Provider News from Blue Cross and Blue Shield of Vermont

June 17, 2021

Revised Medical Policies for September 1, 2021

  • Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) 
    Formerly titled "Prostatic Urethral Lift"
  • Charged Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions

Click here for full details.


June 11, 2021

Robotic & Computer Assistive Devices

These services have been allowed in error.  Over the next few weeks, facility and professional claims for these services will be recovered.

Reminder, we do not provide separate or additional reimbursement for the use of robotic or computer assisted surgical systems.  Details are available in our Payment Policy CPP_04 Robotic & Computer Assistive Devices. Payment policies are located on the secure provider portal under BCBSVT Policies. If you need a copy sent to you, please email providerrelations@bcbsvt.com or request by phone at (888) 449-0443 option 1

Exclude at Launch Pharmacy Medical Policy

This medical policy formalizes the requirements and process when a new drug is approved by the FDA.  The medical policy is effective July 1, 2021 and has been posted to the Medical Policy area of our provider website.


May 27, 2021

New Medical Policy

The new Medical Policy for Mental Health/Substance Use Disorders (MHSUD) Residential Treatment will not go into effect as of July 1, 2021. Once a new effective date is established, we will provide a notice.


May 27, 2021

Revised Medical Policies for August 1, 2021

  • Bariatric Surgery
  • Temporomandibular Joint (TMJ) Dysfunction

Click here for full details.


May 25, 2021

Preventive Guide Update:

Image
Preventive Guide Chart

An updated preventive guide will be posted shortly.


May 24, 2021

Off-Label Drug Medical Policy

Is updated as of July 1, 2021 to add durations of 12 months for medically necessary approvals. The updated medical policy will be posted by June 1, 2021.


May 10, 2021

Update to External Insulin Pump Medical Policy

Effective June 1, 2021 automated insulin delivery system artificial pancreas device system designated as hybrid closed loop insulin delivery system (with low glucose suspend before low features) may be considered medically necessary in patients with type 1 diabetes who are age 2 or older (The previous policy allowed age 6 or older).


April 27, 2021

Preventive Guide Updates

Our preventive service guide located at: Understanding Your Preventive Care Benefit | Blue Cross Blue Shield of Vermont (bcbsvt.com) will be updated as of May 1, 2021 and include the following changes:

Image
Preventive Guide Chart

 


April 23, 2021

Medical Policies: New and Revised for July 1, 2021

  • Ambulatory Cardiac Monitors and Outpatient Telemetry
  • Dental Services for Accidental injury, Gross Deformity, Head and Neck Cancers, and Congenital/Genetic Disorders
  • Dental Services for Pediatric for (Qualified Health Plan)
  • Gastric Electrical Stimulation
  • Light Therapy for Dermatologic Conditions
  • Monitored Anesthesia Care (MAC) during Gastrointestinal Endoscopy, Bronchoscopy, or Interventional Pain Procedures in Outpatient Settings

Click here for full details.


April 23, 2021

Frequency of Supplies (Diabetic and CPAP/BIPAP) Payment Policy (CPP_03) Update

Effective May 4, 2021 the quantity limits for A9277 and A9278 is changed to allow 4 units every 365 days. The updated policy has been posted to the Provider Resource Center. If you need a copy emailed, please contact providerrelations@bcbsvt.com.


April 21, 2021

Dental Practices

Click here for clarification of dental contracts, claim processing, customer service and eligibility verification.


April 20, 2021

Introducing the eQuote Guide

There is a NEW on-line tool that assists with verifying a member’s benefits. It is available 24/7, so anytime you need it. 

We are pleased to announce eQuote Guides!  This tool is used by our customer service team and we are excited to bring it to you. The eQuote Guide will:

  • Provide a simplified and more thorough benefit quote virtually, including State Mandates and employer specific benefits.
  • Link you to important information such as a member contract documents, Medical Policies and Prior Approval lists. 
  • Provide a reassurance reference number that can be used to as proof you have verified a member’s benefits.
  • Save you time by avoiding call center wait times.

Click here for full details or click here for a link to the eQuote Guide Training Document.


April 15, 2021

Update to Vision Services Medical Policy

Effective June 1, 2021 codes V2623, V2624, V2625, V2626, V2628 and V2629 no longer require prior approval, and will be considered medically necessary if the requirement of the policy is met. The updated policy will be posted by May 1, 2021.


April 5, 2021

ClaimsXten-Select™ Upgrade

We have tentatively scheduled an update to ClaimsXten-Select™ on Tuesday, May 4, 2021. This update will ensure that our version of ClaimsXten-Select™ is current and aligns with industry standards. Click here for full details.


March 31, 2021

Wireless Capsule Endoscopy Medical Policy

Has been reviewed and updated. The updated medical policy is effective June 1, 2021. Click here for the complete notice.


March 29, 2021

Breast Surgery and Breast Prosthesis Medical Policy

Effective May 1, 2021 the medical policy is updated to include the addition of medical necessity indication of breast tissue rearrangement, at the time of or following lumpectomy or partial mastectomy, for code 19318 (reduction mammoplasty).  No prior approval will be needed if billed with a diagnosis of breast cancer.


March 26, 2021

Appeal Submission

Providers can submit appeals on behalf of a member for a denied service that are benefit related.  Full details on appeals are available in our Provider Handbook located at:  https://www.bcbsvt.com/provider/provider-handbook-and-reference-guides

Appeals need to be faxed to “Attention Appeals” at (866) 617-8969 or Emailed (using a secure method) to appeals@bcbsvt.com.

Please Note:

  • The fax number was new as of March 2020, if you are still using the (802) 229-0511, please update your records.
  • This fax/email are for appeals only – benefit, claims or other questions will NOT be responded to. 

March 25, 2021

Vermont Blue Rx

Effective July 1, 2021, we have a new name for Blue Cross and Blue Shield of Vermont’s pharmacy program: Vermont Blue Rx. Vermont Blue Rx will continue to offer all the same services and benefits that members and providers have had over the years. Beginning July 1, 2021, the pharmacy claims will be administered by OptumRx rather than Express Scripts. Click here for FAQ’s about Vermont Blue Rx.


March 24, 2021

Update: Community MD Rx and HIT Fee Schedule Review

Community Home Infusion Therapy (HIT) Rx Services will have adjustments in allowances effective April 1, 2021. HIT NDC Fee schedule specific information will be available, upon request, from your provider relations consultant no later than April 15, 2021. All other drugs administered in a physician’s office are still under review, and if updates are needed to the community fee schedule for the categories/codes below, a separate communication will be posted. Click here for the original notice on this review.


March 24, 2021

Clinical Trial billing for Medicare Advantage Members

Effective April 18, 2021 claims for members in clinical trials must report the clinical trial number.  For 837 electronic claims, please report in 2300 loop REF*P4 segment. Information on how to submit clinical trial information on a paper claim will be posted shortly.


March 23, 2021

Payment Policy for Modifier-22

This policy has been updated effective June 1, 2021.  Updates include formatting and clarification that the maximum allowed amount for reimbursement is the provider’s allowed charges.  The updated policy has been posted to the Provider Resource Center under BCBSVT Policies/Payment Policies.

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


March 22, 2021

Medication Therapy Management Program

Medication Therapy Management (MTM) sessions are one-on-one consultations offered in person or via telehealth with a pharmacist to help your patients understand their medications, including their effects, safety, price, simplicity, and tolerability, and address any concerns or questions they may have. The pharmacist works together with the patient and the patient’s healthcare team to bring opportunities and recommendations forth in a collaborative manner.

Note: These MTM services are intended for practices that do not already have a BCBSVT credentialed MTM pharmacist providing MTM services for your patients.

Click here to for more information or a copy of a brochure to share with patients.


March 18, 2021

Provider Vouchers

The March 16, 2021 provider vouchers have been posted to the Provider Resource Center.

If you have questions or concerns, please contact the provider relations team by email at providerrelations@bcbsvt.com or phone at (888) 449-0443, option 1.


March 16, 2021

New & Revised Codes for April 1, 2021 (Adaptive Maintenance)

We are in the process of completing our review of the CPT® and HCPCS additions, deletions and revisions for April 1, 2021. This could result in some changes to:

  • Prior approval
  • Investigational services
  • Unit designation
  • Non-Covered
  • Fee/Allowed Amounts

Click here for full details.


March 15, 2021

FEP Benefit Changes

Effective immediately and retroactive to January 1, 2021, the FEP program is allowing preventive services rendered by telemedicine.

Claims that denied will be adjusted.  You do not need to take any action.

If you have any questions or need to verify a FEP members benefits, please call the FEP customer service team at (800) 328-0365.


March 15, 2021

Quality Improvement Policies

Our Quality Improvement Policies have been moved to the provider public page, you no longer have to sign into the Provider Resource Center to view them. Check it out:  https://www.bcbsvt.com/provider/policies/blue-cross-and-blue-shield-of-vermont-quality-improvement-policies.


March 11, 2021

Laboratory Services

Laboratory services must be referred within the BCBSVT network.  Any of our contracted facility can be used, or a contracted independent laboratory.  Our list of contracted independent laboratories has been expanded to include Acutis Diagnostics (COVID testing only), and Progenity (genetic testing).

Click here to view the updated listing of all eligible, contracted independent laboratories.


March 9, 2021

Board Certification or Board Eligibility Requirements

Effective May 15, 2021, credentialing requirements for MDs and DOs include the provision of proof of board certification or board eligibility. Providers already credentialed who have not already provided this information through their CAQH profile need to do so. If you have any questions, please contact the provider file team by email at providerfiles@bcbsvt.com or phone at (888) 449-0443 option 2.


March 8, 2021

Physician Assistants

Starting on May 15, 2021 Physician Assistants can hold a patient panel. A Provider Enrollment and Change Form needs to be submitted for each PA that wants to hold a patient panel checking the “Accepting New Patients” box on the form.  The form is located at https://www.bcbsvt.com/provider/contracting-enrollment-credentialing-and-demographic-changes.  If you are a PA practicing independently, we will need the name of the physician with whom you have entered into a collaboration agreement.  

Full details about the PCP Selection Criteria policy is available on the secure provider portal at www.bcbsvt.com/prc under BCBSVT Policies, then the Quality Improvement link, or, you can contact the provider relations team for a copy providerrelations@bcbsvt.com.


March 8, 2021

Update regarding Corporate Policy 33 - Frequency of Supplies (Diabetic and CPAP/BIPAP):

For members of the State of Vermont employer group (prefixes FVT and EVT), we will not apply the frequency limits of this payment policy until September 1, 2021. The policy remains in effect for all other members since January 1, 2021.

Click here for details.


March 8, 2021

Practitioner Credentialing Policy:

The Quality Improvement Policy for Practitioner Credentialing Policy has been updated and is effective on March 15, 2021. It is available on the Provider Resource Center under BCBSVT Policies, Quality Improvement. If you need a copy emailed to you, please contact the provider relations team by email at providerrelations@bcbsvt.com or phone at (888) 449-0443 option 1.

PCP Selection Criteria:

The Quality Improvement Policy for PCP Selection Criteria has been updated and is effective on March 15, 2021. It is available on the Provider Resource Center under BCBSVT Policies, Quality Improvement. If you need a copy emailed to you, please contact the provider relations team by email at providerrelations@bcbsvt.com or phone at (888) 449-0443 option 1.


March 2, 2021

UPDATE: Single-Photon Emission Computerized Tomography (SPECT)

Prior approval through BCBSVT for SPECT imaging services (codes 78803, 78830, 78831, 78832) is required for dates of service April 1, 2021 forward. BCBSVT medical policy will be applied. The medical policy will be available by March 1, 2021.

Please note: Our original notice advised AIM Specialty Health would be prior approving their services using their guidelines. It will be BCBSVT. Prior approval can be submitted through Acuity Connect or by fax.


March 1, 2021

Provider Directory/File Updates:

Every month we select a random sample of provider profiles to audit, comparing the information found in CAQH ProView® Profile to what we have in our system.  Please do not rely on our audits to capture changes you have made to your profile.

We need your help.

Please review your profile in CAQH ProView® Profile, update the information as necessary and re-attest to it as soon as possible.  Then, at least quarterly, please make sure you review and re-attest.

Click here to review a one page tip sheet that provides details on why this is important and what information needs to be kept up to date a how.


March 1, 2021

Postal Service Delays

Due to the recent weather in the Midwest, you may find your February payments and 1099s are taking longer than you might expect to get to your practice.  Upon request, checks can reissued if they have been outstanding for a 30-day period. It can take 6-8 weeks for the reissue to occur.

We offer free electronic payments; all you have to do is sign up. Click on this link for more details https://www.bcbsvt.com/provider/electronic-payment-eft. If you have questions or need assistance, please contact the provider relations team by email at providerrelations@bcbsvt.com or phone at (888) 449-0443 option 1.

Did you realize:

  • Checks are mailed by a company located in the Midwest every Friday through the United States Postal Service (USPS).
  • We are not able to guarantee the date you will receive your check. If the weather is perfect, USPS is not overwhelmed with packages/mailings, and world events don’t interfere, your paper check may arrive at your office the week after it is mailed.
  • If a check is not received by your office, is misplaced, or is stolen it takes us 6-8 weeks to cancel and reissue a new check.

March 1, 2021

Medical Policy updates for May 1, 2021

  • Durable Medical Equipment, Prosthetics, Orthotics and Supplies
  • Assay of Genetic Expressions in the Tumor Tissue as a Technique to determine Prognosis in Patients with Breast Cancer

Click here for full details.


February 15, 2021

HEDIS Record Data Collection

Is starting in February this year. Again this year, we are partnering with Change Healthcare. If you are contacted by Change Healthcare for record retrieval please respond to them in a timely manner.

If you have any concerns or issues with the process, please contact the provider relations team by email at providerrelations@bcbsvt.com or phone at (888) 449-0443 option 1.


February 2, 2021

Single-Photon Emission Computerized Tomography (SPECT)

Prior approval through AIM Specialty Health for SPECT imaging services (codes 78803, 78830, 78831, 78832) is required for dates of service April 1, 2021 forward. AIM clinical appropriateness guidelines will be applied.


January 29, 2021

Prior approval through AIM Specialty Health for SPECT imaging services (codes 78803, 78830, 78831, 78832) is required for dates of service April 1, 2021 forward. AIM clinical appropriateness guidelines will be applied.


January 29, 2021

1099 Delay

We encountered an unexpected issue when generating the 1099s for 2020 payments. The issue has been fixed and we expect you should receive your 1099s by mid-February. We apologize in advance for the delay.

New Medical Policy:

Effective April 1, 2021 we have a new medical policy for the drug Ketamine. The medical policy will define the medical necessity, prior approval and investigational policy guideline criteria for the administration of Ketamine. The medical policy will be posted to our website by March 1, 2021.

Modifier -50 and/or -RT/-LT

Since January 1, 2021 our claim editing software has been incorrectly denying claim lines billed with a single unit and modifier -50 and/or -RT/-LT.  The denial states “the number of days or units or service exceeds our acceptable maximums” and claim adjustment reason codes CO96, N362.

The issue has been corrected and claims processing on or after January 29, 2021 are applying the correct editing logic. We will be adjusting claims processed from January 1 – 28, 2021 that were denied in error.  No action is required on your part.


January 27, 2021

Cochlear Implant and Implantable Bone Conduction Hearing Aids Medical Policy

Effective February 1, 2021 the medical policy statement will expand indications for children
ages 9 - 12 months with profound bilateral sensorineural hearing loss. The updated policy
as been posted.


January 20, 2021

Emailing Customer Service?

Right now, this is the recommended way to get your questions answered as our phones are extremely busy and hold times can be lengthy.  When emailing, please make sure you include all the information you would if calling the customer service team:  billing NPI number, member name, member identification number, member date of birth and date(s) of service.  Including this information in your initial email will reduce back and forth and overall response time. Please note, all emails sent by BCBSVT are secure and HIPAA compliant.

customerservice@bcbsvt.com for BCBSVT, New England Health Plan, Access Blue 
fepcustomerservice@bcbsvt.com for Federal Employee Program
bluecard@bcbsvt.com for BlueCard 
MedicareAdvantage@bcbsvt.com for MedicareAdvantage (non-Vermont Blue Advantage) - please note, only emails are accepted for these inquiries.


January 20, 2021

Medical Policy Reviews

The medical policies listed have completed review and have changes effective April 1, 2021.  We also have a new medical policy for telemedicine and telehealth that will be effective April 1, 2021.
Click here for details.

Revised Medical Policies:

  • Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynotoses
  • Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry
  • Occupational Therapy
  • Physical Therapy/Medicine
  • Speech Language Pathology/Therapy Services
  • Transgender Services

January 19, 2021

Continuous or Intermittent Glucose Monitoring Medical Policy

Effective February 1, 2021, this policy has been updated to consider intermittent glucose monitoring for periods of less than 72 hours.  The updated policy has been posted.


January 19, 2021

Where to submit Medicare Advantage Claims

Claims for non-Vermont Medicare Advantage members with a date of service January 1, 2021 or after

  • Paper Claim – VBA, P O Box 260755, Plano, TX  75026
  • Electronic – submit to BCBSVT as you do today, using a plan code such as BCBSVT or SB915, we will direct the claim to VBA for processing

Claims for non-Vermont Medicare Advantage members with a date of service prior to January 1, 2021

  • Paper Claim – BCBSVT, P O Box 186, Montpelier, VT  05601
  • Electronic – submit to BCBSVT

If you have any questions, please contact the provider relations team by email at providerrelations@bcbsvt.com or phone at (888) 441-0443 option 1.


January 15, 2021

ClaimsXten-Select™ Logic - UPDATE

Editing logic for new and revised codes will be applied starting with claims processing, Saturday, January 16, 2021. Claims processed prior to the application of the E&M editing logic will not receive an automatic adjustment. However, if a claim requires adjustment after the application of the E&M logic, it will be subject to the updated logic, regardless of the date of service.


January 13, 2021

Telemedicine Co-payment Change

For the benefit year 2021, Engelberth Construction Inc. employees have a $10 co-payment for services provided by telemedicine with a primary care provider or a
$20 co-payment for specialty care provider by telemedicine.  The standard co-payments for primary care or specialty care are only applicable for face-to-face visits.  

At this time, the eligibility look-up tool on the Provider Resource Center and 270/271 transactions are not reflecting this new co-payment.  We apologize and are working to get updates in place.

Note: This is the only employer group that has opted for a lower co-payment for telemedicine services.  All other employer groups or individually insured members have standard benefits applied to telemedicine services.


January 11, 2021

Want to Avoid Hold Times?

The first quarter of any year is the busiest time of year for our customer service team and hold times can get quite lengthy.  Most questions related to member eligibility and claim status can be answered by using the Provider Resource Center.  However, if you still have a questions, we encourage you to outreach by email directly:
  
BCBSVT, New England Health Plan, Access Blue New England Inquires:  customerservice@bcbsvt.com
Federal Employee Program Inquiries:  fepcustomerservice@bcbsvt.com
NEW! - BlueCard inquiries:  bluecard@bcbsvt.com
NEW! – Medicare Advantage inquiries (non-Vermont Blue Advantage):  MedicareAdvantage@bcbsvt.com – please note, only emails are accepted for these inquiries.

You will receive an initial email confirmation and a follow up within 3 business days.


December 30, 2020

Questions on the Processing of a Medicare Advantage claim?

Starting January 4, 2020 inquires related to the processing of Medicare Advantage claims for other Blue Plan members must be emailed to MedicareAdvantage@bcbsvt.com. There is a dedicated team that will review the inquiry and respond to you within 3 business days.  Please note, phone calls are no longer accepted.  If you call us, you will be re-directed to send an email.


December 30, 2020

Permanent Telemedicine Payment Policy (CPP_03) updated

The policy was updated in December of 2020 (effective January 1, 2021) with the following changes:

  • Deleted 99201
  • Revised the descriptors for 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99354, 99355.
  • Added 99417, 99446, 99447, 99448, 99449, 0378T, 0379T, G0508, G0509, D9995, D9996, 90963, 90964, 90965, 90966
  • Added G2250, G2252, G2211, and G2212 as eligible with Medicare primary; added G2251 as not eligible.
  • Moved the “Document precedence” section
  • Updated the references to statutory provisions

The policy is available on the Provider Resource Center under BCBSVT Policies/Payment Policies.  If you need a copy emailed to you, please contact the provider relations team by email at providerrelations@bcbsvt.com or phone at (888) 449-0443 option 1.


December 29, 2020

Update to Payment Policy CPP_14 Home Infusion Therapy (including enteral nutrition and total parenteral nutrition)

The following changes are effective as of January 1, 2021:

  • Added HCPCS code G0088, G0089 and G0890 to the coding table and moved B4160 to non-covered.

The updated policy is available on the Provider Resource Center under BCBSVT Policies/Payment Policies. If you need a copy emailed to you, please contact the provider relations team by email at providerrelations@bcbsvt.com or phone at (888) 449-0443 option 1.


December 23, 2020

Clear Claim Connection™ (C3) Tool

Effective January 2, 2021 there are changes in the information you need to supply to get a result in the Clear Claim Connection™ (C3) Tool. Click here for details.


December 23, 2020

REVISED from December 17, 2020 - New & Revised Codes for January 1, 2021 (Adaptive Maintenance)

We are in the process of completing our review of the Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) additions, deletions, and revisions for January 1, 2021. This could result in some changes to:

  • Prior Approval
  • Investigational Services
  • Unit Designation
  • Non-Covered
  • Other Changes
  • Fee/Allowed Amounts

Click here for full details.


December 18, 2020

Credentialing Policies

Our Credentialing Policies have been reviewed and updated.  You can find the updated versions on this link under credentialing:  https://www.bcbsvt.com/provider/contracting-enrollment-credentialing-and-demographic-changes.


December 18, 2020

Paper Claims - Medicare Advantage

Starting January 1, 2021, all paper claims for Medicare Advantage members (Vermont Blue Advantage (VBA) or members of another Blue Plan with Medicare Advantage) must be mailed to:  VBA, PO Box 260755, Plano, TX 75026, or you can fax to (800) 479-8973.  Electronic claims for Medicare Advantage and VBA member still come into BCBSVT with a Plan code of BCBSVT


December 17, 2020

Laboratory Draw Stations Update

Laboratory Draw Stations are asking people call to schedule an appointment.  Click here for an updated list of Laboratory Draw Stations, locations and phone numbers.


December 16, 2020

FEP Prior Approval for 2021

The FEP Prior Approval Requirements for 2021 have not changed, they remain the same as 2020.  Updated FEP Prior Approval lists have been posted to the Prior Approval/Authorization link.


December 14, 2020

FEP Dentists

The FEP Maximum Allowable Charge is changing for 2021. Click here for the 2021 FEP MAC.
 
We apologize for our previous posting advising there were not changes for 2021.


December 9, 2020

UVM (college) Retirees Benefits for January 1, 2021

University of Vermont (college) retirees will be covered under the Medicare Advantage solution, Vermont Blue Advantage effective January 2, 2021.  Click here for more details.


December 8, 2020

Attention: Acupuncture Providers

Corporate Payment Policy CPP_02 Acupuncture has been updated and changes will take effect on January 1, 2021.  Updates include:

  • expansion of the list of evaluation and management services that are eligible
  • clarification of guidelines regarding the use of acupuncture service codes 
  • acupuncture coding table was moved to the body of the policy

The complete policy is available on the Provider Resource Center under BCBSVT Policies/Payment Policies or by contacting the provider relations team by email at providerrelations@bcbsvt.com or phone at (888) 449-0443, Option 1.


December 7, 2020

Corrected Claims Submission

If you are submitting a corrected claim, either on paper or electronically, only include the original services and charges you submitted on the original claim.  Do not report any service lines our claim editing software may have added.  

The corrected claim will go through the claim editing software again and if appropriate, corrected lines will be added back in.

Instructions on how to submit a corrected claim are available on the provider website under Provider Handbook and Reference Guides/General, Corrected Claim Submission Guidelines.  

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


December 7, 2020

Attention Orthopedic Providers

Prior approval requests for supplies needed by patient post-surgery cannot be submitted  for consideration until after the surgery has been performed.  

An example of this would be Continuous Passive Motion (CPM) in the Home Setting.  

Prior approval must be submitted post-surgery with medical notes to establish if medical criteria has been met.  Prior approvals for these services should not be marked as urgent unless it meets the qualification below.

Urgent services are those health care services that are necessary to treat a condition or illness of an individual that if not treated within 24 hours presents a serious risk of harm, or, applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine, could seriously jeopardize the ability of the individual to regain maximum function, or, in the opinion of a Physician with knowledge of the individuals medical condition, would subject the individual to severe pain that cannot be adequately managed without care within 24 hours.

  • Marking a request as “urgent” does not guarantee immediate review; state guidelines permit us up to 48 hours to review a request marked as “urgent” (or one that is automatically treated as urgent under state rules).
  • The most appropriate time to mark a request as “urgent” will be in situations involving urgently needed care (as defined by state regulations).
  • We must respond to all prior approval requests within two business days, whether they are marked “urgent” or not.
  • Please remember to submit requests before the member’s appointment.
  • Please avoid submitting requests on a Friday unless necessary.

December 7, 2020

Medical Policy Reviews

The following medical policies have completed review and have changes effective March 1, 2021.  Click here for full details. 

  • Breast Surgery and Breast Prosthesis
  • Neuromuscular Electrical Stimulator (NMES)
  • Temporomandibular Joint Dysfunction

December 7, 2020

Attention PT/OT Providers

Starting January 1, 2021, the physical therapy/medicine and occupational therapy session limits defined in our medical policies (also pasted below) will be applied with the initial claim processing:

A PHYSICAL THERAPY/MEDICINE SESSION IS DEFINED AS UP TO ONE HOUR OF SERVICES (treatment and/or evaluation) or up to three modalities provided on any given day.  In any case billing for the three modalities cannot exceed one hour per session.

AN OCCUPATIONAL THERAPY SESSION IS DEFINED AS UP TO 1 HOUR OF OT (treatment and/or evaluation) or up to three OT modalities provided on any given day. In any case billing for the three modalities cannot exceed one hour per session.

Prior to January 1, 2021 we used to enforce this requirement by adjusting claims after they had processed.


December 4, 2020

Suggestions on how to improve the Provider Resource Center (PRC)

If your team has suggestions for how we can improve the information on the PRC related to claims processing to help prevent the need for phone calls into the call center we welcome the feedback and will take it into account as we look to improve the end-user experience. Please have your teams share feedback regarding suggested improvements with the provider relations  team or the customer service representative.


December 4, 2020

Make sure all staff (including third-party billers) have access to the Provider Resource Center (PRC)

Starting in December, if a caller with claim status questions has not checked the PRC, the caller may be re-directed to the PRC for self-service. If there is still a question, a follow up inquiry can be made to the appropriate customer service team.

The first quarter of any year is the busiest time of year for our customer service team and hold times can get quite lengthy. Most questions related to member eligibility and claim status can be answered by using the PRC. The PRC should always be the first resource used to answer questions. It is available 24/7 and does not have a wait time.

Please make sure that all representatives (office staff or third-party vendors/billers) who follow up on patient accounts have access to the PRC. In addition, you will want to make sure they are familiar with the functionality and how to best utilize the tool.

If you need assistance in granting staff/third-party billers access to the PRC, or if you need assistance with training them on how to use the PRC, please contact the provider relations team by email at providerrelations@bcbsvt.com or phone at (888)449-0443, Option 1.


November 30, 2020

Medical Policy Reviews

The following medical policies have completed review and there are no changes:

  • Enteral Nutrition
  • Home Infusion Therapy
  • Home Infusion Therapy for State of Vermont members 
  • Medical Food for Inherited Metabolic Disease
  • Total Parenteral Nutrition (TPN) in the Home Setting
  • Tumor Treatment Field for CNS Cancers

November 30, 2020

Home Birth Payment Policy

Payment Policy CPP_18 Home Births was updated November 17, 2020 for an effective date of January 1, 2021.

The following changes have been made:

  • (a) removed section IV under Policy/Eligible Services/Billing Guidelines (Billing for labor time when delivery not performed in home setting), as these services are no longer separately reimbursable;
  • (b) removed codes from coding table (99212-99215, 99354 & 99355);
  • (c) added a reference to new code 99417 (non-covered, provider liability).

The policy has been posted to the Provider Resource Center under BCBSVT Policies/Payment Policies.  If you would like a copy emailed to you, please contact the provider relations team by email at providerrelations@bcbsvt.com or phone at (888) 449-0443, Option 2.


November 23, 2020

Payment Policy Update

CPP_30 Temporary/Emergency Waiver of Cost Share for COVID-19-Related Testing, Diagnosis, and Inpatient Treatment has been updated.

Updates to CPP_30 include:

  • extends the end date of the policy to July 1, 2021
  • edited references to diagnosis codes
  • adds information about CPT ®s 99072 and 99001
  • updates reference to Vermont Department of Financial Regulation H-2020-06-E

Click here to view the updated policy.


November 20, 2020

Billing for a colonoscopy after a Fecal Immunochemical Test (FIT) or Cologuard

With the pandemic affecting how patients choose to access care, you may be seeing an increase in the number of patients using a FIT/Cologuard test.  As a reminder, if a Blue Cross and Blue Shield of Vermont (BCBSVT) member has opted to have a FIT/Cologuard test, regardless of the FIT/Cologuard test result, the follow up colonoscopy must be billed as a preventive screening.  Click here for full details.


November 19, 2020

Attention Ambulance Providers:

All non-emergency transport, including transport by land, air or water requires prior approval.  If you fail to obtain prior approval prior for the services being rendered, you can submit a request for retrospective prior approval.  It is a very simple process and is the best course of action to reduce claim denials and the need to submit an appeal. 

To request a retrospective prior approval simply complete and submit a prior approval form noting it is a retrospective review and include all supporting documentation.  

The completed form needs to be faxed to Integrated Health at (866) 387-7914.  You will be notified of the outcome.  

If you have any questions, contact the provider relations team by email at providerrelations@bcbsvt.com or phone at (888) 449-0443 option 1.


November 19, 2020

Medical Policy Update

We have updated the Sleep Disorders Diagnosis and Treatment Medical Policy.  Changes will be in effect as of February 1, 2021.  The updates include adding medical criteria for splint night studies and clarifying language for supervised polysomnography.  The updated policy will be posted by January 1, 2021.


November 13, 2020

Medication Therapy Management Program

We are exploring the adoption of a Medication Therapy Management (MTM) program for pharmacists who are not in a dispensing role. Such a program, if implemented, would allow reimbursement for the MTM services provided in your office.

Initially, the program will be for information gathering with no reimbursement made. The data we collect during the information gathering period will inform our next steps.

Click here for detail on how to enroll.


November 12, 2020

Medical Policy Updates

There are updates to existing medical policies that are effective as of December 2020, January and February 2021. Click here for full details.


November 12, 2020

Temporary/Emergency Policies due to COVID-19

BCBSVT:

All temporary/emergency policies and related medical policy created for COVID-19 are extended until July 1, 2021.  Below is the list of policies (with direct links to the policy). Please note, some policies may still reflect the December 31, 2020 end date. We are underway with updating and will get them re-posted shortly.

Federal Employee Program (FEP):

FEP has some interim measures for telehealth, click here for full details.  The FEP changes are in place until further notice.

If you have any questions about the policies, please contact the provider relations team by email at providerrelations@bcbsvt.com or phone at (888) 449-0443 option 1.


November 10, 2020

Medicare adjusted claims for member's of other Blue Plans

Effective December 1, 2020, Medicare adjusted claims must be submitted to the member’s Blue Plan directly. They can no longer be submitted to us for processing.

Please remember, most claims cross over to the member’s Blue Plan directly from CMS, so direct claim submission is not necessary. This change is only for claims that are the result of a Medicare adjustment and did not cross over to the member’s Blue Plan.

Having you submit and work directly with the member’s Blue Plan for these types of claims reduces processing time and gets you a payment more quickly.


November 9, 2020

Provider Demographic and Practice Affiliation

The self-reported data in your CAQH ProView profile for demographic information or practice affiliation(s) has become the primary source we will use to validate our provider directory. When we find discrepancies between our data and the CAQH ProView profile, we will use the CAQH ProView profile as the source of “truth” and update our directories and provider files accordingly.  

Please note, if you have added a provider affiliation to CAQH ProView, you will need to submit a Provider Enrollment and Change Form to add it to the existing group contract. Within CAQH ProView we are only terminating group affiliations that no longer exist.


November 4, 2020

Prior Approvals

Please consider the following before marking a Prior Approval Request as “urgent”:

  • Marking a request as “urgent” does not guarantee immediate review; state guidelines permit us up to 48 hours to review a request marked as “urgent” (or one that is automatically treated as urgent under state rules).
  • The most appropriate time to mark a request as “urgent” will be in situations involving urgently needed care (as defined by state regulations).
  • We must respond to all prior approval requests within two business days, whether they are marked “urgent” or not.
  • Please remember to submit requests before the member’s appointment.
  • Please avoid submitting requests on a Friday unless necessary.
  • Please ensure a request for prior approval is complete and contains required clinical information, as this will expedite the process.

November 4, 2020

Attention Dentists

Our Medicare Advantage solution, Vermont Blue Advantage has benefits for dental services.  United Concordia Dental was selected to provide the network and care to our Vermont Blue Advantage members.  If you are already part of their network, thank you.  If you are not, you may want to consider participation so you are eligible to provide care to our Vermont Blue Advantage members.