Administrative bulletin: 2026-07-003 Reminders

Professional and facility Providers

Independent laboratory network expansion and changes

KEY POINT: Capital Blue Cross and its affiliates (Capital) are conducting 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 is no longer utilizing Avalon’s laboratory network for laboratory services.

Becoming a participating laboratory

Independent laboratories interested in participating with Capital Blue Cross should visit the Join Our Network page for additional information and enrollment instructions.

Adoption of EviCore medical policies

Capital Blue Cross has adopted Evicore’s medical policies for laboratory services (replacing Avalon) beginning July 1, 2026.

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.

Provider data attestation and demographic updates

KEY POINT: Provider demographic changes must be submitted using the Capital Blue Cross Provider Maintenance and Facility Maintenance tools in our provider web portal, and NOT through Availity’s Provider Data Management tool. Providers are also reminded to review and attest to their data once every 90 days.

Attestation process:

The Provider Maintenance Tool will display the due date and allow providers to review all data that is required in accordance with the Consolidated Appropriations Act, 2021. Once the data has been reviewed, you have two options:

• Attest that the data is accurate.
• No further action is required.
• Attest but updates are required.
• Provider has 3 business days to log back in and update information.

Attestation must be completed as outlined; otherwise, the system will not allow providers to move forward with other day-to-day activities or updates on the tool.

Large groups or health systems should continue using the roster process currently in place directly with Capital.

Demographic change process:

Important Note: On the Availity Essentials home page, you may see a dropdown for Availity’s Provider Data Management Tool. Changes entered into this tool ARE NOT submitted to Capital Blue Cross. Instead, please follow instructions below to ensure you are on the Capital Blue Cross Payer Spaces page.

1. Log into Availity. From the home page, select Capital from the Payer Spaces dropdown.
2. Click on the Applications tab.
3. From here, choose Provider Maintenance to submit your Professional demographic changes electronically, or choose Facility Maintenance to submit your Facility demographic changes electronically.

Helpful user guides

Capital has created these helpful user guides to walk you through the process.

• Facility provider maintenance guide
• Professional provider maintenance guide

Note to Medicare Advantage Par Providers: Per 42 CFR § 422.111(b)(3), the Centers for Medicare & Medicaid Services (CMS) require Medicare Advantage Organizations to have accurate provider directories, allowing Medicare beneficiaries the ability to identify and locate providers. Therefore, CMS encourages all providers to keep their National Provider Identifier (NPI) data current with the National Plan and Provider Enumeration System (NPPES).