Administrative bulletin: 2026-10-001 Updates and new information

Professional and facility Providers

FP-01.008 – Services Not Separately Reimbursed: Codes added

KEY POINT: New codes have been added to reimbursement policy FP-01.008 – Services Not Separately Reimbursed effective January 1, 2027.

Effective January 1, 2027, Capital Blue Cross will no longer reimburse for the following codes for Commercial and Medicare Advantage.

New! Capital Blue Cross resources simplify attestations, credentialing, and demographic updates

KEY POINT: Capital Blue Cross has developed new Quick Reference Guides (QRGs) to support providers in efficiently completing the credentialing process, demographic updates, and attestations.

Capital Blue Cross has developed new Quick Reference Guides (QRGs) to support providers in efficiently completing the credentialing process, demographic updates, and attestations.

Regular demographic updates and attestations play an important role in maintaining accurate provider directory information, supporting member access to care, and meeting regulatory standards. Attestations and demographic updates are required on a regular cadence.

The following newly developed quick reference guides provide detailed instructions.

• Provider Demographic Updates QRG
• Provider Attestations QRG
• Provider Credentialing Overview QRG

Visit the Provider Hub to access these resources and additional tools designed to simplify your administrative processes.

Preauthorization update – Submit requests through ProAuth

KEY POINT: Providers are reminded to submit preauthorization requests through ProAuth. Effective December 1, 2026, preauthorization requests submitted via phone or fax will no longer be accepted. Additionally, for multiple services, all applicable CPT codes must be included as separate lines on the preauthorization request at the time of submission.

As a reminder, Capital Blue Cross requires preauthorization requests to be submitted through the ProAuth tool on Capital’s Provider portal (Availity Essentials) to support enhanced provider communications and CMS interoperability initiatives.

Exceptions

Phone or fax submissions will be considered only in the following circumstances:

• A documented portal-related issue exists, and a valid Availity support ticket number is provided.
• The request is for a Neonatal Intensive Care Unit (NICU) patient, in accordance with PA Act 81.

Advantages of electronic submission

• Faster processing of requests.
• Real-time status visibility.
• Access to reviewer notes.
• Access to determination letters.

Accessing the ProAuth tool

From the Availity Essentials home page, click on Patient Registration in the top left corner, then drop down to Authorizations and Referrals.

Providers seeking preauthorization for multiple services must include all applicable CPT codes as separate lines on the preauthorization request at the time of submission. Codes requiring preauthorization can be found on Capital Blue Cross’s Single source list.

Capital Blue Cross will review and render determinations only for the CPT codes entered. CPT codes listed in clinical documentation, medical records, attachment notes, letters of medical necessity, or other supporting documents, but not entered as authorization lines, will not be reviewed or authorized.

Facility Providers only

New Itemized Bill Review (IBR) vendor – Machinify

KEY POINT: Capital Blue Cross will transition our Itemized Bill Review (IBR) services from Equian/Optum to Machinify effective December 1, 2026. To support this change, Machinify will offer provider trainings.

Capital Blue Cross is committed to continuously improving our claims review processes and enhancing operational efficiency. As part of this commitment, Machinify will become the designated vendor responsible for conducting itemized bill reviews on behalf of Capital Blue Cross. As a result, providers may receive itemized bill review requests, correspondence, and determinations from Machinify rather than Equian/Optum.

To prepare for the transition, we ask that providers:

• Ensure applicable staff are aware of this vendor transition.
• Review and respond promptly to requests from Machinify to avoid processing delays.
• Review and update email addresses and/or fax numbers as needed.

We are working closely with both Equian/Optum and Machinify to ensure a seamless transition and minimize disruption to provider operations and claims processing activities.

Upcoming machinify training opportunities

To help providers prepare for this transition, Machinify will offer three live training sessions via Microsoft Teams. The training will provide an overview of the Machinify Provider Portal, including how to:

• Access and navigate the portal.
• Respond to Itemized Bill Review requests.
• Review findings letters.
• Submit disputes and supporting documentation.

Save the date for one of the following training sessions:

• Tuesday, December 1, 2026, from 10:00 AM to 11:00 AM (EST)
• Tuesday, December 1, 2026, from 2:00 PM to 3:00 PM (EST)
• Thursday, December 3, 2026, from 11:00 AM to 12:00 PM (EST)

Additional details, including registration information and meeting links, will be available in November.

New reimbursement policy FR-02.005 – Room and Board Unbundling

KEY POINT: Effective January 1, 2027, Capital Blue Cross will implement a new facility reimbursement policy, FR-02.005 – Room and Board Unbundling.

The new policy provides guidance for billing medical and surgical services, supplies, and equipment associated with a facility stay and reinforces the itemized billing reviews currently in place.

Under this policy, certain services, supplies, equipment, and routine facility expenses are considered part of the primary room and board charge, facility charge, or other applicable service charges. These costs must be included in the institution's overall accommodation or facility fees and are not separately reimbursable. Providers should not bill these charges separately.