Overview
With PIMSY, track all funding sources, including grant-funded, patient responsibility, and third-party payers with the payer list.
Required Permissions and Prerequisites
- Setting up your payer list is only available on the Desktop platform.
- Please assign the Create, Modify, View, and Delete permissions for the following rule(s):
- Insurance Company
Step-by-Step Instructions
Step 1: Insurance Company Set Up
From the top navigation menu, go to:
Administration > Insurance Co., Payers, Charge Types
Step 2: Create a new Payer
To create a new payer, simply enter the name in the name field on the right panel and click Save. To create another payer, the New button is available after saving the previous entry.
Step 3: Additional Fields
On the right-side panel, enter as much information as possible.
*Address and phone numbers are necessary if electronic secondary claims are filed.
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Important Fields:
- Payer # - obtained by the clearinghouse for professional (CMS-1500) claim formats. This five-digit code routes claims to the appropriate payer.
- UB Payer # - obtained by the clearinghouse for institutional (UB-04) claim formats. This five-digit code routes claims to the appropriate payer.
- Eligibility Payer # - obtained by the clearinghouse for eligibility transactions. This five-digit code identifies which payer you are seeking information from. For ClaimMD users, you may leave this blank. The system will use the Payer # for these transactions.
- Exclude from EDE - when checked, any claims created under this payer will NOT go out electronically on any 837 until this box is unchecked. *Check this box if no payer number is entered.
- Include on statement - controls whether a session billed under this payer should be calculated on a client's statement. Historically, Medicaid programs and other payers that prohibit billing client's directly should have this unchecked.
- Type Indicator - controls which type of funding source is identified on a claim form (equivalent to the radio buttons in box 1 on a CMS-1500 form). Please note, "Additional Charges" automatically go to Patient Responsibility in addition to any self pay charges for the sessions. This is often used when additional charges are added to a session fee (returned check fee, educational materials sold, etc.).
- Coding Requirements - controls which diagnosis code set to allow on the claim (DSM 5/10 after 2015 unless billing an EAP that allows ICD-9).
Step 4: Add Billing Codes (if applicable)
If tracking specific fee schedules for each payer, billing codes can be selected on the bottom half of this window. Additionally, fee schedules can be specified at different levels such as:
- Allowed Amounts by Modifiers - note this does not stamp the modifiers on the claim.
- Allowed Amounts by Title Category - an easy way to group one rate for all masters-level clinicians, interns or doctors.
- Allowed Amounts by User Title - can be used to bill / track expected amounts for an LPC and a different amount for an LMFT, for example.
- Default Amounts - used to bill or expect an amount for this payer that differs from the amount indicated on the company billing code setup
Step 5: Edit Existing Payer
Select the payer to edit on the left-hand side to populate the details on the right. When the information displays, make your edits, then click Save.
Once your information has been added, go to Utilities and then select Refresh Pick Lists to disperse your changes.