Overview
Submitting claims via an 837 file in PIMSY streamlines the billing process and enables efficient transmission to insurance payers. Below is an example of what one of those claims looks like.
Required Permissions and Prerequisites
- This article is in reference to our Desktop application
- Please ensure you have the appropriate profile assigned for billing
Example of an 837 Claim
ISA*00* *00* *ZZ*3900 *ZZ*3900 *131213*1455*^*00501*000000050*1*P*:~
GS*HC*3900*98999*20131213*1455*1*X*005010X222A1~
ST*837*000000050*005010X222A1~
BHT*0019*00*50*20131213*1455*CH~
The previous four lines are hard-coded and represent the clearinghouse, submitter ID, and EDE file information.
NM1*41*2*YOURTHERAPIST*****46*405970~
Agency that is submitting claims. Also hardcoded into the 837. This is housed in the EDE type in the Pick List Management.
PER*IC*BILLING SERVICE*TE*2032700097~
Account Holder that signed up and transmits the files to the clearinghouse. Also hardcoded in the file.
NM1*40*2*CLAIMMD*****46*431420764000000~
HL*1**20*1~
PRV*BI*PXC*101YP00000X~
Billing Provider’s Taxonomy Number (pulled from Organization Management)
NM1*85*2*YOURTHERAPIST*****XX*1234567890~
Billing Agencies Name and NPI pulled from Organization Management
N3*987 THOMAS STREET~
Billing Agencies Address, pulled from Organization Management
N4*DOWNTOWN*NC*782450199~
Billing Providers City, State, and nine digit zip (required for 5010 format)
REF*EI*440123444~
Billing providers tax ID number, pulled from the Organizational Management tab in PIMSY
HL*2*1*22*0~
(Claim Information Begins)
SBR*P*18*3378414******CI~
This information is pulled from clients chart. The “18” is the clients relationship to the insured (numbers are hard coded and generated based on what relationship is chosen on client's insurance tab. Following are Insurance Group number “3378414” (If Applicable). All entered on the Insurance tab in the Clients chart
NM1*IL*1*PLUM*MARY****B*U111111111~
Patients Last name, First name, Middle initial, then Insurance number. Pulled from clients chart (Clients Detail tab)
N3*490 MAIN STREET ~
Clients Address, which is pulled from the clients details page in PIMSY N4*PROSPECT*NC*28701~ Clients City, State, and zip
DMG*D8*19740131*F~
Clients Date of birth in YYYYMMDD format, followed by clients Gender. Information is located in the client’s details page of the clients chart
NM1*PR*2*CIGNA*****PI*62308~
Payer Information claim is sent to. This the insurance that is set up under “Administration” tab, then “Insurance Co/Payers/Charge Types”. Followed by insurance type indicator (Private Insurance), followed by Payer Id number
N3*900 COTTAGE GROVE ROAD~
Insurance Company Street Mailing Address, pulled from Administration menu, then Insurance Co/Payers/Charge Types
N4*CHATTANOOGA*TN*67002~
Insurance Company City, State, Zip, pulled from Administration menu, then Insurance Co/Payers/Charge Types
CLM*INV-130*140.00***11:B:1*Y*A*Y*I*P~
Claim Information Begin. “INV” Is the Invoice number that PIMSY assigns the note. This is found in the invoicing screen. The next segment is “140.00” which represents the TOTAL CHARGE for the entire claim. If there are any add-on services for this claim, you will see the total amount listed here on this line. The next number listed is the location code where the service was rendered. The next letter is hard coded. The next digit represents if it is new claim (“1”) or resubmission or corrected “7” claim (which can be done by checking the resubmission box in the invoicing screen in PIMSY, or a Void ("8"). The Next Digit is Yes or No if the user who performed the service has a signature on file. This is pulled from the user’s chart, and the documents thread. The next four digits are hard coded
REF*EA*P-C-40~
This line represents the clients number that is generated when entering clients in the system. This is found on the client's detail page on the Client's Chart
NTE*ADD*1630~
This line represents the time the service was performed. Pulled from the note
HI*ABK:F341~
This line represents the Primary Diagnosis pulled from the diagnosis tab on the clients chart. “ABK” is for Primary. If the setting in PIMSY is set to send out multiple diagnosis, then you may also see “ABF” on this line following the “ABK” which represents additional diagnosis
NM1*82*1*SMITH*JANE****XX*1234567890~
Rendering Provider. This is who performed the service (or who released the note (depending on how you have your setting in PIMSY). Followed by the provider’s NPI. This pulls the name from the note, then pulls that provider’s NPI from the providers chart under the User’s tab in Administration
PRV*PE*PXC*101YP00000X ~
The rendering provider’s Taxonomy Number, which pulls the name from the note, then looks to the providers rates/codes tab to take the Taxonomy code under the User’s tab in Administration. If no taxonomy code is listed here, it will look to the default billing code set up to see if there is a Default Taxonomy code listed there.
LX*1~ SV1*HC:90837*140.00*UN*1***1~
Indicates the Service Line. The third segment shows the billing code (90837), then the amount being billed. Followed by “Units” of “1”. Pulled from the invoice. The last number is the service diagnosis code pointer. In this example it's pointed to the diagnosis in the primary spot.
DTP*472*D8*20241209~
This line is the date of service in YYYYMMDD format pulled from the note
REF*6R*INV-130~
Invoice assigned by PIMSY when the note was generated
HL*3**20*1~
This line is hardcoded and signals the end of the “Loop” or claim
SE*31*000000050~
This line represents the number of lines in the EDE file. It also contains the EDE ID Number. This is automatically generated
GE*1*50~
This line also contains the EDE ID Number
IEA*1*000000050~
This line also contains the EDE ID Number and is the last line in the form