Administrative bulletin: 2026-11-001 Updates and new information

Professional and facility Providers

Benefit change to acupuncture services for individual accounts ONLY

KEY POINT: Effective January 1, 2027, acupuncture services will no longer be covered under Individual Account products.

Starting January 1, 2027, Acupuncture services will no longer be covered for medically necessary treatment of migraine and tension headache, as well as chronic back and neck pain (longer than three months).

Removing this benefit coverage will ensure Individual Account members purchasing coverage through Pennie.com will have access to full premium subsidy.

This benefit change for 2027 applies only to Individual Account members and does not impact our commercial group coverage.

If you have any questions regarding a member’s benefits, please access “Eligibility and Benefit Inquiry” located under “Patient Registration” on our Provider Portal (Availity Essentials).

CMS Interoperability Provider access API coming January 2027

KEY POINT: As part of the Centers for Medicare & Medicaid Services (CMS) Interoperability initiative, Capital Blue Cross will launch the Provider Access Application Programming Interface (API) in January 2027.

This new capability will provide eligible providers with secure electronic access to certain member health information maintained by Capital Blue Cross, helping support care coordination, continuity of care, and more informed clinical decision-making.

Through the Provider Access API, eligible providers may access available medical and pharmacy claims information. By making relevant information more readily available, the API is designed to help reduce administrative burden and improve the delivery of coordinated care.

Members will be automatically enrolled in Provider Access API data sharing, allowing eligible information to be available to authorized providers when access requirements have been met. Members may choose to opt out at any time and may opt back in at a later date. If a member has opted out, information will not be available through the Provider Access API, even when a provider has a verified treatment relationship with that member.

To protect member privacy, Capital Blue Cross will verify that a provider has an appropriate relationship with the member before information is made available. This relationship may be confirmed through claims history or provider attestation. If access requirements are not met, the member has opted out, or the requested information is not available through the API, information may not be returned.

The Provider Access API is one of several CMS-required interoperability initiatives intended to improve the secure exchange of health information across the healthcare system.

Healthcare data sharing through payer-to-payer API

KEY POINT: Starting January 2027, Capital Blue Cross will offer a secure way for members to share their current health information with providers involved in their care and also share health information from previous health plans.

The new payer-to-payer application programming interface (API) has been developed to support continuity of care, reduce gaps in information, and help ensure relevant member health data is available when needed.

This functionality will benefit providers by providing a more complete view of a member’s care history. Providers benefit indirectly because the receiving payer may have access to a more complete patient history, including prior authorization, claims, encounter, and clinical data. This information can support care coordination, transitions of care, quality activities, and administrative efficiency by potentially reducing duplicate information requests.

Members have the right to choose whether their information is shared through payer-to-payer exchange. To protect a member's choice and privacy, Capital Blue Cross will default members to an opt-out status unless the member elects to opt in and provide their other payer information. This means member information will not be shared through the payer-to-payer API unless the member chooses to participate.

Capital Blue Cross will make a reasonable effort to inform members about their right to opt in, including the purpose of data sharing, the type of information that may be available, and how they can make or update their election. Providers may direct members to contact the Member Services number on the back of their ID card with any questions they may have.

Prior authorization FHIR API coming January 2027

KEY POINT: Beginning in January 2027, Capital Blue Cross will support electronic prior authorization through a Fast Healthcare Interoperability Resources (FHIR) application programming interface (API). This change is in support of the Centers for Medicare & Medicaid Services (CMS) Interoperability and Prior Authorization Final Rule (CMS-0057-F).

What is FHIR?

Fast Healthcare Interoperability Resources, or FHIR, is a standards-based framework for securely exchanging electronic health information. FHIR APIs allow different healthcare systems, including electronic health record (EHR) systems and payer systems, to exchange information using a standardized format.

What is changing?

Under the CMS implementation timeline, Capital Blue Cross must support electronic prior authorization through standards-based application programming interfaces (APIs). As part of Capital's implementation, the Prior Authorization API is intended to make it easier for providers to electronically:

• Determine whether prior authorization is required.
• Identify required documentation.
• Submit prior authorization requests.
• Receive responses to authorization requests.

Prior authorization requirements will not be eliminated. Rather, the API will provide another electronic capability intended to support a more efficient exchange of prior authorization information between provider and payer systems.

What should Providers do now?

Providers should continue to follow Capital Blue Cross's current prior authorization submission requirements. Starting December 1, 2026, preauthorization requests submitted via phone or fax will no longer be accepted, with few exceptions. More information can be found in Capital’s recent provider article: Preauthorization update – Submit requests through ProAuth.

To prepare for the new functionality, providers should:

• Review your current prior authorization submission workflows and identify areas that may be impacted by electronic prior authorization capabilities.
• Coordinate with your electronic health record, clearinghouse, or technology vendor to understand readiness for standards-based prior authorization transactions.
• Ensure staff members responsible for prior authorization understand the upcoming changes to submission, documentation, status inquiry, and denial response processes.
• Continue to submit prior authorization requests through existing channels until new prior authorization functionality is formally communicated and available.
• Monitor future communications for implementation details, training materials, provider education resources, and go-live timelines.
• Providers can also refer to the CMS Interoperability link for additional guidance and details to help them prepare for the upcoming changes to prior authorizations. Interoperability | CMS

Additional information about the FHIR API and implementation will be communicated as it becomes available.

New culturally appropriate care training available

KEY POINT: Americans with Disabilities Act (ADA) training resources are now available on the provider page of CapBlueCross.com.

As part of our commitment to fostering positive interactions between members and providers, we encourage you to explore Welcoming Customers with Disabilities, a training course from the Southeast ADA Center. The course provides information on interacting with and accommodating people with disabilities.

Find this and other useful trainings in the Provider hub of CapBlueCross.com under Resources and Education.

Facility Providers only

Postponed - New Itemized Bill Review (IBR) vendor – Machinify

KEY POINT: The previously announced transition (AB2026-10-001) of Itemized Bill Review (IBR) services from Equian/Optum to Machinify has been postponed.

Capital Blue Cross will provide additional information about the transition and related provider training opportunities in December. Providers should continue to follow current processes until further notice.