Boletín administrativo: Actualizaciones y nueva información 2026-08-001

Proveedores profesionales y de centros

Availity training for electronic appeals submission

KEY POINT: Availity Essentials offers online training demos to support providers with Capital’s electronic appeals process.

Early this year, Capital Blue Cross launched a new electronic appeals process, allowing providers to submit appeals and upload supporting medical records and documentation through Capital’s provider portal (Availity Essentials).

To help providers navigate this process, online training is available through the Availity platform. To access the training, follow the steps below:

• Inicie sesión en Availity Essentials.
• From Availity’s home page, click on the Help and Training drop-down menu in the upper right corner, then choose Get Trained.
• Click Catalog.
• Using the Search function, type “Appeals.”
• Scroll down to the Availity Appeals -Training Demo. (Select the Non-Payer Specific course).

When submitting electronic appeals, providers are reminded to submit complete and accurate appeal requests with all required documentation at the time of submission to help avoid delays or dismissals.

Use of Availity Essentials supports more efficient processing, improved status tracking, and reduced administrative follow-up.

New reimbursement policy – FP‑01.009 Venipuncture and Lab Services

KEY POINT: Effective for dates of service on or after October 1, 2026, Capital Blue Cross will implement reimbursement policy FP-01.009 Venipuncture and Lab Services.

Under this policy, venipuncture services (CPT codes 36415, 36416, 36591, and 36592) will be reimbursed only when the collected specimen is sent to an external laboratory and the corresponding clinical laboratory test is billed by that outside facility.

When a clinical laboratory test is performed in the provider's own office or facility and the provider bills both the laboratory test and the venipuncture service for the same member on the same date of service, the venipuncture will not qualify for separate reimbursement. Venipuncture services are considered incidental to the laboratory testing performed and are included in the reimbursement for the laboratory service.

Reimbursement policy retirement – NR-05.601 Global Obstetrical Allowance and Concurrent Services

KEY POINT: Capital Blue Cross is updating its maternity services reimbursement policies.

To prepare for industry-wide changes to CPT^® maternity services coding, Capital Blue Cross has implemented policy FP 01.011 Obstetrical Maternity Services, effective September 1, 2026, to align with visit-based service reporting (see AB2026-07-001).

As part of this transition, policy NR 05.601 Global Obstetrical Allowance and Concurrent Services will be retired effective December 31, 2026.

Prior to September 1, 2026, (global-based billing) – For patients presenting for their first prenatal visit after the confirmation of pregnancy:

• Providers should continue to follow NR 05.601 Global Obstetrical Allowance and Concurrent Services, as well as obstetric coding guidance from the American College of Obstetricians and Gynecologists (ACOG) and the American Medical Association (AMA) when billing prenatal, delivery, and postpartum services.

On or after September 1, 2026, (visit/service-based billing) – For patients presenting for their first prenatal visit after confirmation of pregnancy:

• Providers should follow FP 01.011 Obstetrical Maternity Services and report prenatal, delivery, and postpartum services at the individual visit or service level rather than as a single global obstetrical package.

Actualizaciones de la lista de autorizaciones previas de una sola fuente

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

Effective October 1, 2026, the following procedure code(s) will require preauthorization for Medicare Advantage.

Effective September 1, 2026, the following procedure code(s) will not require preauthorization for Commercial.

Effective September 1, 2026, the following procedure code(s) will not require preauthorization for Medicare Advantage.

Effective September 1, 2026, the following procedure code(s) will not require preauthorization for Commercial and Medicare Advantage.

Nota: Los códigos que requieren autorización previa se mantienen en la lista de autorizaciones previas de una sola fuente de Capital Blue Cross que se encuentra en la página web de proveedores de Capital.