Boletín administrativo: 2026-02-002 Recordatorios

Proveedores profesionales y de centros

Provider change notifications

KEY POINT: All provider organizational changes and notifications must be communicated to Capital via email: notifications@capbluecross.com.

Capital Blue Cross is always looking for opportunities to improve our relationship with you, our providers. We have made it easier for our providers to communicate organizational changes to Capital. Using our new email, notifications@capbluecross.com, will allow providers one place to notify us of changes to your organization related to acquisitions, mergers, and other business changes. This also provides Capital with a centralized location for gathering and tracking these changes.

Please note:

• Any notifications sent outside this mailbox could cause delays if action is needed.
• This email is for organizational changes only and does not apply to provider demographic changes (e.g., provider address changes, fax and phone number changes, office hours, adding and terminating practitioners, etc.).
• If your agreement with Capital requires you to send these types of notices to a specific person at Capital, using this mailbox is an acceptable alternative to that requirement.

Provider data attestation and demographic updates

KEY POINT: Provider demographic changes must be submitted using the Capital Blue Cross Provider maintenance and Facility maintenance tools in our provider web portal, and NOT through Availity's Provider Data Management tool. Providers are also reminded to review and attest to their data once every 90 days.

Attestation process:

The Provider maintenance Tool will display the due date and allow providers to review all data that is required in accordance with the Consolidated Appropriations Act, 2021. Once the data has been reviewed, you have two options:

• Attest that the data is accurate.
• No se requiere ninguna acción adicional.
• Attest but updates are required.
• Provider has 3 business days to log back in and update information.

Attestation must be completed as outlined; otherwise, the system will not allow providers to move forward with other day-to-day activities or updates on the tool.

Large groups or health systems should continue using the roster process currently in place directly with Capital.

Demographic change process:

Important note: On the Availity Essentials home page, you may see a dropdown for Availity's Provider Data Management Tool. Changes entered into this tool ARE NOT submitted to Capital Blue Cross. Instead, please follow instructions below to ensure you are on the Capital Blue Cross Payer Spaces page.

1. Log into Availity. From the home page, select Capital from the Payer Spaces dropdown.
2. Click on the Applications tab.
3. From here, choose Provider Maintenance to submit your Professional demographic changes electronically, or choose Facility Maintenance to submit your Facility demographic changes electronically.

Helpful user guides

Capital's Facility Provider maintenance guide and the Provider maintenance guide offer step-by-step instructions and helpful tips to support you in completing all required demographic updates efficiently and correctly.

Note to Medicare Advantage par Providers: Per 42 CFR § 422.111(b)(3), the Centers for Medicare & Medicaid Services (CMS) require Medicare Advantage Organizations to have accurate provider directories, allowing Medicare beneficiaries the ability to identify and locate providers. Therefore, CMS encourages all providers to keep their National Provider Identifier (NPI) data current with the National Plan and Provider Enumeration System (NPPES).

Professional Providers only

CAQH attestation – Reminder

KEY POINT: Providers must ensure their Council for Affordable Quality Healthcare (CAQH) application is updated at least every 120 days.

Providers can remain compliant by:

• Reviewing your CAQH application regularly.
• Ensuring all information is up to date and accurate.
• Completing the re-attestation process every 120 calendar days.

Failure to re-attest within the 120-day timeframe may result in delays in credentialing, contracting, and/or network participation.

More information is available by visiting CAQH for Providers or by calling 888.600.9802. Your cooperation in adhering to this requirement is greatly appreciated.

Payment integrity audit concepts – Medicare inpatient-only procedures

KEY POINT: Providers are reminded that 'inpatient-only' procedures, as designated by CMS, and any additional services rendered on the same date of service are not eligible for reimbursement when performed in an outpatient place of service.

The Centers for Medicare and Medicaid Services (CMS) has a designated list of 'inpatient-only' services that are not appropriate to be furnished in a hospital outpatient department due to the nature of the procedure. CMS identifies these services with an Outpatient Prospective Payment System (OPPS) status indicator of "C" in Addendum B.

There is no payment under the OPPS for services that CMS designates to be 'inpatient-only' services, and CMS does not pay for any additional services provided on the same day as the 'inpatient-only' procedure. Providers should take care to ensure that 'inpatient-only' procedures are provided to members only in an inpatient place of service, and that the procedure is permitted to be billed for the setting in which the service was rendered.

New graduates requesting to join the network

KEY POINT: Requirements for new graduates requesting to join the Capital Blue Cross network.

All new graduates must have completed all their post-graduate education prior to submitting their request to join the network. In addition, providers must also have been granted admitting privileges with at least one participating hospital that is designated as their primary admitting facility (for physicians that admit patients) or have other arrangements for hospitalization that have been approved by Capital Blue Cross prior to submitting their request to join the network.

Physicians who are not required to have admitting hospital privileges are anesthesiologists, allergists, emergency room physicians, dermatologists, pathologists, and radiologists.

Provider appointment availability standards

KEY POINT: Providers are reminded to review Appointment Availability Standards within the Provider Manual.

Appointments must be available to members from the provider or the covering practice within the recommended guidelines listed in the Provider manual - Chapter 1, Unit 4.