Boletín administrativo: Actualizaciones y nueva información 2026-03-001

Date: March 1, 2026

Los temas tratados en este boletín administrativo aplican a:

Proveedores profesionales y de centros

Solo proveedores profesionales

A menos que se indique lo contrario, si tiene alguna pregunta relacionada con la información de este boletín, comuníquese con su asesor para proveedores o visite capbluecross.com/wps/portal/cap/provider/pec-look-up e ingrese su NPI o ID tributaria para identificar su punto de contacto designado en Capital Blue Cross.

Proveedores profesionales y de centros

Postponed: Appeals and Medical Records Submissions Through Capital's Provider Portal

  • CHIP
  • EPO
  • FEP PPO
  • HMO
  • Medicare Advantage HMO
  • POS
  • PPO
  • Tradicional e Integral
  • Medicare Advantage PPO

KEY POINT: In order to address technical issues, Capital postponed the February 23, 2026, launch of its enhanced electronic submission process for appeals and medical records through the provider portal (Availity Essentials).

Until the new launch date is announced, Capital will continue to accept appeals by mail or fax. Capital is actively working to implement this functionality as soon as possible. We will share additional updates once Capital confirms the new go-live date for this process.

Evolent – CG-2068 for brain and neck Computed Tomography Angiography (CTA) – New medical policy

  • CHIP
  • EPO
  • FEP PPO
  • HMO
  • Medicare Advantage HMO
  • POS
  • PPO
  • Tradicional e Integral
  • Medicare Advantage PPO

KEY POINT: Effective May 1, 2026, Evolent will begin using the newly adopted medical policy CG-2068 for utilization management of Brain and Neck Computed Tomography Angiography (CTA) combined studies.

Evolent is Capital's delegated vendor for utilization management decisions for high-tech radiology.

As part of the current high-tech radiology review scope, the following new medical policy has been reviewed and approved by Capital's committee for use with our Commercial and Medicare Advantage population.

Comercial y Medicare Advantage Vigencia: 1 de mayo de 2026
New policy

CG-2068 brain and neck Computed Tomography Angiography (CTA)

  • This study examines blood vessels in the brain, neck and cervical regions when medical necessity has been met for both brain and neck vascular imaging.

A link to Evolent's medical policies is available on Capital's medical policies web page.

Actualizaciones de la política de reembolso

  • CHIP
  • EPO
  • FEP PPO
  • HMO
  • Medicare Advantage HMO
  • POS
  • PPO
  • Tradicional e Integral
  • Medicare Advantage PPO

PUNTO CLAVE: Las actualizaciones de las Políticas de reembolso de Capital se realizarán como se describe a continuación.

Actualizaciones de la política de reembolso En vigencia desde el 1 de abril de 2026
Número de la política
Nombre de la política
Tipo de política
Acción
Destacado
Productos afectados

FP-01.001

Metodología de reembolso y codificación correcta

Profesional y centro

Revisado

Added the Uniform Billing Editor as a nationally accepted standards list of resources.

Comercial, CHIP, FEP, Medicare Advantage

Actualizaciones de la política de reembolso Vigencia: 1 de mayo de 2026
Número de la política
Nombre de la política
Tipo de política
Acción
Destacado
Productos afectados

NR-30.026

Servicios de telesalud

Professional Providers

Revisado

Licensed Genetic Counselors can bill for code 96041 for telehealth POS.

Comercial, CHIP

NR-30.022

Reembolso de servicios de asesoramiento en genética

Professional Providers

Revisado

To include reimbursement for code 96041, Medical genetics and genetic counseling services, each 30 minutes of total time provided by the genetic counselor on the date of the encounter, in the telehealth setting.

Comercial, CHIP

Actualizaciones de la lista de autorizaciones previas de una sola fuente

  • CHIP
  • EPO
  • FEP PPO
  • HMO
  • Medicare Advantage HMO
  • POS
  • PPO
  • Tradicional e Integral
  • Medicare Advantage PPO

PUNTO CLAVE: Las actualizaciones de la Lista de autorizaciones previas de una sola fuente se realizarán como se describe a continuación.

Effective May 1, 2026, the following procedure codes will require preauthorization for Commercial and Medicare Advantage.

Comercial y Medicare Advantage Vigencia: 1 de mayo de 2026
Códigos

C7568

C7569

C7570

C7571

22526

22527

Note: Codes that require preauthorization are maintained on the Capital Blue Cross Single source preauthorization list located on Capital's provider web page.

TurningPoint – Expansion of cardiology program – Delegated services and medical policies

  • CHIP
  • EPO
  • FEP PPO
  • HMO
  • Medicare Advantage HMO
  • POS
  • PPO
  • Tradicional e Integral
  • Medicare Advantage PPO

KEY POINT: Effective May 1, 2026, TurningPoint will begin providing utilization management services for an expanded set of cardiac procedure codes.

TurningPoint is Capital's delegated vendor for utilization management decisions for select diagnostic and surgical cardiology services.

Effective May 1, 2026, Capital will expand our current partnership with TurningPoint and broaden the existing cardiology utilization review scope to include the following additional procedures:

  • Cardiac catheter ablations.
  • Percutaneous transcatheter cardiac defect closures.

The delegated list of services and applicable medical policies that fall under the expanded review scope for utilization management through TurningPoint have been reviewed and approved by Capital committees.

Effective May 1, 2026, the following procedure codes will require preauthorization through TurningPoint for Commercial and Medicare Advantage.

Códigos

93580

93653

93654

93656

To support the expanded Cardiac review scope, the following new medical policies are effective May 1, 2026.

TurningPoint Commercial and Medicare Advantage new policies

CA-1020 Cardiac Catheter Ablation

  • Coverage criteria for minimally invasive procedure used to treat abnormal heart rhythms (arrhythmias).

CA-1021 Percutaneous Transcatheter Cardiac Defect Closure

  • Coverage criteria for surgical procedure commonly used to treat heart defects.

Note: Codes that require preauthorization are maintained on the Capital Blue Cross Single source preauthorization list located on Capital's Provider web page. A link to access TurningPoint's medical policies is available on Capital's medical policies web page.

TurningPoint- Expansion of Musculoskeletal (MSK) program – Delegated services and medical policies

  • CHIP
  • EPO
  • FEP PPO
  • HMO
  • Medicare Advantage HMO
  • POS
  • PPO
  • Tradicional e Integral
  • Medicare Advantage PPO

KEY POINT: Effective May 1, 2026, TurningPoint will begin providing utilization management services for an expanded set of Musculoskeletal (MSK) procedure codes.

Currently, TurningPoint is Capital's delegated vendor for utilization management decisions for a limited scope of Musculoskeletal (MSK) services, primarily involving the large joints (e.g., hip, knee, spine, select shoulder procedures).

Effective May 1, 2026, Capital will expand our current partnership with TurningPoint and broaden the existing MSK utilization review scope to include the following additional clinical review categories:

  • Ankle procedures (e.g., fusions, replacements, revisions)
  • Elbow procedures (e.g., replacements, revisions)
  • Wrist procedures (e.g., fusions, replacements, revisions)
  • Shoulder procedures (e.g., arthroscopy and arthrotomy procedures)
  • Implantable infusion pumps (e.g., implantations, replacements, revisions, electronic analysis, infusion pump systems)
  • Spinal cord neurostimulators (e.g., insertions, removals, revisions, implant devices)

The comprehensive list of services and applicable medical policies that fall under the expanded review scope for utilization management through TurningPoint, have been reviewed and approved by Capital committees.

Effective May 1, 2026, the following procedure codes will require preauthorization through TurningPoint for Commercial and Medicare Advantage.

Ankle procedures

27700

27702

27703

27704

27860

27870

29892

29899

Elbow procedures

24160

24164

24300

24360

24361

24362

24363

24365

24366

24370

24371

 

 

 

 

 

Wrist procedures

25332

25441

25442

25443

25444

25445

25446

25449

25800

25805

25810

25820

25825

 

 

 

Shoulder procedures

23040

23044

23100

23101

23105

23106

23107

29805

29806

29807

29819

29820

29821

29822

29823

29824

29825

29828

 

 

 

 

 

 

Implantable infusion pumps

62350

62351

62360

62361

62362

62365

62367

62368

62369

62370

C1772

C1891

C2626

E0782

E0783

E0785

E0786

 

 

 

 

 

 

 

Spinal cord neurostimulators

63650

63655

63661

63662

63663

63664

63685

63688

0784T

0785T

C1767

C1778

C1787

C1816

C1820

C1822

C1897

L8679

L8680

L8681

L8682

L8683

L8685

L8686

L8687

L8688

L8689

L8695

 

 

 

 

To support the expanded MSK review scope, the following new medical policies are effective May 1, 2026.

TurningPoint Commercial and Medicare Advantage new policies

OR-1021 Total Ankle Replacement

  • Coverage criteria for surgical replacement of ankle joint utilized to treat pain and disability when non-operative treatments have failed.

OR-1030 Ankle Fusion

  • Coverage criteria for surgery to fuse the bones of ankle into one piece to relieve pain from arthritis and joint deformity.

OR-1022 Elbow Replacement

  • Coverage criteria for surgical replacement of the elbow joint utilized to treat pain and disability when non-operative treatments have failed.

OR-1033 Wrist Replacement

  • Coverage criteria for surgical replacement of wrist joint utilized to treat pain and disability when non-operative treatments have failed.

OR-1032 Wrist Fusion

  • Coverage criteria for surgery to fuse the small bones of the wrist to each other or to the bones in forearm to relieve pain and stabilize the joint.

OR-1015 Spinal Cord Stimulators

  • Coverage criteria for implantable devices used to exert electrical signals to the spinal cord to manage chronic pain.

OR-1034 Implantable Infusion Pumps

  • Coverage criteria for implantable infusion pumps surgically implanted under the skin to provide continuous or intermittent drug infusion on a long-term basis.

Note: Codes that require preauthorization are maintained on the Capital Blue Cross Single source preauthorization list located on Capital’s provider web page. A link to access TurningPoint’s medical policies is available on Capital's medical policies web page.

TurningPoint – OR-1039 for thermal intradiscal procedures – New medical policy

  • CHIP
  • EPO
  • FEP PPO
  • HMO
  • Medicare Advantage HMO
  • POS
  • PPO
  • Tradicional e Integral
  • Medicare Advantage PPO

KEY POINT: Effective May 1, 2026, TurningPoint will begin using the newly adopted medical policy OR-1039 for utilization management of Thermal Intradiscal Procedures (TIPs) for Commercial members.

TurningPoint is Capital's delegated vendor for utilization management decisions for Musculoskeletal (MSK) services.

As part of the current MSK review scope, the new medical policy OR-1039 for Thermal Intradiscal Procedures (TIPs) has been reviewed and approved by Capital's committee for use with our Commercial population.

Effective May 1, 2026, the following new medical policy will apply.

New policy

OR-1039 Thermal Intradiscal Procedures

  • Thermal intradiscal procedures (TIPs) involve applying direct heat/energy through the skin(percutaneous) via a catheter or probe to the disc in between the back bones to treat back pain.
  • These procedures are considered investigational and require further evidence to establish safety and effectiveness over existing treatments.

A link to access TurningPoint's medical policies is available on Capital's medical policies web page.

Solo proveedores profesionales

Provider Appointment Availability Survey coming in May

  • CHIP
  • EPO
  • FEP PPO
  • HMO
  • Medicare Advantage HMO
  • POS
  • PPO
  • Tradicional e Integral
  • Medicare Advantage PPO

KEY POINT: The Provider Appointment Availability Survey will be released in mid-May.

The annual Provider Appointment Availability Survey will be released in May 2026. This short survey is vital for understanding the availability of appointments offered to our members. You will receive the survey through the Availity document center and by email. You may respond using either method. In some cases, we may also conduct outreach by telephone.

Additional instructions about the survey will be released in an upcoming bulletin. For full guidelines regarding appointment availability, please refer to Capital's Provider Manual – Chapter 1, Unit 4, Member access to physicians and facilities.