Administrative bulletin: 2026-04-001 Updates and new information

Professional and facility Providers

Appeals and medical records submissions through Capital's Provider portal

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.

We’re excited to share an important update that will enhance your experience when working with 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.

What this means for you

• A simpler, more secure way to submit appeals and supporting documents, with faster processing and better tracking.
• Improved response times by allowing all required information to be submitted upfront, reducing missing documents and technical issues.
• Fewer status inquiries and fewer appeals dismissed due to incorrect or incomplete forms.

Electronic appeals training

To ensure a smooth transition, providers are encouraged to familiarize themselves with the process. Training is available through Availity Essentials using the steps below:

• From the home page, click on the Help and Training drop-down menu in the upper right corner.
• Select Get Trained.
• Use the Search function, click Catalog, and type “Appeals”.
• Drop down to Availity Appeals -Training Demo. (Select the Non-Payer Specific course).

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

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.

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

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

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.

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. For example:

• 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. Example:
• 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.