Boletín administrativo: 2026-02-001 Updates and new information

Proveedores profesionales y de centros

Appeals and medical records submissions through Capital’s Provider portal

KEY POINT: Effective February 23, 2026, Capital will launch an enhanced process for submitting appeals and medical records electronically through the provider portal (Availity Essentials). Effective April 1, 2026, Capital will no longer accept appeals submitted via mail or fax.

We’re excited to share an important update that will enhance your experience when working with Capital.

Effective February 23, 2026, Capital will begin accepting appeals and associated medical records through our provider portal (Availity Essentials), streamlining the submission process and improving electronic transactions between Capital and Providers.

What this means for you

• A simpler, more secure way to submit appeals and supporting documents, with faster processing and better tracking.
• Improved response times by allowing all required information to be submitted upfront, reducing missing documents and technical issues.
• Fewer status inquiries and fewer appeals dismissed due to incorrect or incomplete forms.

Electronic appeals training

To ensure a smooth transition, providers are encouraged to familiarize themselves with the process. Training is available through Availity Essentials using the steps below:

• From the home page, click on the Help and Training drop-down menu in the upper right corner.
• Select Get Trained.
• Use the Search function, click Catalog, and type "Appeals".
• Drop down to Availity Appeals - Training Demo. (Select the Non-Payer Specific course).

Beginning April 1, 2026, all appeals must be submitted electronically through Capital's provider portal (Availity Essentials), or they will not be processed.

Note: The BlueCard Common Appeals Form is exempt from this requirement and will continue to be accepted via fax or mail.

Capital Blue Cross BlueCard Executive Contact – Provider MDL settlement

KEY POINT: Capital Blue Cross, following BCBSA guidelines and the requirements of the Provider MDL Settlement, has appointed a BlueCard Executive to handle escalated claims from providers who remained in the Settlement Class.

What is the BlueCard Executive?

The BlueCard Executive is a designated senior-level individual at Capital Blue Cross accountable for managing escalated issues regarding certain BlueCard claim payments. Providers must use existing disputes and appeals processes first to address all other BlueCard issues.

Eligible providers serviced by Capital Blue Cross can request eligible escalations by emailing BlueCardExecutive@CapBlueCross.com.

¿Quién es elegible para derivar las reclamaciones a BlueCard Executive?

Solo los proveedores que se encuentran dentro del área de servicio de 21 condados de Capital Blue Cross y que forman parte del Grupo de demandantes de MDL para proveedores pueden recurrir al BlueCard Executive de Capital Blue Cross. Providers that opted out of the Provider MDL Settlement are not eligible.

What claims can be escalated to the BlueCard Executive without first pursuing existing dispute and appeals processes?

BlueCard Executives can receive escalations from eligible providers for claims that meet the following criteria:

• Open BlueCard claims aged forty-five calendar days or more from the submission date and billed charges of $1 million or more
• Open BlueCard claims aged sixty calendar days or more from the submission date and billed charges of $500,000 or more
• Open BlueCard claims aged ninety calendar days or more from the submission date and billed charges of $300,000 or more

How do I contact the Capital Blue Cross BlueCard Executive?

Eligible providers within Capital Blue Cross' 21-county Service Area can contact our BlueCard Executive by emailing BlueCardExecutive@CapBlueCross.com.

Si una reclamación elegible requiere información o asistencia de otro plan Blue, BlueCard Executive de Capital Blue Cross se coordinará con el otro plan para abordar la consulta.

Para obtener más información sobre el acuerdo, visite www.bcbsprovidersettlement.com.

Evolent – High-tech radiology, cardiac imaging, and radiation oncology - Medical policy updates

KEY POINT: Capital committees recently approved Evolent's medical policies for utilization management decisions for delegated High-Tech Radiology, Cardiac Imaging, and Radiation Oncology services. Evolent has included additional medical policies as outlined below, effective March 1, 2026.

The following ad hoc medical policy updates are effective March 1, 2026.

On behalf of Capital Blue Cross, Evolent Specialty Services, Inc. (Evolent), reviews certain medical specialty requests to see if they are medically necessary and a covered service under the Capital Blue Cross benefit plan. Evolent is an independent company.

A link to Evolent's medical policies is available on Capital's Medical Policies web page. A complete list of CPT/HCPCS codes requiring preauthorization can be found on Capital's single source preauthorization List.

Radiology procedure coding update – Anatomical modifiers

KEY POINT: Effective for claims processed on or after April 1, 2026, Capital Blue Cross will require the reporting of an anatomical modifier when performing radiology procedures that require anatomical modifiers.

The Network Reimbursement Policy FP-01.001 Correct Coding and Reimbursement Methodology states that Capital requires each code and modifier submitted for reimbursement consideration to be the most appropriate code, coded to the highest level of specificity, for that procedure, item, or diagnosis.

Anatomical modifiers include the side of the body (RT, LT), fingers (FA, F1-F9), and toes (TA, T1-T9). Claims submitted without the required anatomical modifier will be denied for incorrect coding.

By using these anatomical modifiers, you can:

• Help ensure prompt and accurate claim adjudication and payment.
• Reduce duplicate denials.
• Decrease the need for medical reviews and appeals.

Please note the following regarding anatomical modifiers:

• Anatomical modifiers should be utilized when the procedure or service is performed to specify the exact location of the procedure.
• Modifiers 59, XU, XS, XP, and XE should not be used in place of an anatomical modifier. Please code with the most specific modifiers.
• Anatomic modifiers must correspond with the definitions of procedure codes.
• Example: For procedure code 73140 – RADEX FINGER MINIMUM 2 VIEWS, anatomic modifier should be one of the following: FA, F1 - F9
• Anatomic modifiers must align with ICD-10 diagnosis codes that refer to the place where the procedure was performed. If the diagnosis pertains to the toes, the anatomic modifier should specify which toe.
• Services with anatomic modifiers are subject to multiple procedure reductions (when applicable).

Reimbursement policy updates

KEY POINT: Updates to the Capital’s Reimbursement Policies will occur as outlined below.

Actualizaciones de la lista de autorizaciones previas de una sola fuente

KEY POINT: Updates to the Single source preauthorization list will occur as described below.

Effective March 1, 2026, the following procedure codes will not require preauthorization for Commercial and Medicare Advantage.

Effective April 1, 2026, the following procedure codes will require preauthorization for Medicare Advantage.

Note: Codes that require preauthorization are maintained on the Capital Blue Cross single source preauthorization list located on Capital’s Provider web page.

TurningPoint’s Provider web portal enhancement integrates SmartScan AI

KEY POINT: Effective March 1, 2026, TurningPoint will implement a provider web portal enhancement using SmartScan AI technology, designed to reduce administrative burden and streamline the healthcare experience for Capital’s Provider Network.

TurningPoint is Capital’s delegated vendor for utilization management decisions for Musculoskeletal (MSK) and Select Diagnostic and Surgical Cardiac Services.

Through the integration of SmartScan AI technology, Providers can expect real-time documentation feedback for web portal submissions, allowing them to identify issues upfront and instantly address missing clinical information.

This innovative technology will enable more efficient utilization management decisions, reduce requests for additional information, accelerate turnaround times, and ultimately strengthen the provider experience. SmartScan is optional and supports, but does not replace, the medical review process. It does not make clinical recommendations or assess medical policy. All cases will continue to be reviewed by TurningPoint nurses and physicians after submission.

Capacitación para proveedores

Live training sessions will be offered throughout February and can be scheduled through the TurningPoint Provider Portal. For portal access or support, providers may email portalsupport@turningpoint-healthcare.com or providersupport@turningpoint-healthcare.com or call 1.866.422.0800.

On behalf of Capital Blue Cross, TurningPoint Healthcare Solutions LLC assists in the administration of our [musculoskeletal benefits program and/or cardiac authorization program(s)]. TurningPoint Healthcare Solutions, LLC es una compañía independiente.

Facility Providers

Claims editing system – Recovery room without anesthesia

KEY POINT: Effective for claims processed on or after April 1, 2026, Capital will update our facility outpatient claims editing system to deny reimbursement for post‑anesthesia recovery room services (revenue code 0710) when they are billed without corresponding anesthesia services (revenue code 037x) on the same date of service.

Capital follows nationally accepted standards as outlined in Network Policy FP-01.001 - Correct Coding and Reimbursement Methodology. This requirement follows coding guidelines from the Uniform Billing Editor and the National Uniform Billing Committee (NUBC).

Additionally, providers are reminded that reimbursement for diagnostic testing and radiology services includes routine preparation prior to the service and post-recovery afterward.

New reimbursement policy – FR-02.004, Critical care when patient is discharged to home

KEY POINT: Effective for dates of service on or after April 1, 2026, Capital will deny payment for critical care services billed on emergency department (ED) outpatient claims if the patient is discharged home during the same encounter.

To support this denial, a new reimbursement policy, FR-02.004, “Critical Care When a Patient is Discharged to Home,” will go into effect on April 1, 2026. This reimbursement policy states that Capital will not reimburse critical care services (CPT codes 99291-99292) performed during an ED encounter (revenue code 045x) if the patient is discharged to home (discharge status 01) on the same day.

Patients who require true critical care services are, by definition, critically ill or critically injured, with acute impairment of one or more vital organ systems and a high probability of imminent or life-threatening deterioration. Such patients typically require ongoing intensive monitoring and management, making discharge home during the same encounter inconsistent with the provision of critical care.

Given this definition, it is highly unlikely that a patient would be both critically ill and discharged home from the ED during the same encounter. Therefore:

• Claims for critical care services provided in the ED will be denied if the patient is discharged home during the same encounter.
• Use appropriate ED E/M codes (i.e., 99284 or 99285) if the patient is not critically ill and is discharged home.
• Ensure the documentation accurately reflects the patient’s clinical status and supports the submitted codes.