Pharmacy Updates

REQUIREMENTS: By September 1, 2026 (for dates of service after this date): - Billing team must update claim submission protocols to bill prenatal care using E/M codes (99201-99215 range) appended with modifier -TH instead of global obstetric codes 59425 and 59426 - Ensure ICD-10-CM codes from Z34A category (with required 4th character for gestation) are included on all first prenatal visit claims - Providers must update documentation templates to ensure medical decision making (MDM) or time-based elements support E/M code billing per CPT guidelines - Update encounter forms to include diagnosis code selection for contraceptive management from preventive guide (first position diagnosis must align with eligible diagnoses) - Coders must review AMA CPT 2027 Maternity Care Services resources and attend the September 16, 2026 webinar By October 1, 2026: - Practice administrators must enroll in Electronic Fund Transfer (EFT) for payment processing; paper checks will no longer be issued after this date - Administrative staff must ensure all third-party billers/vendors have authorized access documented in Provider Handbook Section 6.1; be prepared to provide proof of business associate relationship upon request By October 30, 2026: - Billing team must audit and correct all NDC, Unit of Measure, and Quantity billing for claims submitted after this date; NDC billing rules will be systematically enforced and previously accepted claims may now be denied for non-compliance - Update billing software to enforce NDC rules Before November 1, 2026: - Billing and coding teams must review all updates to medical policies, provider handbook, preventive guide, and codes that take effect November 1, 2026 Ongoing: - All claims must be submitted within 180 days of date of service or face denial - VBA claims for 2025 services must be submitted by December 31, 2026 - Stop using AI-generated or automated inquiries when contacting Blue Cross VT; suspected AI calls will be disconnected