AB2026-07-003 Reminders

REQUIREMENTS: By July 1, 2026 (IMMEDIATE - 1 day away): - Billing team must update laboratory claim submission procedures to comply with EviCore medical policies (replacing Avalon policies). Review EviCore Clinical Guidelines and CPT codes on Capital's Medical Policies page. - All laboratory billing staff must understand that non-compliant lab services will be denied at claims adjudication; verify services meet EviCore coverage criteria BEFORE submitting claims. - Update internal protocols to verify member eligibility and benefits prior to rendering all laboratory services (independent labs, physician office labs, hospital-based labs). - For BlueCard Host members: apply eligibility, benefits, and medical policy based on Home Plan criteria per EviCore standards. By August 1, 2026: - Billing team must transition from monitoring USPS mail for closed-claim letters to weekly review of the new Electronic Closed Letter Detail (eCLD) file. - Designate specific staff responsible for accessing eCLD files via Availity Essentials → Capital Payer Space → Secure File Transfer (SFT). - Establish process to review eCLD files weekly and resubmit claims with required information; ensure no claims are overlooked in transition from paper to electronic format. Immediate (Before July 1, 2026): - Billing/credentialing staff must use Capital Blue Cross Provider Maintenance Tool (not Availity's Provider Data Management Tool) for all demographic changes and provider data updates. - DO NOT enter demographic changes in Availity's Provider Data Management Tool—changes entered there are NOT submitted to Capital and will be ignored. - Complete provider data attestation in the Provider Maintenance Tool immediately and establish calendar reminder for 90-day attestation cycle. - During attestation: review all required data per Consolidated Appropriations Act 2021, then either attest accuracy or attest with required updates (provider has 3 business days to complete updates). - Large groups/health systems: continue using roster process directly with Capital. - Medicare Advantage participating providers: ensure NPI data is current in NPPES (National Plan and Provider Enumeration System) to comply with 42 CFR § 422.111(b)(3) CMS requirements for accurate provider directories. CONSEQUENCES OF INACTION: - Laboratory claims not meeting EviCore coverage criteria will be denied. - Failure to attest to provider data will prevent day-to-day system access and ability to make updates in the Provider Maintenance Tool. - Claims submitted with outdated or inaccurate demographic information may be denied or delayed. - Closed-claim letters may be missed if staff do not transition to eCLD file monitoring.