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Getting started with insurance billing

Getting started with insurance billing

 

This guide outlines the process of setting up your account for insurance billing in SimplePractice. By following these steps, you’ll be equipped to file claims and document insurance income through your SimplePractice account. 

Below, we'll cover:


The credentialing process

Becoming credentialed and accepted on a payer’s panel is the first step towards being able to submit claims to an insurance payer. When you join an insurance panel for the first time, you’ll go through the credentialing process, which allows you to become an in-network provider on the insurance panel.

SimplePractice can’t assist with this process, as it’s completed directly with the payer. A good starting point is to visit the payer’s website to locate information about getting credentialed with them.  

Until you’re credentialed with a payer, you won’t be able to submit any claims or enrollments through SimplePractice. Credentialing can take several months, so we recommend beginning the process once you’ve determined you’ll be accepting insurance. 

Important: When submitting credentialing applications, complete them as if you're not using SimplePractice and will be filing claims to that payer directly. You’ll then be set up correctly on the payer's panel. Once paneled, you can enter your license and billing information in your account so you’ll be able to file claims electronically through SimplePractice.


Entering your billing information 

Before entering your billing information in your account, verify what information insurance payers have on file for you and that the information is still up-to-date. Once you’ve verified your information, you can follow the steps below to enter the information in your solo or group practice SimplePractice account. 

Important: The information you enter in the following sections of this guide will automatically populate on your claims. If any required information is missing or incorrect, your claims may be scrubbed or rejected.


Entering solo billing information

When submitting claims as a solo provider, confirm you’ve entered the following information in your account. 

Personal NPI

  • Navigate to Settings > Profile & Security > Clinical
  • Enter your personal (Type 1) NPI Number 

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  • Click Save Information

This NPI will populate in the rendering provider section (box 24j) of your claims. 

Taxonomy Code

A taxonomy code is a ten-character code that is specific to specialty. Certain payers require this code on your claims. To enter this information: 

taxonomycode.simplepractice.clinical.png

  • Click Save Information

This code won't appear directly on your electronic claim, but it's included in the backend data that's sent to the payer. 

Practice Information

To enter your practice information:  

  • Navigate to Settings > My Practice > Details
  • Enter your practice name, practice email, and phone number
  • Click Save Information
  • Toggle to the Locations tab to list your office locations

For more details, see Entering your practice settings

Organization NPI (if applicable)

If you're billing under an organization, instead of under only your individual information, your organization (Type 2) NPI will need to be entered. To do this:

  • Navigate to Settings > Billing & Services
  • Enter your Organization NPI and click Save 
    • If you don't have a group or organization NPI, leave this field blank 

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Tax ID or SSN#

Every NPI is linked to either a Tax ID/TIN or a Social Security number. If you’re unsure which is associated with your NPI, contact the insurance payer for confirmation.

Important: The Tax ID/SSN entered in your account populates in box 25 of your claims and must be the number associated with your billing NPI. The billing NPI is what appears in box 33 of your claims and will be your individual NPI if submitting claims under your personal information, or your organization NPI if submitting claims under your organization information. 

To enter a Tax ID or Social Security number:

  • Navigate to Settings > Billing & Services and enter either your Tax ID or SSN
    • If you’re using a SSN, enter it in this format: XXX-XX-XXXX
    • If you’re using an EIN, enter it in this format: XX-XXXXXXX
    • Click Save

Note: A Tax ID will be listed on other billing documents, such as superbills and invoices. If you're using a SSN and it's entered in the correct format, you'll have the option to hide it from these billing documents.  hideSSN.simplepractice.billinginformation.jpg

Billing provider info 

Boxes 25 and 33 are required on claims and contain important billing information. The set of information used in these boxes must match what’s on file with the payer, or you may experience claim rejections or denials. Box 25 contains your Tax ID or SSN. Box 33 contains your billing provider information. To have this information populate claims:

  • Navigate to Settings > Billing & Services > Insurance
  • Click Edit next to the default Billing provider info 

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  • Choose the Individual or Organization option

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  • Enter your billing provider NPI, taxonomy code, and address 
    • Toggle Use default information from practice settings to automatically populate your name or practice name, billing provider NPI, and Client Billing address from your settings
  • Click Save profile 

Note: If you use different billing information when filing claims to different payers, you can create additional billing profiles. This feature is only available on the Plus plan. For more information, see Managing billing profiles for insurance.  

Service Facility Location (Box 32) 

If your billing address is different from the address where you perform your services, you can confirm with the payer if they require box 32 on claims. Because most payers don’t require it, we recommend excluding it unless explicitly requested that it be included.   

If a payer does request this information: 

  • Navigate to Settings > Billing & Services > Insurance  
  • Under Service Facility Location (Box 32), check Include on Claim Form  

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  • Click Save 

Entering group billing information

When submitting claims as part of a group practice, the following information must be entered.

Personal NPI

If you’re part of a group practice, make sure that every clinician in the account enters their personal (Type 1) NPI. To do this, each clinician can: 

  • Navigate to Settings > Profile & Security > Clinical  
  • Enter their individual NPI Number

  • Click Save Information

This NPI will populate the rendering provider section (box 24j) of your claims. 

Taxonomy Code

Every clinician in a group practice should enter the taxonomy code associated with their personal NPI. To do this, each clinician can:  

This code won't appear directly on the electronic claim, but it's included in the backend data that's sent to the payer. 

Practice Information

To enter your practice information:   

  • Navigate to Settings > My Practice > Details
  • Enter your practice name, practice email, and phone number
  • Click Save Information
  • Toggle to the Locations tab to list your office locations

For more details, see Entering your practice settings

Organization NPI

When billing under an organization, instead of under only your individual information, your organization (Type 2) NPI should be entered. To do this: 

organizationNPI.simplepractice.billinginformation.jpg

  • Click Save

Important: Unlike the individual NPI, which is specific to every clinician’s account, there can only be one organization NPI entered at a time. The organization NPI entered in this section will populate in box 33 on all claims that are submitted under the group practice. 

Tax ID or SSN#

Every NPI is linked to either a Tax ID/TIN or a Social Security number. If you’re unsure which is associated with your NPI, contact the insurance payer for confirmation. 

Important: The Tax ID/SSN entered in your account populates in box 25 of your claims and must be the number associated with your billing NPI. The billing NPI is what appears in box 33 of your claims and will be your individual NPI if submitting claims under your personal information, or your organization NPI if submitting claims under your organization information. 

To enter a Tax ID or Social Security number:

  • Navigate to Settings > Billing & Services and enter either your Tax ID or SSN
    • If you’re using a SSN, enter it in this format: XXX-XX-XXXX
    • If you’re using an EIN, enter it in this format: XX-XXXXXXX
    • Click Save

Note: A Tax ID will be listed on other billing documents, such as superbills and invoices. If you're using a SSN and it's entered in the correct format, you'll have the option to hide it from these billing documents. hideSSN.simplepractice.billinginformation.jpg

Billing provider info

Boxes 25 and 33 are required on claims and contain important billing information. The set of information used in these boxes must match what’s on file with the payer, or you may experience claim rejections or denials. Box 25 contains your Tax ID or SSN. Box 33 contains your billing provider information. To have this information populate claims:

  • Navigate to Settings > Billing & Services > Insurance
  • Click Edit next to the default Billing provider info  

edit.simplepractice.defaultbillingprofile.jpg

  • Choose Organization as the Provider type 

organization.simplepractice.billingprofile.jpg

  • Enter your practice’s name, billing provider NPI, taxonomy code, and address 
    • Toggle Use default information from practice settings to automatically populate your practice name, organization NPI, and Client Billing address from your settings
  • Click Save profile 

Note: If specific clinicians use different billing information when filing claims to different payers, you can create additional billing profiles. This feature is only available on the Plus plan. For more information, see Managing billing profiles for insurance.

Service Facility Location (Box 32) 

If your billing address is different from the address where you perform your services, you can confirm with the payer if they require box 32 on claims.  Because most payers don’t require it, we recommend excluding it unless explicitly requested that it be included.   

If a payer does request this information: 

  • Navigate to Settings > Billing & Services > Insurance  
  • Under Service Facility Location (Box 32), check Include on Claim Form  

box32.simplepractice.billinginformation.jpg

  • Click Save

Setting up your clients’ profiles

Before you can start billing insurance for a client, you'll need to confirm that all of their insurance information is entered properly in their profile. 

You can refer to Setting up insurance billing for your clients for a complete walkthrough of the process.

Important: If the minimum information required to submit a claim is missing from a client’s file, claims will be rejected or scrubbed. For more information, see Filing primary claims.


Enrollments

An enrollment is the process of informing an insurance payer that you plan to submit electronic claims and/or receive electronic Payment Reports (ERAs) through SimplePractice. Many payers don’t require claim filing enrollments, but all payers that we have Payment Report connections with require electronic Payment Report enrollments if you want to receive ERAs. To enroll with a payer: 

  • Navigate to Settings > Insurance
  • Click Search available payers

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  • Follow the steps to fill out the necessary information and submit the enrollment 

For a complete walkthrough of setting up your enrollments, see Submitting enrollments to file claims and receive Payment Reports

Note: Enrollments can take several weeks for payers to accept. While waiting for a claim filing enrollment to be accepted, we recommend that you download claims and file them directly with the payer outside of SimplePractice to avoid delays in reimbursement. For more information, see Creating and printing a CMS 1500 (HCFA) claim form.


Creating and submitting claims

In addition to entering your client's insurance information, the following are required before you can create and submit a claim: 

  • At least one appointment for your insurance client
  • At least one diagnosis code in your client’s profile

Note: You can add multiple diagnoses if needed.

Once those are entered, you’re ready to create and submit a claim. To do this:

  • Navigate to the client’s Overview page 
  • Click the Billing tab
  • Click New > Claim/CMS 1500

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  • Check the box next to the appointment(s) you want to include on the claim

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  • Click Create Claim

Note: You can include up to six appointments/services codes on a single claim. For more information, see Billing insurance with multiple service codes.

  • When you've reviewed the claim, click Submit

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Note: For additional information on creating and submitting claims, see Filing primary claims. If you’d like to create multiple claims at the same time, see Creating batch claims


Tracking your claims

A claim can go through several statuses ranging from Accepted and Paid, to Denied or Deductible. See Checking a claim status: The different phases of an insurance claim for an overview of each status. 

Important: Without an accepted Payment Report enrollment, the furthest a claim status will update in your account is Accepted, which indicates the payer has received it for processing. Claim’s won’t automatically update to Paid, Denied, or Deductible unless you’re enrolled with that payer. For more information, see Enrolling to receive Payment Reports

To check a claim’s status:

  • Navigate to Insurance > Claims 
  • Filter by date, insurance payer, client, or status to locate the claim

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  • Review the Status column, or click View to review the status in the claim 

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  • If the claim was submitted multiple times, you can view the status of each submission by clicking Claim Details > History 

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Note: An Account Owner will also receive an email each time a claim status is updated. Claim status notifications for other team members are dependent on their access levels. For more information, see Team member roles and access levels.


Documenting insurance income 

Insurance payments can be entered manually or automatically.

  • If you’ve submitted a Payment Report enrollment and the enrollment is accepted, insurance payments will be entered automatically for you
  • If your Payment Report enrollment hasn’t been accepted (or if the payer doesn’t provide Payment Reports), you can enter your payments manually

If a Payment Reports enrollment has been accepted:

SimplePractice will automate the bookkeeping for claims with this payer. Insurance payments will be added and client responsibilities updated to match the information on the Payment Report. 

To review a Payment Report (ERA) that was received: 

  • Navigate to Insurance > Claims
  • Locate the claim in question
  • Click View 
  • Click Claim Details 
  • Review the Insurance payment report (ERA) section

paymentreportsection.simplepractice.claimdetails.jpg

Note: For more information, see ERAs in SimplePractice (Payment Reports).

If a Payment Reports enrollment hasn’t been accepted (or if the payer doesn’t provide Payment Reports):

You can add the insurance payments manually. You’ll need the EOB (Explanation Of Benefits) or Electronic Remittance Advice (ERA) you received from the insurance payer. Once insurance payments have been added that account for the claim, the claim status will update to Paid

Note: See Adding insurance payments for a detailed walkthrough of this process.

You can enter an insurance payment in two places in SimplePractice:

  • Navigate to a client’s Overview page 
  • Expand the Insurance tab
  • Click Add Insurance Payment
    • Note: This button will only appear if the client’s Billing Type is set to Insurance

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You can also add insurance payments from your Insurance page. To do this: 

  • Navigate to Insurance > Payments
  • Click Add insurance payment

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Once you're on the Add Insurance Payment page:

  • Enter the Check or Wire number
  • Set the Payment Date that's on the check/wire
  • Enter the Amount of the payment
  • Under All Appointments, filter by date and client to locate the appointment(s) the payment applies to

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To allocate the payment to the appointment(s): 

  • Enter the amount paid by insurance in the Insurance Paid field

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  • If necessary, update the client’s responsibility in the Client Owes field 
  • If there’s a remaining balance, you can click the wheel icon in the Write-Off column to automatically calculate the write-off 
    • This indicates that you won’t be receiving additional reimbursements from the insurance payer
  • Click Save

To review insurance payments that have been added for a claim: 

  • Navigate to Insurance > Claims
  • Locate the claim in question
  • Click View 
  • Click Claim Details 
  • Review the Payment overview section  
    • If an appointment has been fully accounted for, the Status will be Settled 

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Note: For more information using a claim’s Payment overview, see Reviewing the Claim Details page.

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