Administrative bulletin: 2026-06-001 Updates and new information

Professional and facility Providers

Claim rejection code C1167I - Submit claim to member’s home plan

KEY POINT: Effective August 1, 2026, Capital Blue Cross will implement a new front-end claim edit that will reject claims submitted to Capital Blue Cross that should have been submitted to the member’s home plan.

The claim rejection code is C1167I, and the rejection reason is “Submit Claim to Member’s Home Plan”.

If you have questions or need assistance, please contact Provider Automation.

Environmental Lead Investigation for CHIP members

KEY POINT: On January 1, 2026, the Pennsylvania Department of Human Services (DHS) issued a requirement that children be covered for in-home screenings for lead exposure. Capital Blue Cross will cover in-home environmental lead investigation for CHIP members with an elevated blood lead level of 3.5 micrograms per deciliter (mcg/dL) and higher.

As of January 1, 2026, Capital has designated Accredited Environmental Technologies (AET) to perform comprehensive lead environmental investigations for CHIP members with a blood lead level of 3.5 mcg/dL.

Requesting an Environmental Lead Investigation:

• For a child with a BLL ≥ 3.5 ug/dl, please complete the AET Environmental Lead Investigation Referral Form, which can be found on our provider portal (Availity Essentials) under the Resources tab > Provider Forms.
• One referral form should be filled out for all children residing in the same household and submitted only once.
• Be sure to include relevant clinical notes.
• Send to AET, Inc. via:
• Fax (610.891.0559) or
• Email (m.mcerlean@aetinc.us).
• A copy of AET’s environmental lead investigation report will be sent to both Capital Blue Cross and to the referring provider to ensure appropriate management of the child’s health condition.

Billing and coverage information:

• AET may submit claims to Capital Blue Cross using procedure code T1029 (Comprehensive environmental lead investigation) with the appropriate primary diagnosis code indicating abnormal lead levels or exposure to lead.
• Capital Blue Cross will cover the environmental lead investigation by AET, at no cost share to the CHIP member.
• Coverage will extend to the child’s primary residence. In shared‑custody situations, up to two residences may be recognized as the child’s primary residence, and an environmental investigation may be performed at both locations.

For any questions about the AET form or investigation process, please call AET at 1.800.969.6238.

Independent laboratory network expansion and changes

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). See additional update below regarding BlueCard.

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.

Process for BlueCard host members:

When providing services to out-of-area BlueCard Host members (i.e., patients who are Members of other Blue Plans), the Host Plan (Capital) will apply eligibility, benefits, and medical policy based on the Home Plan's criteria.

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 on Capbluecross.com.

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.

New electronic distribution of closed-claim letters

KEY POINT: Capital Blue Cross is introducing an updated delivery process to notify providers about claims that do not complete adjudication. This process is designed to improve accessibility and support timely claim reconciliation.

Today, when a claim has certain errors that prevent it from being adjudicated, letters are sent to the provider via USPS mail indicating why the claim was closed and the information needed to resubmit the claim. Effective August 1, 2026, these letters will transition from USPS mail to a weekly electronic release of a new Electronic Closed Letter Detail (eCLD) file.

The release of the eCLD file will function similarly to the current Accept and Reject reports available on our provider portal (Availity Essentials). The file can be accessed via:

• Availity Essentials → Capital Payer Space
• Secure File Transfer (SFT)

The eCLD file explains the rationale for claims that were accepted by Capital but could not be adjudicated and therefore do not display in Availity Claim Status.

Providers should ensure access to Availity and identify staff responsible for reviewing electronic claim files.

Reimbursement policy updates

KEY POINT: Updates to the Capital’s Reimbursement Policies will occur as outlined below.

Single source preauthorization list updates

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

Effective July 1, 2026, the following procedure codes will no longer require preauthorization for Commercial and Medicare Advantage.

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.

Professional Providers only

Capital Blue Cross covering low-cost Humira^® and Stelara^® biosimilars

KEY POINT: Effective May 1, 2026, Capital’s commercial prescription drug plans began covering two biosimilars for Humira^® and Stelara^® when prescribed through Mark Cuban’s Cost Plus Drug Company.

These biosimilars represent a meaningful opportunity to provide cost-saving, clinically equivalent treatment options for people who depend on these medications.

• Adalimumab-fkjp, an interchangeable biosimilar for Humira^®, currently priced at $423 through Cost Plus Drugs (two 40 mg/0.8 mL pens). Humira’s current list price is $8,000 for a 30-day supply.
• Starjemza, an interchangeable biosimilar for Stelara^®, currently priced at $360 through Cost Plus Drugs (one 45 mg or 90 mg/0.5 mL dose) for a 30-day supply. Stelara’s current list price is around $30,000.

How to prescribe:

Providers can submit prescription orders to "Mark Cuban Cost Plus Drug Company"- NCPDP ID #5755167 to take advantage of these two low-cost biosimilar options for their patients with Capital commercial pharmacy benefits.

Facility Providers only

ClaimLogiq Provider Portal is now Machinify

KEY POINT: ClaimLogiq (formerly operating as an Apixio company) has unified under the new name, “Machinify”.

Capital Blue Cross’ Diagnosis Related Group (DRG) vendor, ClaimLogiq, has been consolidated as part of this rebranding effort. This name change reflects a broader organizational branding strategy.

Workflows and processes on the portal will not be impacted.