If a claim was submitted to the incorrect payer for a client's insurance plan, you may receive a rejection right away, or the claim may remain in the Accepted state. In either situation, you’ll need to create a new claim so 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
Explaining scenarios that lead to claims being submitted incorrectly
There are two common situations that cause claims to be submitted to the wrong payer.
Client provided the incorrect payer ID
Clients may accidentally enter an incorrect payer ID when completing intake documentation, especially if they recently changed insurance plans without notifying their provider. Claims will continue to populate with the incorrect payer ID until it’s updated in the client’s file. Because payer IDs route claims to specific payers, an incorrect ID prevents the claim from reaching the correct payer.
Client has multiple insurance policies
Clients with primary and secondary insurance require claims to be processed in the correct order, known as Coordination of Benefits (COB). If a claim is submitted to the secondary payer before the primary payer processes it, the result may be rejections, denials, or incorrect payments.
Resolving claims submitted incorrectly
When claims are submitted to the wrong payer, you’ll need to update the client’s insurance information and then create a new claim with the correct payer information.
Updating a client’s insurance information
Begin by updating the client’s insurance details so future claims populate correctly.
Note: To learn more about this workflow, see Setting up insurance billing for your clients.
- Navigate to the client’s Overview page > Edit > Billing and Insurance
- Under Insurance Information, click Edit
Note: If you're unsure which payer to choose, see Adding insurance payers and selecting the correct payer ID.
- If primary and secondary policies were entered incorrectly, select the correct Primary insurance
- For the policy previously marked as primary, select Secondary insurance
- Click Save Client
After saving, the selected payer will populate box 1 of all new claims for this client.
Important: When updating a client’s insurance information, save prior policies as Other and add the new one as Primary insurance. This preserves historical data and allows you to manage insurance payments associated with the old policy.
Creating an updated claim
SimplePractice only allows one primary claim per appointment. Because the Payer ID in box 1 can’t be edited once a claim is created, you must delete the incorrect claim and create a new one with accurate payer information.
Important: Deleting a claim is permanent. All claim information is removed and cannot be recovered. Before deleting, download a copy for your records and save the clearinghouse reference number and claim number. For instructions on storing files, see Uploading a new client file.
To delete a claim:
- Locate the claim that was submitted incorrectly
- Click the trash icon
- Select Yes, delete
Once the incorrect claim is deleted, create a new claim for the appointment. The new claim will populate with the updated insurance information and can be submitted to the correct payer.
Important: New claims automatically display Original in box 22. Leave this field unchanged, as it’s a new claim being submitted to a payer who hasn’t processed it previously.