CommercialAdministrativeHigh impact
AB2026-09-001 Updates and new information
Capital Blue Cross·OB-GYN, Radiology·Provider News
Effective date
Nov 1, 2026
We identified it
Sep 1, 2026
Summary
Capital Blue Cross issued a comprehensive administrative bulletin with four key changes effective November 1, 2026 (or August 1, 2026 for InterQual criteria): (1) Evolent will now administer first-level pre-service medical necessity appeals for High Tech Imaging services for Commercial members, (2) all maternity-related procedure codes must now include HCPCS modifier TH appended (not just E/M codes), (3) InterQual 2026 criteria are now active for medical necessity reviews, and (4) the Theon platform will be down for maintenance September 14-22, 2026. Billing teams must update systems to route high-tech imaging appeals to Evolent and ensure maternity coding compliance by the November effective date.
Action Required
REQUIREMENTS BY OCTOBER 31, 2026: (1) Billing team: Update claims submission workflows to route all first-level pre-service medical necessity appeals for High Tech Imaging (Commercial FI and ASO members) to Evolent via RadMD.com portal, fax (888-656-0701), mail (P.O. Box 3618, Portland, ME 04104), or phone (866-972-9842). Continue routing post-service/claim denial appeals to Capital Blue Cross. (2) Providers and billing team: Update all maternity-related procedure code billing to append HCPCS modifier TH to ALL maternity procedure codes (not just E/M codes), per updated policy FP-01.011. Update EMR templates and billing system validation rules to require TH modifier for maternity codes. (3) Billing team: Update medical necessity review protocols to reflect InterQual 2026 criteria (effective August 1, 2026 for Commercial and Medicare Advantage plans). (4) All staff: Do not use Theon platform from September 14, 2026 at 6:00 AM through September 22, 2026 at 7:00 AM due to scheduled maintenance. Plan workarounds for HEDIS measurement year data refresh. Claims submitted without proper appeal routing or missing TH modifiers on maternity codes will be denied or require rework.