If a claim was submitted to the incorrect payer for a client's insurance plan, you may receive a rejection right away, or you may find that the claim gets stuck in the Accepted state. In either case, you'll need to create a brand new claim so that it can be submitted to the correct payer.

In this guide, we'll cover:

• Explaining scenarios that lead to claims being submitted incorrectly
• Resolving claims submitted incorrectly
  
• Correcting insurance payments that were added in error
  

Explaining scenarios that lead to claims being submitted incorrectly

There are two situations we see that often cause claims to be submitted incorrectly for the client’s insurance plan.

Client provided the incorrect payer ID

When filling out intake documentation, clients may accidentally enter an incorrect payer ID that’s not associated with their insurance provider. This often happens when clients switch to a new insurance plan without notifying their provider of the change.

In these cases, claims will continue to populate with the payer ID that was initially entered in the client’s file. Payer IDs are used to route the claims to the insurance payer, so an incorrect payer ID will prevent the claim from reaching the correct insurance payer for processing.

Client has multiple insurance policies

We also see scenarios where clients have both primary and secondary insurance policies. In these cases, the order in which their claims need to be processed matters and is referred to as their Coordination of Benefits (COB). If a claim is submitted directly to the secondary insurance payer without first being processed by the primary payer, it can lead to rejections, denials, or accidental payments.

Resolving claims submitted incorrectly

When claims are submitted incorrectly, they'll need to be corrected and resubmitted to the payer. In this section, we’ll review how to update a client’s insurance information and create a new claim to submit to the correct payer.

Updating a client’s insurance information

To resolve claims submitted incorrectly, you’ll first need to update the client’s insurance information.

Note: To learn more about this process, see Setting up insurance billing for your clients.

To do this:

• Navigate to the client’s Overview page > Edit > Billing and Insurance
• Under Insurance Information, click Edit

Note: If you're unsure which payer to select, see Adding insurance payers and selecting the correct payer ID.

• If the client’s primary and secondary insurance policies were entered out of order, determine which is their correct primary policy and select Primary insurance

• For the the policy that was previously marked as primary, select Secondary insurance
• Click Save Client

After this process is completed, the payer that’s selected will populate box 1 of all claims for this client moving forward.

Important: When updating a client’s insurance information, save their prior information as Other and add the new one as Primary insurance. This way, you’ll have a record of it and will still be able to add, edit, and delete insurance payments that have appointments associated with the old insurance.

Creating an updated claim

In SimplePractice, only one primary claim can exist for an appointment. When a claim is submitted to an incorrect payer, you’ll first need to delete the existing claim, as the Payer ID field in box 1 can’t be edited. This is because backend data is attached to a claim when it’s originally created. Once deleted, you can create a new claim for the date of service that'll have the correct backend data tied to it so it can be billed to the correct payer. 

Important: Deleting claims is a permanent action. When claims are deleted, all information listed in them is deleted from our database and can't be recovered. To keep this information for your records, we recommend downloading and saving a claim to a client's profile before deleting it. See Uploading a new client file for steps on how you can store this. When deleting a claim, it’s recommended that you save the clearinghouse reference number and claim number for your records as well.

To delete a claim:

• Navigate to the client’s Billing page
• Select the claim that was submitted incorrectly
  • It can be found next to its corresponding appointment on the client’s Billing tab, as well as under Billing documents

• Click the trash icon

• Select Yes, delete

After the original claim is deleted and the appointment is no longer linked to it, create a new claim for the client. This new claim will populate with the client’s updated insurance information and can be submitted for processing.

Important: All new claims are automatically marked as Original in box 22. You’ll need to leave this field as-is because it’s a new claim going to a payer who hasn’t seen it yet.

To create and submit a new claim:

• Navigate to the client’s Billing page
• Update the date range filter to include the correct appointment
• Click New > Claim/CMS1500

• Once reviewed and ready, click Submit to file the claim with the correct insurance payer

Correcting insurance payments that were added in error

Rather than rejecting or denying a claim that was submitted incorrectly, insurance payers may issue a payment in error. Once the error is noticed, payers often recoup incorrect payments by either requesting a check or withholding the overpaid amount from a future payment.

If you’ve been paid for a claim that was submitted to an incorrect insurance payer, we recommend proactively reaching out to the payer directly to clarify their preferred method of recouping the overpayment. This will help to avoid any complications down the line.

If the payer withholds the overpaid amount from a future payment, this will be reflected in any payment reports (ERAs/EOBs) that are received. No additional action is needed on your part.

If the payer is requesting a check, you can record this retraction in your account by adding a negative insurance payment. To do this:

• Click Add Insurance Payment in the client’s file

• Enter the negative amount of what was initially paid in the Amount and Insurance Paid fields