Administrative bulletin: 2026-05-001 Updates and new information
Date: May 1, 2026
Topics covered in this administrative bulletin are applicable to:
Professional and facility Providers
- Independent laboratory network expansion and changes.
- EviCore - Clinical Guidelines for Lab Management Program, version 2.0.2026.
- New Reimbursement Policy NR-09.008 – Preventive Medicine Visit with E/M.
Unless otherwise noted, if you have any questions regarding the information in this bulletin, please contact your Provider Engagement Consultant or visit capbluecross.com/wps/portal/cap/provider/pec-look-up and enter your NPI or Tax ID to identify your designated point of contact at Capital Blue Cross.
Professional and facility Providers
Independent laboratory network expansion and changes
- CHIP
- EPO
- FEP PPO
- HMO
- Medicare Advantage HMO
- POS
- PPO
- Traditional and Comprehensive
- Medicare Advantage PPO
KEY POINT: Capital Blue Cross and its affiliates (Capital) have started direct contract negotiations with independent laboratory providers across all lines of business1 for services rendered on or after July 1, 2026. This replaces prior arrangements managed by Avalon Client Services, LLC (Avalon).
As of June 30, 2026, Capital will no longer utilize Avalon’s laboratory network for laboratory services.
Becoming a participating laboratory
Independent laboratories interested in participating with Capital Blue Cross should visit our join our network page for additional information and enrollment instructions.
Adoption of EviCore medical policies
Beginning July 1, 2026, Capital Blue Cross will adopt Evicore’s medical policies for laboratory services (replacing Avalon).
All providers will be required to comply with the medical policy criteria outlined in these policies. This requirement applies to outpatient laboratory services across all provider types, including:
- Independent laboratories.
- Physician's office laboratories.
- Hospital-based laboratories.
Providers are reminded of the importance of verifying member eligibility and benefits prior to rendering services.
Medical policy enforcement
Medical policy enforcement will occur during claims adjudication. Laboratory services that do not meet applicable coverage criteria will be considered non-covered by Capital Blue Cross.
Accessing EviCore clinical guidelines and CPT codes
Providers and office staff are encouraged to review EviCore’s clinical guidelines and associated CPT codes to ensure accurate billing and appropriate utilization.
A link to EviCore’s Clinical Guidelines is available on Capital’s medical policies page.
Disclaimer: Capital Blue Cross contracts with eviCore healthcare (EviCore), an independent company, to review requests for certain services for medical necessity and appropriateness.
1Providers must participate with Traditional Medicare in order to participate in Capital Blue Cross Medicare Advantage products.
EviCore - Clinical Guidelines for Lab Management Program, version 2.0.2026
- CHIP
- EPO
- FEP PPO
- HMO
- Medicare Advantage HMO
- POS
- PPO
- Traditional and Comprehensive
- Medicare Advantage PPO
KEY POINT: Effective July 1, 2026, EviCore will implement Clinical Guidelines for Lab Management Program, version 2.0.2026, for both utilization management and medical policy enforcement through claims editing.
Currently, EviCore serves as Capital’s delegated utilization management vendor for the Molecular Lab Preauthorization Program. Beginning July 1, 2026, Capital will expand this partnership to include medical policy enforcement through claims editing for non-molecular laboratory services and select molecular laboratory services that are not subject to preauthorization. Additional details are available in the article titled Independent Laboratory Network Expansion and Changes.
EviCore's Clinical Guidelines for Lab Management Program, version 2.0.2026, along with the delegated list of services, has been reviewed and approved by Capital Utilization Management committees for implementation effective July 1, 2026. This comprehensive policy manual outlines the clinical criteria that will be applied in both utilization management determinations and medical policy enforcement for Capital members.
The Clinical Guidelines for Lab Management Program have been revised from the prior version as follows.
Clinical Guidelines for Lab Management Program, version 2.0.2026
New clinical guidelines, effective July 1, 2026 |
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Retired clinical guidelines, effective July 1, 2026 |
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Substantive criteria updates for clinical guidelines, effective July 1, 2026 |
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Non-Substantive criteria updates for clinical guidelines, effective July 1, 2026 |
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To preview EviCore’s Clinical Guidelines for Lab Management Program, Version 2.0.2026, select Future, and Capital Blue Cross Lab Management Guidelines Effective 07/01/2026-12/31/2026.
A complete list of CPT/HCPCS codes requiring preauthorization can be found on Capital's single source preauthorization list.
Disclaimer: Capital Blue Cross contracts with eviCore healthcare (EviCore), an independent company, to review requests for certain services for medical necessity and appropriateness.
New Reimbursement Policy NR-09.008 – Preventive Medicine Visit with E/M
- CHIP
- EPO
- FEP PPO
- HMO
- Medicare Advantage HMO
- POS
- PPO
- Traditional and Comprehensive
- Medicare Advantage PPO
KEY POINT: Effective July 1, 2026, Capital will introduce Reimbursement Policy NR-09.008 – Preventive Medicine Visit with E/M.
The new policy establishes guidelines for a problem-oriented evaluation and management (E/M) visit billed on the same date of service as a preventive medicine visit, annual wellness visit, or “Welcome to Medicare” visit.
Capital Blue Cross permits reimbursement for both services when modifier 25 is appended to a separately identifiable problem-oriented E/M visit furnished by the same physician or qualified health care professional on the same date of service.
Under these circumstances, the preventive or wellness visit will be reimbursed at 100 percent of the contracted allowable rate, and the problem-oriented E/M visit will be reimbursed at 50 percent.