Blue Cross Blue Shield of Vermont uses the Vermont Uniform Prior Authorization Form, a standardized PDF that every health insurer in the state is required by law to accept. The current version was revised in July 2024 and is available as a free download from the Vermont Department of Financial Regulation.1Department of Financial Regulation. Prior Authorization Forms Providers can also submit requests electronically through the BCBSVT Prior Authorization Portal inside the Provider Resource Center.2Blue Cross Blue Shield of Vermont. Prior Approval Authorization The uniform form requirement comes from 18 V.S.A. ยง 9418b.3Vermont General Assembly. 18 VSA 9418b – Prior Authorization
Check First Whether the Service Needs Authorization
Before filling out anything, confirm the service actually requires prior approval. BCBSVT maintains an online Prior Approval Database listing every CPT code that triggers the requirement. Categories include cosmetic and reconstructive procedures, genetic testing, bariatric and gastric bypass surgery, non-emergency ambulance transport, certain autism spectrum therapies, and adoptive immunotherapy including CAR-T, among others.4BlueCross BlueShield of Vermont. Prior Approval Database The list changes as clinical policies update, so check it close to the time of scheduling.
One important carve-out: advanced imaging. CT, CTA, MRI, MRA, MRS, and PET scans are handled by Carelon (formerly AIM Specialty Health), not through the standard BCBSVT channels. Submit those requests by calling Carelon at (800) 701-0080 or through Carelon’s own provider portal.2Blue Cross Blue Shield of Vermont. Prior Approval Authorization
Filling Out the Form
The uniform form has four blocks. Fields marked with an asterisk are required, and blank required fields are a common cause of processing delays.
Request Type
At the top, mark whether the request is pre-service or post-service, elective or non-elective, and urgent or non-urgent. The urgent designation triggers a faster decision clock, but checking “urgent” when the situation does not meet clinical urgency criteria can delay processing rather than speed it up.
Patient and Member Information
Enter the patient’s first and last name, date of birth, health insurance ID number from the front of the BCBSVT card, mailing address, and telephone number. Gender identity and middle initial are optional but reduce the chance of matching errors when the insurer has members with similar names.
Provider Information
There are two separate provider blocks, and both need to be filled in.
- Referring or requesting provider: the clinician ordering the service. Enter name, NPI, Tax Identification Number, specialty, address, and phone, plus the office contact person completing the form and that person’s direct line.
- Rendering or attending provider: the clinician or facility that will perform the service. Complete the same fields.
When the ordering and performing provider are the same person, fill out both blocks with identical information. Leaving the rendering provider blank forces the review team to send the form back.
Required Clinical Information
This section decides whether the request is approved on first review or kicked back for more detail. Start by checking the type of service. The form offers categories including surgery, diagnostic imaging, mental health or substance use disorder, oncology, DME, home health, and occupational, physical, and speech therapy. Then complete:
- Primary and secondary diagnosis in plain text, with ICD-10 codes.
- Name of the proposed procedure and its CPT, HCPCS, or revenue code.
- Proposed service start and end dates.
- Facility where the service will be performed.
- Volume: number of inpatient days or outpatient visits requested.
- For durable medical equipment: equipment name, HCPCS code, duration of need, purchase price, and monthly rental price.
- Whether the request is out-of-network. Out-of-network requests face additional review under most plan types.
At the bottom, indicate how many pages of supporting clinical documentation you are attaching. Include recent labs, imaging reports, clinical notes showing failed prior treatments, and specialist consultations that support medical necessity. Thin documentation is the single biggest reason first submissions get denied. Attach everything that shows why this specific service is the right next step for this patient.
Submitting the Form
BCBSVT accepts prior authorization requests through three channels. The fastest is the web-based Prior Authorization Portal in the Provider Resource Center, which also lets you track submitted requests.5Blue Cross and Blue Shield of Vermont. Contact Information for Providers
If you fax the form, use the line that matches the patient’s plan:
- Standard medical prior approval through BCBSVT: (802) 371-3489
- Integrated Health plans: (866) 387-7914
- Vermont Blue Advantage: (866) 900-2491
- Pharmacy, CVS/Caremark for Blue Medicare Rx, new requests only: (844) 403-1029
Confirm the patient’s plan before sending. Faxing to the wrong number can cost days. BCBSVT’s provider contact sheet does not list a mailing address for prior authorization submissions; fax and the portal are the intended channels.5Blue Cross and Blue Shield of Vermont. Contact Information for Providers
How Long BCBSVT Has to Decide
Under Vermont Regulation H-2009-03, urgent requests where delay could seriously harm the patient must be decided within 48 hours of receipt. Standard, non-urgent requests must be decided within two business days after BCBSVT has all the information it needs.6Vermont Department of Financial Regulation. Vermont Regulation H-2009-03 – Consumer Protection in Managed Care The “all necessary information” qualifier is the catch: an incomplete form or missing documentation stops the clock until the insurer receives everything.
Both the provider and the member receive written notice of the decision. An approval letter specifies how long the authorization is valid and any conditions attached.
If the patient’s coverage is through Vermont Blue Advantage, the Medicare Advantage product, federal timelines under the CMS Interoperability and Prior Authorization Rule may apply alongside state rules starting January 1, 2026: seven calendar days for standard requests and 72 hours for urgent requests.7Centers for Medicare & Medicaid Services. CMS Interoperability and Prior Authorization Final Rule CMS-0057-F
If the Request Is Denied
A denial letter must explain the specific clinical reasons the request did not meet BCBSVT’s criteria. That explanation is the starting point for an appeal.
Internal Appeal
The first step is an internal appeal directly with BCBSVT, and it must be completed before an external review. The denial letter contains the instructions and the deadline. Attach additional clinical evidence that addresses the stated reason for denial: a letter of medical necessity from the treating physician, updated test results, or peer-reviewed literature supporting the requested treatment.
External Appeal Through the Vermont DFR
If BCBSVT upholds its denial, the patient can request an independent external review through the Vermont Department of Financial Regulation. External appeal is available when the denial was based on medical necessity, a determination that the treatment is experimental or investigational, or an improper limitation on provider selection.8Department of Financial Regulation. Healthcare External Appeal
The filing deadline is 120 days or four months from receipt of the final denial letter, whichever is longer. The DFR charges a $25 filing fee, payable by check, and waives it in financial hardship situations without requiring income documentation. Once the DFR has the complete file, an independent review organization issues a binding decision within 30 days.8Department of Financial Regulation. Healthcare External Appeal
For emergencies outside normal business hours, the DFR operates an external appeals answering service at (802) 232-2878. Non-emergency questions go to (802) 622-4423 during business hours.
If Authorization Was Never Requested
When a required prior approval is not obtained before the service is performed, BCBSVT holds contracted providers and facilities financially responsible. The provider cannot bill the patient for the shortfall, and cannot file an appeal based solely on the fact that authorization was never requested.2Blue Cross Blue Shield of Vermont. Prior Approval Authorization
BCBSVT will conduct a retrospective review of medical necessity in limited circumstances described in its provider handbook. If one of those exceptions applies, the provider must contact BCBSVT within 60 calendar days of the date of service to request the review.2Blue Cross Blue Shield of Vermont. Prior Approval Authorization That window is firm. Missing it typically means the provider absorbs the full cost.