Boletín administrativo: Actualizaciones y nueva información 2026-04-001

Date: April 1, 2026

Los temas tratados en este boletín administrativo aplican a:

Proveedores profesionales y de centros

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

Apelaciones y presentaciones de registros médicos a través del portal para proveedores de Capital

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

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

Nos complace compartir una actualización importante que mejorará su experiencia al trabajar con Capital.

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

¿Qué significa esto para usted?

  • Una forma más sencilla y segura de enviar apelaciones y documentos de respaldo, con un procesamiento más rápido y un mejor seguimiento.
  • Tiempos de respuesta mejorados al permitir que toda la información requerida se envíe por adelantado, lo que evita que falten documentos y disminuye los problemas técnicos.
  • Menos consultas sobre el estado y menos apelaciones desestimadas debido a formularios incorrectos o incompletos.

Capacitación sobre apelaciones electrónicas

Para garantizar una transición sin problemas, se recomienda a los proveedores que se familiaricen con el proceso. Se puede hallar la capacitación en Availity Essentials siguiendo los pasos que se indican a continuación:

  • En la página de inicio, haga clic en el menú desplegable Help and Training (Ayuda y formación), en la esquina superior derecha.
  • Seleccione Get Trained (Capacitarse).
  • Use the Search function, click Catalog, and type “Appeals”.
  • Drop down to Availity Appeals -Training Demo. (Seleccione el curso Non-Payer Specific, Específico para no pagadores).

Beginning May 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.

CAS codes required on COB claims - New front-end claim edit

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

KEY POINT: Effective June 1, 2026, Capital Blue Cross will implement a new front‑end claim edit requiring Claim Adjustment (CAS) codes on all Coordination of Benefits (COB) claims submitted electronically.

When Capital Blue Cross is the secondary payer, submitted claims must include: other insurance payer information, payment amounts, and Claim Adjustment Reason Codes (CARCs) as outlined below.

CAS reporting on COB electronic claims
Claim type
Información obligatoria
Ubicación

837P and 837I claim level

Other insurance payer information
  • Loop 2330B other payer name
  • NM1 segment - Other payer name
  • DTP segment – Remittance data

Payment amounts and Claim Adjustment Reason Codes (CARCs)
  • Loop 2320 other subscriber information
  • SBR segment – Other subscriber information
  • CAS segment - CAS02 Claim Adjustment Reason Code
  • CAS segment - CAS03 adjustment amount
  • OI segment – Other insurance coverage information

837P and 837I line level

Other insurance payer information
  • Loop 2330B other payer name
  • NM1 segment - Other payer name
  • DTP segment – Remittance data

Payment amounts and Claim Adjustment Reason Codes (CARCs)
  • Loop 2430 line adjudication information - Line Adjustment
  • CAS segment - CAS02 Claim Adjustment Reason Code
  • CAS segment - CAS03 adjustment amount

Claims missing any required COB data will reject starting June 1, 2026.

Reject code: S4005A – COB data required: Claim submitted without other payer adjustment reason code.

If you have questions or need assistance, please contact Provider Automation.

Multi-factor authentication for Prime MPS GatewayPA portal

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

KEY POINT: Effective March 28, 2026, Prime began requiring Multi Factor Authentication (MFA) for all users accessing the Medical Pharmacy Solutions (MPS) GatewayPA Portal to place or view an authorization.

If users experience any difficulties logging in, an MFA Log-In Reference Guide is available under Resources on the GatewayPA home page.

Additional questions may be directed to the Prime Provider Relations mailbox.

National Drug Code (NDCs) are required for professional and outpatient claims

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

KEY POINT: Effective June 1, 2026, Capital Blue Cross will implement a new reimbursement policy to align with billing requirements for all applicable drugs and biologics billed on professional (CMS‑1500/837P) and outpatient facility (UB‑04/837I) claims.

New Reimbursement Policy: FP-01.006 – NDCs are Required for Professional and Outpatient Claims.

National Drug Codes (NDCs) must be reported on all applicable drug claim lines as follows:

  • In 11-digit format with appropriate leading zeros.
  • Valid and active on the date of service.
  • Maps correctly to the HCPCS code reported.
  • Reported with correct NDC unit of measure (UN, ML, GR, F2).
  • Reported with accurate quantity.

* Do not include the N4 qualifier within the 11-digit NDC field.

NDC reporting locations
Claim type
Ubicación

837P

Loop 2410

837I

Nested loop 2410

CMS-1500

Box 24A (shaded)

UB-04

Form locator 43

Reimbursement will be considered for drugs and biologicals only when claims meet the following criteria.

  • Contains an NDC in locations indicated above.
  • The NDC is valid, active, and crosswalks to the HCPCS code.
  • The NDC is reported in 11-digit format.
  • Correct Quantity or Unit of Measure (UOM) is included.
  • Must bill the drug-specific HCPCS code when one exists.

These requirements align with FDA drug listing standards and CMS NDC reporting rules to support accurate reimbursement and product identification.

NDC to be billed for the product actually administered.

Providers must report the NDC from the inner package or vial actually administered, not the outer carton. Por ejemplo:

  • A box contains 10 single-dose vials → bill the NDC printed on the vial.
  • A vial requiring reconstitution → bill the NDC of that vial, not diluents or ancillary items.
    • For kits and co-packaged products
    • Use outer package NDC when:
      • The FDA assigns one unified NDC for the entire kit or co-packaged product. Components are intended to be dispensed and used together as one product. Ejemplo:
        • Drug and required diluent manufactured and listed as a single product.
        • Diagnostic or therapeutic kits with an assigned kit level NDC.
    • Use the inner package NDC when:
      • The kit contains components with their own individual FDA-assigned NDCs.
      • Only one component is administered.
      • Components are not FDA-identified as a unified co-packaged product.
    • For repackaged drugs
    • Only NDCs assigned by registered, FDA-listed repackagers may be billed.
    • Providers must submit the repackager’s NDC, not the original manufacturer’s NDC.
    • For compound drugs
    • Each ingredient must be billed on its own claim line and must include:
      • Valid 11 digit NDC.
      • Correct UOM and quantity.
      • Ingredient-specific HCPCS code (or NOC code when applicable).
      • Prescription or Compound Drug Association Number (if required).

Claims will deny if ingredients are combined into one line or if any NDC is missing or invalid.