Administrative bulletin: 2026-09-001 Updates and new information
Date: September 1, 2026
Topics covered in this administrative bulletin are applicable to:
Professional and facility Providers
- Evolent: High tech imaging medical necessity appeals.
- FP-01.011 Global Obstetrical Maternity Service Policy update.
- InterQual® criteria 2026.
- Theon platform upcoming maintenance.
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
Evolent: High tech imaging medical necessity appeals
- CHIP
- EPO
- FEP PPO
- HMO
- Medicare Advantage HMO
- POS
- PPO
- Traditional and Comprehensive
- Medicare Advantage PPO
KEY POINT: Effective November 1, 2026, Evolent will administer first-level pre-service medical necessity appeals for High Tech Imaging services for Commercial members.
High tech imaging medical necessity appeals: (appeal of a preauthorization denial): Evolent will review and issue determinations for medical necessity appeals related to High Tech Imaging services for Commercial FI and ASO members
- First-level pre-service (appeal of a preauthorization denial): Evolent will review and issue determinations for medical necessity appeals related to High Tech Imaging services for Commercial FI and ASO members.
- First-level post-service (appeal of a claim denial): Capital Blue Cross will continue to process medical necessity appeals related to High Tech Imaging services for Commercial FI and ASO members.
Evolent appeal submission methods include:
- Evolent's portal ‐ RadMD.com
- Fax: 888.656.0701
- Mail: P.O. Box 3618, Portland, ME 04104
- Phone: 866.972.9842
FP-01.011 Global Obstetrical Maternity Service Policy update
- CHIP
- EPO
- FEP PPO
- HMO
- Medicare Advantage HMO
- POS
- PPO
- Traditional and Comprehensive
- Medicare Advantage PPO
KEY POINT: Capital Blue Cross has issued an update to Reimbursement policy FP-01.011 – Global Obstetrical Maternity Service effective November 1, 2026.
Providers must append HCPCS modifier TH to all maternity-related procedure codes, not just evaluation and management (E/M) procedure codes, as previously communicated in AB2026-07-001.
The updated policy also includes guidance for billing encounters related to conditions or services provided during pregnancy that are not associated with labor management.
InterQual® criteria 2026
- CHIP
- EPO
- FEP PPO
- HMO
- Medicare Advantage HMO
- POS
- PPO
- Traditional and Comprehensive
- Medicare Advantage PPO
KEY POINT: Effective August 1, 2026, Capital Blue Cross transitioned to 2026 InterQual criteria.
Capital uses InterQual® criteria for many of its Commercial and Medicare Advantage medical necessity utilization reviews. Effective August 1, 2026, Capital transitioned from InterQual 2025 to InterQual® 2026 criteria to determine medical necessity for select medical/surgical and behavioral health services (including preauthorization for acute inpatient care), and long-term acute care hospital (LTACH).
Theon platform upcoming maintenance
- CHIP
- EPO
- FEP PPO
- HMO
- Medicare Advantage HMO
- POS
- PPO
- Traditional and Comprehensive
- Medicare Advantage PPO
KEY POINT: Beginning September 14, 2026, at 6:00 AM, Capital Blue Cross will perform maintenance on the Theon platform.
Capital Blue Cross will be performing maintenance on the Theon platform beginning Monday, September 14 at 6:00 AM. The system will be unavailable until Tuesday, September 22, at 7:00 AM. Please refrain from using Theon during this timeframe. During the maintenance, we will convert to Healthcare Effectiveness Data and Information Set (HEDIS®) Measurement Year (MY) 2026 specifications and perform a data refresh. Following the maintenance, you will be able to resume business as usual.