Boletín administrativo: 2026-05-005 Recordatorios

Proveedores profesionales y de centros

Certificación de datos de proveedores y actualización de información demográfica

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. También se les recuerda a los proveedores que deben revisar y validar sus datos una vez cada 90 días.

Proceso de certificación:

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:

• Certificar que los datos son precisos.
• No se requiere ninguna acción adicional.
• Certificar, pero hacer las actualizaciones correspondientes.
• El proveedor tiene 3 días hábiles para volver a ingresar y actualizar la información.

La certificación debe realizarse como se describe; de lo contrario, el sistema no permitirá a los proveedores continuar con otras actividades diarias ni actualizaciones de la herramienta.

Los grupos grandes o los sistemas de salud deben continuar utilizando el proceso de lista vigente directamente con Capital.

Proceso de cambio de datos demográficos:

Important Note: On the Availity Essentials home page, you may see a dropdown for Availity’s Provider Data Management Tool. Los cambios introducidos en esta herramienta NO se envían a Capital Blue Cross. En cambio, siga las instrucciones detalladas a continuación para asegurarse de estar en la página de Espacios del pagador (Payer Spaces) de Capital Blue Cross.

1. Inicie sesión en Availity. En la página de inicio, seleccione Capital en el menú desplegable Espacios del pagador (Payer Spaces).
2. Haga clic en la pestaña Applications (Solicitudes).
3. Desde allí, elija Maintenance Provider (Mantenimiento del proveedor) para enviar los cambios de datos demográficos del profesional electrónicamente, o seleccione Facility Maintenance (Mantenimiento del centro) para enviar los cambios de datos demográficos del centro electrónicamente.

Helpful Guides to completing demographic updates can be found on the Resources tab.

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. Por lo tanto, los CMS recomiendan a todos los proveedores mantener sus datos de Identificador Nacional de Proveedores (NPI) actualizados en el Sistema Nacional de Enumeración de Planes y Proveedores (NPPES).

Medically Unlikely Edits (MUE) – Claims editing system update and billing reminder

KEY POINT: Capital is implementing system updates to ensure MUEs are applied consistently and accurately across all provider types. These enhancements correct identified gaps and align our process as communicated in earlier administrative bulletins*.

An MUE for a HCPCS / CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.

There are three (3) types of MUE Adjudication Indicators (MAI)

• MAI 1 – MUE limit applied at the claim line level. Appropriate use of modifiers will enable reporting of medically necessary units of service greater than the MUE limit.
• MAI 2 – MUE limit applied based on date of service. CMS has not identified any instances where a higher value is payable.
• MAI 3 – MUE limit applied based on date of service. In rare or unusual circumstances, additional units may be considered for reimbursement. These MUE denials may be appealed with supporting documentation.

MUE limits applied at the claim line level (MAI 1)

When units of service exceed the MUE value, report as follows:

• Units reported on each line must not surpass the limit.
• When billing multiple lines for the same service, append modifiers such as 76, 77, 91, RT, or LT as appropriate.

Claim lines with units that exceed the MUE value are not eligible for payment.

MUE limits applied based on date of service (MAI 2 or 3)

When reporting units of service for the same date that exceed the MUE value, report as follows:

• Report units up to the MUE on one line.
• Report units over the MUE value on the subsequent line.

This allows the units of service up to the MUE value to be eligible for payment.

Referencias:

FP 01.001 Correct Coding and Reimbursement Methodology

Administrative Bulletin: 2022-06-001

Administrative Bulletin: 2022-12-001

Administrative Bulletin: 2025-05-002

Preventive breast cancer screenings

KEY POINT: This bulletin provides guidance on additional imaging covered as preventive when it is recommended to complete the preventive breast cancer screening process or to address findings identified on the initial preventive screening mammogram.

In alignment with state and federal mandates, Capital Blue Cross’ preventive coverage includes mammographic examinations for covered persons age 40 and older (and for those under 40 when recommended by the member’s physician).

For women at average risk of breast cancer, preventive coverage also includes additional imaging—such as mammography, MRI, and ultrasound—and, as of January 1, 2026, pathology evaluation (biopsy) when it is recommended to complete the preventive screening process or to address findings identified on the initial preventive screening mammogram.

Providers should ensure that all additional screening services and any pathology evaluation performed as part of the initial preventive breast cancer screening to determine malignancy are billed as preventive until a diagnosis is established.

Additionally, as of January 1, 2026, for both breast and cervical cancer screenings, coverage will include patient navigation services and follow-up, when applicable, to support adherence to screening recommendations based on the patient’s assessed need for navigation support.

Providers are encouraged to review the Preventive Services Health Coverage Guidelines, available under “Education and Manuals” in the Provider Library on our provider web portal, to ensure members receive eligible preventive services with no cost-share when applicable.

Additional resource guidance:

Patient Navigation Services for Breast and Cervical Cancer Screening Recommendations | WPSI

Solo proveedores profesionales

Certificación de CAQH - Recordatorio

PUNTO CLAVE: Los proveedores deben asegurarse de que su solicitud ante el Consejo de Atención Médica de Calidad Asequible (CAQH, por sus siglas en inglés) se actualice al menos cada 120 días.

Los proveedores pueden cumplir con la normativa de la siguiente manera:

• Revisando su solicitud de CAQH regularmente.
• Garantizando que toda la información esté actualizada y sea precisa.
• Completando el proceso de recertificación cada 120 días calendario.

Si no se vuelve a certificar dentro del plazo de 120 días, se pueden producir retrasos en la acreditación, la contratación y/o la participación en la red.

More information is available by visiting CAQH For Providers or by calling 888.600.9802. Agradecemos enormemente su cooperación en el cumplimiento de este requisito.

Hemophilia clotting factor billing requirements and unit reporting: Claims editing system updates

KEY POINT: Effective June 1, 2026, Capital will be enhancing our claims editing system to better support the application of correct coding guidelines for Hemophilia factor products.

Providers are reminded to ensure the quantity billed (QB) accurately reflects the number of international units (IU), milligrams (mg), or micrograms (mcg) administered, as defined in the HCPCS code descriptor.

Following conversion of the administered dosage into billable units, claims must be assessed to ensure compliance with correct coding guidelines. Multiple claim lines are required when:

• The units of service exceed the line level MUE limit (MAI 1) assigned to that HCPCS code, or
• The units exceed the system maximum of 9,999 units per claim line.

For the same HCPCS code and the same date of service, no single claim line may exceed either the MUE limit or the 9,999 unit system limit maximum. If total units exceed either limit, the units must be divided and billed across multiple claim lines, following all applicable modifier and coding rules.

MUE limits applied at the claim line level (MAI 1)

When units of service exceed the MUE value, report as follows:

• Units reported on each line must not surpass the limit.
• When billing multiple lines for the same service, append modifiers such as 76, 77, 91, RT, or LT as appropriate.

Claim lines with units that exceed the MUE value are not eligible for payment.

Ejemplo:

J7214 (Injection, Factor VIII/von Willebrand factor complex) has an MUE of 7500 units per claim line.

For details on FP 01.001 – Correct Coding and Reimbursement Methodology, refer to Capital’s Reimbursement Policies.

Additional information is available via the CMS Practitioner Services MUE Table.

Nuevos graduados que solicitan unirse a la red

PUNTO CLAVE: Requisitos para los nuevos graduados que solicitan unirse a la red de Capital Blue Cross.

Todos los nuevos graduados deben haber completado toda su educación de posgrado antes de presentar su solicitud para unirse a la red. Además, los proveedores también deben haber recibido privilegios de admisión en al menos un hospital participante designado como su centro de admisión principal (para médicos que admiten pacientes) o tener otros acuerdos de hospitalización que hayan sido aprobados por Capital Blue Cross antes de enviar su solicitud para unirse a la red.

Los médicos que no están obligados a tener privilegios hospitalarios de admisión son anestesiólogos, alergólogos, médicos de sala de emergencias, dermatólogos, patólogos y radiólogos.

Solo proveedores de centros

Urgent and emergent admission notification

KEY POINT: Providers are reminded to notify Capital Blue Cross within appropriate timeframes for urgent and/or emergent inpatient admissions.

Urgent and/or emergent inpatient admissions require notification to Capital within 2 business days from admission. Failure to notify Capital may result in denial.

More information can be found in the Capital Blue Cross Provider Manual, Chapter 5, Unit 1 – Concurrent Review.