REQUIREMENTS:
Immediate (Ongoing): Providers and billing staff must review NPI data in the National Plan and Provider Enumeration System (NPPES) at https://nppes.cms.hhs.gov/ and ensure the following are accurate and current: provider name, mailing address, telephone numbers, fax numbers, medical specialty, all active practice locations where patients are seen and appointments made, NPI Type (Type 1 for individual providers, Type 2 for organizations), and sole proprietor status. Remove any inactive practice locations. Certify all updates in NPPES. Providers are legally required to maintain current NPPES data.
For Professional Providers - Ongoing: When lab services are needed outside the practice, billing and clinical staff must refer patients to in-network laboratories using the Capital Blue Cross MyCare Finder (https://www.capbluecross.com/finder). For referring providers located within Capital Blue Cross' 21-county service area (Adams, Berks, Centre, Columbia, Cumberland, Dauphin, Franklin, Fulton, Juniata, Lancaster, Lebanon, Lehigh, Mifflin, Montour, Northampton, Northumberland, Perry, Schuylkill, Snyder, Union, York counties in Pennsylvania), refer only to labs that participate with Capital Blue Cross. For referring providers located outside this service area, refer to labs participating with the Blue Plan in that geographic service area. Update referral protocols and provider education materials accordingly.
Consequence of Inaction: Failure to maintain current NPPES data may result in inaccurate provider directory information; out-of-network lab referrals may result in claim routing errors or denials based on BlueCard rules.