When you submit an insurance claim, it passes through several stages before being finalized and paid by an insurance payer.
In this guide, we’ll cover:
- Processing an insurance claim
- Getting paid by an insurance payer
- Experiencing a delayed insurance payment or Payment Report
Note: To download a PDF overview of the information in this guide, see How do I get paid for insurance claims?
Processing an insurance claim
The following steps summarize the stages of a claim and things that can prevent successful processing along the way.
You create and submit the claim
- For more information, see Creating and submitting claims.
- When creating a claim, you’ll receive an error message if there’s any missing information that’s necessary to create a claim. For more details, see The minimum information required to create a claim.
The claim is checked for errors
- Once you successfully create and submit a claim, we’ll automatically check it for any common errors that cause claims to be rejected by insurance payers. If an error is found, the claim status will update to Scrub. For more details, see Scrub errors when trying to file insurance claims.
The claim is submitted to the payer
- If no errors are found, our clearinghouse will automatically assign a Clearinghouse Reference # and send the claim to the payer and/or trading partners used by the payer. The claim status will update to Submitted.
The payer receives the claim
- When the claim reaches the payer, they’ll send the Received status. The claim will be automatically reviewed by the payer’s system before being accepted for processing.
The payer rejects the claim
- If any errors are found on the payer’s end at this stage, it’ll be Rejected. For more information on how to handle claim rejections, see Resolving claim rejections.
Important: Claims can only be rejected by an insurance payer. If a payer can’t locate a rejected claim, the claim likely was rejected before processing and didn’t get stored in their system.
The payer accepts the claim
- When a claim is accepted into the adjudication process, many payers will send the Accepted status and a Payer Claim #. Processing times vary by insurance payer, but if you don’t receive any updates on a Received or Accepted claim within 30 days, see What should I do if my claim is stuck in the "Received" or "Accepted" state?
Note: If you don’t have a Payment Report (ERA) enrollment with a payer, the last claim status you’ll receive in SimplePractice will be Received or Accepted. For more details on submitting a Payment Report enrollment, see How do I submit an enrollment to file claims or receive Payment Reports?
The payer denies the claim
- At this point in processing, a claim can be Denied by the payer. For more information on handling denied claims, see Handling claim denials.
The payer processes and finalizes the claim
- If a claim passes through all the previous stages and is processed successfully by the payer, the EOB or Payment Report (ERA) and funds for the payment will be delivered by the payer.
For additional information, see Checking a claim status: The different phases of an insurance claim.
Getting paid by an insurance payer
Once a payer has finalized a claim, they’ll deliver any funds to you directly outside of SimplePractice. SimplePractice isn’t involved in any aspect of the transfer of funds between payer and provider, including setup and delivery.
There are three different payment methods that payers normally use:
Your payment method is usually set up when you get credentialed with a payer. When you begin submitting claims from your SimplePractice account, the payer will continue to pay you via the same method. If you’d like to check or update the payment method you have set up with a payer, we recommend that you reach out to them directly.
Note: If an insurance payer is asking for our Trading Partner ID (or Submitter ID) to establish an EFT connection, please submit a help request.
Experiencing a delayed insurance payment or Payment Report
If you experience any issues with receiving the funds for an insurance payment, such as missing, late, or incorrectly paid funds, you can reach out directly to the insurance payer for assistance.
If you received a Payment Report for an insurance payment but haven’t received the funds from the payer, it’s common for there to be a delay between when a payer sends a Payment Report and when they send the funds for the payment. If you don’t receive the funds within a week of receiving a Payment Report, we recommend that you follow up with the payer.
Payers can also send the funds for an insurance payment before sending the Payment Report. In this situation, there can also be a delay between receiving the funds and the Payment Report. If you don’t receive the Payment Report within a week of receiving the funds, see Investigating missing Payment Reports.