Boletín administrativo: 2026-05-002 Medicare only

Proveedores profesionales y de centros

Important information about CMS Risk Adjustment Validation (RADV) audits

KEY POINT: Please see the important information below regarding CMS Risk Adjustment Data Validation (RADV) audit compliance and what Capital Blue Cross providers need to know.

Confidential: Prepared at the Direction of Legal Counsel: Attorney-Client and Work-Product Privileged Communication

The Centers for Medicare and Medicaid Services (CMS) will continue an aggressive plan to catch up on Risk Adjustment Data Validation (RADV) audits. As part of these audits, CMS requires Capital to confirm in-scope patients' medical records support the diagnoses or ICD-10 codes submitted via claims.

Along with other payors, Capital Blue Cross (Capital) was selected for a Payment Year (PY) 2020 RADV audit and anticipates that it will be selected for other RADV audits in the future. Therefore, applicable participating providers in Capital's Medicare Advantage network(s) will receive requests for medical records, and are contractually required to provide the requisite medical records for Capital to respond to CMS's record requests.

The following provides some additional tips regarding these requests for records.

• Capital debe cumplir con los plazos exigentes establecidos por los CMS. Por lo tanto, Capital exige una respuesta muy rápida por parte de los proveedores, ya sea que el registro esté disponible o no. Capital expects providers to respond to a record request by either promptly providing the requisite records or by notifying Capital immediately if the requested records are not available.
• Providers must follow CMS’s 10-year record retention requirements to ensure that they are able to provide the required records for the relevant audit periods prescribed by CMS.

Capital offers several ways to send requested medical records, including:

1. 1. By secure portal, upload: https://capitallinxportal.virtixhealth.com/
2. 2. By secure email (using your secure email system), with Capital Blue Cross CMS-RADV Medical Records in the email subject line. Please use this file naming convention: (MemberID_Firstname_Lastname_RADV_DOSYEAR).

Note: If emailing medical records through secure email, please call 610.820.2626 or email us at CBC.RiskAdjustmentRADV@CapBlueCross.com to provide the passcodes to us separately.

1. 3. By secure fax: 484.531.9366.

We appreciate your attention and compliance in returning the requested medical records as soon as possible.

Single source preauthorization list - Medicare updates

PUNTO CLAVE: Las actualizaciones de la lista única de autorizaciones previas se realizarán como se describe a continuación.

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

Effective June 1, 2026, the following procedure codes ,strong>will not 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.

Solo proveedores profesionales

Medicare mental health - Provider types

KEY POINT: Providers are reminded of the mental health practitioner types recognized by Medicare to provide mental health services.

Capital complies with Section 4121 of the Consolidated Appropriations Act (CAA), 2023, Medicare Physician Fee Schedule for the services rendered and billed by licensed marriage and family therapists (LMFTs), licensed mental health counselors (LMHCs), licensed clinical social workers (LCSWs), and licensed professional counselors (LPCs).

For more information, see CMS's Marriage and Family Therapists and Mental Health Counselors FAQs.

Solo proveedores de centros

Medicare Outpatient Observation Notice (MOON) - Updates

KEY POINT: CMS has issued a revised Medicare Outpatient Observation Notice (MOON). Providers must transition to the new form.

The Office of Management and Budget approved the updated Medicare Outpatient Observation Notice (MOON) for 3 years, expiring February 28, 2029.

CMS improved the notice’s readability and design. The new version is available in English and Spanish and can be found on CMS’s BNI webpage.