Refer to Section 12 of our online provider manual for more details, or contact your provider relations consultant with questions.

Learn more

January 1, 2025

2025 Electronic Fund Transfers (EFTs)

For 2025, all EFT transactions will occur on Fridays, except for the July 4 EFT, which will occur Monday, July 7. If you aren't enrolled to receive EFTs, we encourage you to do so. It is free of charge, improves cash flow, and eliminates waiting for paper checks.

Learn more

January 1, 2025

Use of Third-Party Billers or Vendors

You must authorize third-party billers or vendors with Blue Cross VT for information to be released. Please register any billers or vendors with us and make sure all information is kept current.

We define third-party billers or vendors as those entities/persons who are not physically located at a provider/group office, are not direct employees of the provider/group, and are submitting claims or following up on accounts on behalf of the provider/group and have a business associate relationship with the provider/group. More information is in our Provider Handbook, Section 6.1.

Get details

January 1, 2025

New Plan Year Reminders

Be sure to ask all Blue Cross and Blue Shield of Vermont members (including FEP) for a current identification card at every visit, especially at the first of every new year, as prefixes, ID numbers, and copayments can change. Copy the card and place in the member's file for reference. Calendar year policies renew member liabilities (deductible, coinsurance/copayment).

You can verify a member's benefits and coverage by using 27x transactions, the eligibility search on the Provider Resource Center, or by calling the appropriate service team.

December 20, 2024

New & Revised Codes for January 1, 2025 (Adaptive Maintenance)

Review full details here.

December 19, 2024

Updates to Payment Policies

The below policies are updated, effective January 1, 2025. The changes noted below align the policies with the January 1, 2025, updates to Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding system (HCPCS) and when applicable, Vermont mandates.

Telemedicine (CPP_03)

  • Policy moved to new template
  • Updates made in alignment with Appendix P of the CPT® Manual
  • Added codes: 96041, 98000 - 98007 (newly established by American Medical Association (AMA) effective 01/01/2025)
  • Deleted code: 96040 (expired code as of 12/31/2024)
  • Updated code: G2211 (referencing Corporate Payment Policy CPP_39 (Office & Outpatient Evaluation and Management Visit Complexity G2211)
  • Removed codes: 99212-99215, 99202-99205
  • Removed modifier - GT

Telephone-Only Services (CPP_24)

  • Policy moved to a new template
  • Updates made in alignment with Appendix T of the CPT® Manual
  • Updates to comply with Vermont 108 mandates that commercial health insurers pay for medical services delivered by telephone (audio only) at the same rate as for the
    equivalent in-person service.
  • Updated policy and regulatory guideline sections of the policy
  • Removed deleted codes: 99441-99443 (expired codes as of 12/31/2024)
  • Added codes: 98008-98015 (newly established by AMA effective 01/01/2025)
  • Removed modifiers -V3 & -V4

The policies have been posted tot he Provider Policies page https://www.bluecrossvt.org/providers/provider-policies under Provider Payment Policies.

December 12, 2024

Updated: New and Revised Payment Policies effective February 1, 2024

Read full details

December 2, 2024

2025 FEP PA

2025 Federal Employee Program List of Prior Approval Requirements have been posted. The only change for this year is that High-Cost Drugs have been retitled to Medical Benefit Drugs. 

View PA list here.

November 26, 2024

2025 Holiday Observance Schedule

View Notice

November 19, 2024

Clear Claim Connection (C3)

The Clear Claim Connection tool is available again on the Provider Resource Center.

If you are not familiar with this tool, details about C3 are located in our on-line Provider Handbook: www.bluecrossvt.org/documents/provider-handbook, starting on page 84 under Clear Claim Connections (C3).

November 14, 2024

Revised Medical Policies effective February 1, 2024

Read full details.

November 13, 2024

2025 FEP MAC is now available

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

Act 111 (H.766)

As we work to implement changes to our processes and policies in response to Act 111, we will keep our provider community informed. You can find key updates below – we will also be sending email communications.

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.

View our online instructions for more details.
 

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.

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Provider Handbook

Access our Provider Handbook for a comprehensive reference of resources and requirements for Blue Cross providers.

Provider Handbook
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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.

Provider Prescription Support