Administrative bulletin: 2026-05-002 Medicare only

Date: May 1, 2026

Topics covered in this administrative bulletin are applicable to:

Professional and facility Providers

Professional Providers only

Facility Providers only

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

Important information about CMS Risk Adjustment Validation (RADV) audits

  • CHIP
  • EPO
  • FEP PPO
  • HMO
  • Medicare Advantage HMO
  • POS
  • PPO
  • Traditional and Comprehensive
  • Medicare Advantage PPO

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 must meet the aggressive deadlines set by CMS. Therefore, Capital requires a very rapid response from providers, whether the record is available or not. 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

  • CHIP
  • EPO
  • FEP PPO
  • HMO
  • Medicare Advantage HMO
  • POS
  • PPO
  • Traditional and Comprehensive
  • Medicare Advantage PPO

KEY POINT: Updates to the Single Source preauthorization list will occur as described below.

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

Medicare Advantage effective 7/1/2026
Code
Description

J3404

Injection, zopapogene imadenovec-drba suspension, per therapeutic dose.

J9183

Gemcitabine Intravesical System, 225 mg

J9277

Injection, Pembrolizumab, 1 mg and Berahyaluronidase alfa-pmph

J9278

Injection, Carboplatin (Kyxata), 1 mg

Q5161

Injection, denosumab-kyqq (Aukelso/Bosaya), biosimilar, 1 mg

Q5162

Injection, denosumab-nxxp (Bilprevda/Bildyos), biosimilar, 1 mg

Effective June 1, 2026, the following procedure codes ,strong>will not require preauthorization for Medicare Advantage.

Medicare Advantage effective 6/1/2026
Code
Description

E0270

Hospital bed, institutional type includes: oscillating, circulating and Stryker frame, with mattress.

E1250

Lightweight wheelchair, fixed full-length arms, swing-away detachable footrest.

E1260

Lightweight wheelchair, detachable arms (desk or full-length) swing-away detachable footrest.

E1285

Heavy-duty wheelchair, fixed full-length arms, swing-away detachable footrest.

E1290

Heavy-duty wheelchair, detachable arms (desk or full-length) swing-away detachable footrest.

G0219

Pet imaging whole body; melanoma for non-covered indications.

G0252

Pet imaging, full and partial-ring pet scanners only, for initial diagnosis of breast cancer and/or surgical planning for breast cancer (e.g., initial staging of axillary lymph nodes).

T2007

Transportation waiting time, air ambulance and non-emergency vehicle, one-half (1/2) hour increments

Note: Codes that require preauthorization are maintained on the Capital Blue Cross single source preauthorization list located on Capital’s provider web page.

Professional Providers only

Medicare mental health - Provider types

  • CHIP
  • EPO
  • FEP PPO
  • HMO
  • Medicare Advantage HMO
  • POS
  • PPO
  • Traditional and Comprehensive
  • Medicare Advantage PPO

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.

Facility Providers only

Medicare Outpatient Observation Notice (MOON) - Updates

  • CHIP
  • EPO
  • FEP PPO
  • HMO
  • Medicare Advantage HMO
  • POS
  • PPO
  • Traditional and Comprehensive
  • Medicare Advantage PPO

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.