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Claims Processing

last modified 10/01/2018 - 11:18 AM

Fee Schedules and Other Information for Claims Processing

**Effective April 2018, all fee schedules (excluding OPPS) can be found on the Vermont Medicaid portal. 


** Fee schedule information is updated on a monthly basis. Information such as coverage or prior authorization requirements may be updated throughout the month, but will not be reflected in the fee schedules until the next monthly update. For the most current information regarding changes to coverage or prior authorization requirements, please refer to the weekly banner pages.

**High Tech Cardiology may require a Prior Authorization from eviCore (formerly MedSolutions).


Fee Schedules:    CPT Codes; Durable Medical Equipment (DME); HCPCS; Lab; Radiology; Ladies First; PAC 8 (Deleted Codes) & PAC 9 (Non Covered codes); Vision

  Please note that the tabs for the 2014 Fee Schedule have been modified.  Please read the Index page for more info.

2018 Fee Schedules

2017 Fee Schedules

 2016 Fee Schedules  

 2015 Fee Schedules

 2014 Fee Schedules

  2013 Fee Schedules

  2012 Fee Schedules


OPPS Fee Schedules:    For Outpatient services billed on a UB-04 claim 

 2018 OPPS Fee Schedules

 2017 OPPS Fee Schedules

 2016 OPPS Fee Schedules  

 2015 OPPS Fee Schedules

  2014 OPPS Fee Schedules

  2013 OPPS Fee Schedules

  2012 OPPS Fee Schedules


ICD-10 PCS Codes Requiring Prior Authorization 

  2018 PCS Codes Requiring PA

  2017 PCS Codes Requiring PA

ICD-10 PCS Codes Non Covered or Inactive

  2018 PCS Inactive Codes 

  2017 PCS Inactive Codes


ICD-10 CM Diagnosis Codes Not Accepted (DVHA has temporarily removed the edit for "unspecified" diagnosis codes that may have denied as of 7/1/18. The Global Commitment Register (GCR) proposed policy 18-021: Unspecified Diagnosis Code List Update is open for public comment through 8/23/18. Upon DVHA review, the updated list will be posted online for providers no later than 9/1/18. The edit will be back in place on 10/1/18. For additional questions, please contact a DXC Provider Representative.). 

  2018 CM Not Acccepted Codes


High Tech Radiology and Cardiology Services:    Require a Prior Authorization from eviCore (formerly MedSolutions)

  2016-2017 Cardiology is included in the CPT Fee Schedule (top of this page)

  2013 - 2014 Radiology is included in the CPT Fee Schedule (top of this page)

  2012 Radiology

 eviCore website click here


 Dental Procedures Fee Schedule

  January 1, 2018         ( For services beginning 1/1/18; posted 1/2/2018)

  January 1, 2017         (For services beginning 1/1/17;Posted 1/3//2017)

  January 1, 2016         (For services beginning 1/1/16; Revised/Posted (8/18/2016))

  January 1, 2016         (For services beginning 1/1/16; Revised/Posted (4/26/2016))

  January 1, 2016          (For services beginning 1/1/16;Posted ( 2/26/2015)

  January 1, 2015          (For services beginning 1/1/15; Revised/Posted (11/3/2015)         

  January 1, 2015        (For services beginning 1/1/15; Revised/Posted (10/1/2015)

   January 1, 2015       (For services beginning 1/1/15; Revised/Posted (9/16/2015)

  January 1, 2014        (For services beginning 1/1/14; Revised/Posted (05/05/15)

  November 1, 2013    (For services beginning 11/1/13; Revised/Posted (11/20/13)

  January 1, 2013        (For services beginning 01/01/13; Posted (4/5/13)

  January 1, 2011        (For services beginning 01/01/11; Posted (05/23/11)


Independently Billing Dental Hygienist Fee Schedule (For services beginning 1/1/18; posted 5/29/18)


Non-Emergency Medical Transportation (NEMT) Fee Schedule

  Per Member Per Month    (Valid for dates of service on/after 7/1/2012)

  2011 Fee Schedule          (Valid for dates of service through 6/30/2012)


 Urine Drug Testing Update (Posted 6/1/2015)

Hub & Spoke Health Home Rates  (Posted 2/6/14)

Children's Personal Care Services (Posted 6/12/14)


 Note: CPT and CDT codes, descriptions and other data only are copyright 2014 American Medical Association (AMA) and American Dental Association (ADA), respectively. All rights reserved. CPT is a registered trademark of the AMA. CDT is a registered trademark of the ADA. Applicable FARS and DFARS Restrictions apply to government use. The AMA and ADA assume no liability for data contained or not contained herein.


NOTE: Effective for dates of service  July 1, 2009 to October 31, 2013, Medicaid rates paid to some providers were reduced by 2%. The reduction was captured in the last step of claims processing and not reflected in the rates posted here. The remittance advice (RA) will state that the payment is a reduced amount of 2% from the posted DVHA fee schedules.