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
April 1, 2025
eNewsletter CORRECTION
Our April 1, 2025, eNewsletter for Telemedicine Updates contained an error. CPT®code 99211 will remain eligible for telemedicine services after June 1, 2024.
March 28, 2025
Telemedicine Updates
Reminder: We cover telemedicine services for Blue Cross VT members, but there are new Office-based Evaluation and Management Services (E/M) codes that must be billed for telemedicine services. Review the changes to ensure you're using the proper codes.
As of June 1, 2025, codes 99202-99205 or 99211-99215, as well as modifiers other than -95 or -GQ, are no longer permitted for telemedicine billing. When billing for these services, refer to Attachment 1 of our Telemedicine Payment Policy (CPP_03) for the appropriate codes, or they will be denied as a provider liability. Members cannot be billed for services rendered by telemedicine that are not included in Attachment 1.
March 28, 2025
Provider Medical and Payment Policy Updates
Check out the payment and medical policy updates that go into effect June 1, 2025.
March 28, 2025
Preventive Care Guide Updates
The preventive care guide, effective June 1, 2025, includes updates for added, removed and corrected codes. Be sure to review our notice for more details.
March 28, 2025
Second Quarter CAA Directory Validation
- Second quarter Consolidated Appropriations Act (CAA) directory validations will be released the first week of April 2025.
- Validations MUST be completed by the end of April to ensure you will not be removed from our provider directory and risk possible contract termination.
- If you receive more than one email, please respond to all emails received. Some providers have multiple providers files and multiple verification needs to occur.
- If your practice was removed from the network due to non-response during the first quarter validation, this is your opportunity to be added back into the network directory.
- Details and instructions for the CAA directory validation are located on our Enrollment and Credentialing webpage, under the “CAA Directory Validation” section. If you have questions, please call (888) 449-0443, option 2, or email CAA@bcbsvt.com.
March 28, 2025
Pharmacy Updates
Downtiered Drugs
Drugs are evaluated regularly to be downtiered on the formulary, which may lower costs and increase options for your patients. The following drugs were downtiered in March 2025:
- Ebglyss (lebrikizumab-lbkz), for moderate to severe atopic dermatitis (eczema)
- BCBSVT and NPF Formulary: Tier 2 Preferred Brand (Specialty) with prior authorization
- Opzelura (ruxolitinib), for moderate to severe atopic dermatitis (eczema) and nonsegmental vitiligo
- BCBSVT and NPF Formulary: Tier 2 Preferred Brand with Step Therapy
- Zoryve (roflumilast) cream, for mild to moderate atopic dermatitis (eczema)
- BCBSVT and NPF Formulary: Tier 2 for 0.15% cream and Tier 3 for 0.3% cream Preferred Brand with Step Therapy
- Contour Plus Blood Glucose Test Strips, for diabetes or pre-diabetes
- BCBSVT and NPF Formulary: Tier 2 Preferred Brand with Quantity Limit
New Medication Alert
JournavxTM (suzetrigine) is a new non-opioid drug with a novel mechanism for treating moderate to severe acute pain in adults. It was approved by the FDA on January 30, 2025 and is a Tier 3 Non-Preferred Brand with a quantity limit on our formularies.
Covered Medications
March 28, 2025
Unlisted Codes – CPT® Procedure or Service Codes and Level II HCPCS Codes
CPT Category I and Category III codes cover most procedures and services performed and should be used for accurate reporting. There are instances when a specific code may not exist, and an unlisted procedure or service code may be reported. In these instances, the claim must be submitted on paper with the office and/or operative notes, and include a written description of the service that was supplied and being billed as an unlisted service.
March 28, 2025
Submitting Coding Denial Questions
If you have questions regarding a coding denial of a claim, review our new process for submitting questions. For more information about what qualifies as a coding denial, view our claims editing payment policy. Note: this new process does not apply to coding validation denials.
March 28, 2025
Community Fee Schedule Updates
We have completed the review of our community fee schedule for drugs administered or supplied in a provider’s office (MD Rx HCPCS), Home Infusion Therapy National Drug Codes (NDC), and Home Infusion Therapy Administrative Services. Updates go into effect on June 1, 2025. For a copy of the updated community fee schedule, contact our provider relations team at providerrelations@bcbsvt.com or (888) 449-0443, option 1. Please include your billing NPI number(s).
March 25, 2025
New Find-a-Doctor Tool Launched
We’re thrilled to announce the launch of our new find-a-doctor tool. This enhanced tool features advanced search options and integrates data from the Blue Card national doctor and hospital finder tool, making it easier for members to locate in-network providers nationwide, all in one place. The new find-a-doctor tool will be available through our website, bluecrossvt.org, and within the Member Resource Center (MRC).
March 13, 2025
New and Revised Codes for April 1, 2025 (Adaptive Maintenance)
We are in the process of completing our review of the CPT® and HCPCS additions and revisions for April 1, 2025. As a result, the off cycle Adaptive Maintenance eNewsletter providing the details of our implementation of the new and revised codes will be slightly delayed.
We will post an updated notice once the Adaptive Maintenance eNewsletter is released.
February 28, 2025
Medical Record Retrieval Project Kicks Off
Our annual Healthcare Effectiveness Data and Information Set (HEDIS®) data collection is currently under way! We appreciate your participation in this medical record review process, as it helps your peers and our members understand the quality of care your clinical team provides every day.
February 28, 2025
Provider Payment Policy Updates
View updates for provider payment policies, effective May 1, 2025.
February 28, 2025
Prior Authorization Changes
We continue to find opportunities to reduce the prior authorization requirements for our providers, while ensuring the highest standards of care for our members. In this ongoing effort, we have updated our list of services, equipment, and supplies to remove 13 service types. This will remove over 20% of our prior authorization service types. View the list to learn more about the changes.
February 28, 2025
Pharmacist-led Medication Therapy Management
We are happy to announce the launch of our new, pharmacist-led medication therapy management program. This program brings together our provider and member outreach to identify opportunities to improve our members care by analyzing claims and diagnosis data.
To help close gaps in care and prevent adverse outcomes by ensuring that our members are receiving medications that follow evidence-based best practice, providers may receive clinically appropriate recommendations. In these instances, providers will receive the information via fax, followed by a phone call.
February 28, 2025
Pharmacy Updates: New Generic Drugs and Biosimilars
When new generic drugs come out, they are usually preferred over brand medications due to potential cost savings. Two new drugs we are highlighting are:
- Liraglutide, a new generic drug of the brand diabetes medication Victoza. Liraglutide is a Tier 1 generic drug. Victoza is excluded on the NPF formulary and is a Tier 3 Non-Preferred Brand on the BCBSVT formulary.
- Wezlana, a new biosimilar to the biologic Stelara is on our NPF and BCBSVT formulary lists as a preferred specialty medication to treat many conditions, such as plaque psoriasis, psoriatic arthritis, Crohn’s disease, and ulcerative colitis. Stelara will continue to be included on our formulary. In the next year, more biosimilars to Stelara are anticipated to become available and will be considered for inclusion on our NPF and BCBSVT formulary lists.
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.
February 28, 2025
Medical Record Activity Timeline
Check out our guide that outlines when we will be sending out HEDIS and risk-related medical record requests throughout the year.
February 28, 2025
ClaimsXten-Select™ Upgrade
We have scheduled an update to ClaimsXten-Select™ on Tuesday, April 1, 2025. Review the notice to understand the upcoming changes.
February 28, 2025
Provider Handbook Updates
Check out the latest changes to our Provider Handbook, sections 6.7 and 7. The updates provide clarifying details for these sections.E
February 28, 2025
Expansion of Eligible Hearing Aids
Effective May 1, 2025, we are expanding the existing list of eligible hearing aids for members who have the available benefits.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Act 111 (H.766)
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.
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.
Provider Handbook
Access our Provider Handbook for a comprehensive reference of resources and requirements for Blue Cross providers.
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.