Member Rights and Responsibilities

REQUIREMENTS: By September 1, 2026: Billing team must implement new obstetric billing requirements for prenatal visits. For dates of service on or after September 1, 2026, bill first prenatal visits with an E/M code appended with modifier -TH (not legacy codes 59425 or 59426) and include appropriate Z34A ICD-10-CM code with 4th character required to indicate gestation. Subsequent antepartum visits must also use E/M code with modifier -TH and comply with E/M coding rules requiring documentation of medical decision making or time per CPT guidelines. Update encounter templates and coder training materials. Failure to use correct coding will result in claim denials. By October 1, 2026: Billing team and accounts receivable staff must enroll in Electronic Fund Transfer (EFT) for all provider payments. Paper check issuance will cease October 1, 2026. Complete EFT enrollment immediately to prevent payment delays. Contact provider relations if assistance needed. Before October 30, 2026: Billing team must audit all claims for NDC billing compliance (NDC code, Unit of Measure, Quantity requirements). Review submissions for services billed with NDC codes and correct any non-compliant claims now. Effective October 30, 2026, NDC billing rules will be systematically enforced and previously accepted non-compliant claims will be denied retroactively. By November 1, 2026: Billing team and providers must review all updates to medical policies, provider handbook, preventive guide, and code maintenance changes posted by Blue Cross VT. Updates take effect November 1, 2026. Review contraceptive counseling diagnosis requirements in preventive guide to ensure first-position diagnoses align with eligible diagnoses for cost-share waiver claims. Ongoing: Ensure all third-party billers/vendors have proper authorization on file with Blue Cross VT and can provide proof of business associate relationship upon request per Provider Handbook Section 6.1. Verify all claims (including corrected claims) for 2025 VBA member services are submitted by December 31, 2026 deadline. Maintain 180-day timely filing requirement for all claims.