Claims coding and lookup

Quick reference guide

What is the Claims Coding and Lookup Application?

• The Claims Coding and Lookup application enables users to view previously submitted live claims for both Commercial and Medicare Advantage members to obtain detail regarding clinical editing results.
• Users can also enter ‘hypothetical’ claims for Commercial and Medicare Advantage members and view results of clinical editing by using the coding verification tabs.

Why use Claims Coding and Lookup Application?

• Accurate and complete coding of claims to the highest level of specificity will result in appropriate and timely processing as well as reduce the need for resubmission of corrected claims.
• Code(s) reported on claims must be valid for the date of service on which the service or supply is performed or distributed.

Where is the Claims Coding and Lookup Application located?

Providers are able to access the Claims Coding Lookup application on the Capital Blue Cross Payer Space via Availity, our provider web portal.

Coding Verification Tabs

Using either the Professional or Facility Claim Entry tabs, users can view claim results of clinical editing prior to submitting claims to Capital Blue Cross.

• Since claims entered through this application are considered ‘hypothetical’, the response does not guarantee payment or denial of a similarly billed live claim.
• The system will issue errors, based on Correct Claim Coding edits (CCI), to inform the user when there is unrecognizable data entered into a field.
• Coding Verification tabs can be used to determine the relationships of codes entered and is not a disclosure of the entire adjudication process.
• A charge amount must be entered when using the Claim Entry tab selections.

Claim Lookup Tab

Viewing a previously submitted and finalized claim via the Claim Lookup Tab allows you to view claim edit details.

To search for a claim:

• Click on the Claim Lookup tab.
• Select the form type (Professional or Facility).
• You must use the Capital Blue Cross assigned Practitioner or Facility ID numbers for the claim in question. You have the option to then either enter the adjudicated claim number, or the Patient ID and Date of Service.
• Once a claim is located, view the Disclosure field for edit details.
• The Claim results can also be created into PDF format for saving purposes. On the top right-hand corner of the page, you will see “Export to PDF”.