How SimplePractice can help you file online insurance claims

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As a software company with online claim filing features we're committed to getting your claims processed by your payer. 

  • We can ensure that your electronic connection with payers gets set up and maintained so that payers are able to receive your claims.

We are not professional billers so there are some things that may arise during the course of online claim filing that we won't be able to help with. 

  • We cannot help with billing issues. This means we cannot help figure out how your rejected or denied claims should be coded in order for your payer to reimburse you. We do, however, provide help center articles and videos to help share the information about billing issues that we learn from professional billers and other SimplePractice members.

 

In this Article

1) Services we offer
2) Services we do not offer
3) How to resolve billing issues with a payer
4) How to transition to online claim filing
5) Common coding errors that cause rejected or denied claims
    5a) An invalid Subscriber ID
    5b) An invalid billing code
    5c) Invalid Provider (Entity) Information
6) We can refer you to a professional biller

 

Services we offer

As a software company with online claim filing features we're commited to getting your claims processed by your payer. To do this, these are the services we offer:

  • A simplified Enrollment application for claim filing and payment report enrollments
  • Enrollment services to help you establish your claim filing and payment report connection with the payer
  • The infrastructure enabling you to submit claims to payers
  • Claim scrubbing to help you catch common coding errors before you submit an incorrectly coded claim
  • Claim status updates delivered to you by the payer
  • Email, and in-app notifications for processed claims
  • A translation of the electronic messages delivered by payers with rejected, denied, and accepted claims
  • A display of the payment report (EOB) information delivered to you by the payer after the payer accepts your payment report enrollment application. (Be aware that some payers occasionally do not deliver full adjudication information for electroinically processed claims)

Coming soon:

  • Eligibility verification before claims are submitted

 

Services we do not offer

As a software company that delivers all the technical features to help you process claims, we cannot advise you on billing issues. This means we cannot tell you the correct way to code your online claim. 

These are the billing issues that only the payer or a professional biller will be able to help you with:

  • We do not offer guidance on Denied claims. A denied claim is one that the payer has adjudicated and determined that they will not reimburse. Generally this is due to the details of your contract with the insurance company. This is a billing issue between you and the payer.
  • We do not offer instructions on the proper way to code your unique claims for submission or resubmission. We auto-fill CMS claim forms in the way that most payers require. If this is not the correct coding for your particular payer, then it is your responsibility to research the issue and code the claim correctly. Payer representatives are there to help you out with this.
  • We do not offer EFT enrollments. However, in the future we plan to offer this enrollment service.

 

How to resolve billing issues with a payer

Payers frequently have different coding requirements from one online system to another and even different coding requirements between mail-in claims and online claims. 

For some providers, when switching to a new online claim filing system, there is an adjustment period. Once you find your payer's required way of coding claims, getting claims processed will be quick and simple.

 

Here's what most providers do when transitioning to a new claim filing system:

  1. Submit one claim to a payer for the first time. Code it in the way you think the payer wants it coded
  2. If it's accepted, great job! You've learned how this payer requires claims to be coded and you should begin filing the rest of your claims for this payer.
  3. If it's rejected, then read the rejection message delivered by the payer and adjust the coding on your claim accordingly. Then resubmit the claim.
  4. If it's rejected again, read the rejection message to see if you can learn what is causing this rejection pattern. Then adjust the coding on your claim and resubmit it again.
  5. If it's rejected a third time or if you're unsure how to change the coding on your claim, now it's time to call the payer or consult a professional biller.
  6. When you speak with the payer they will usually be able to tell you what you've coded incorrectly on the claim allowing you to edit your rejected claim and resubmit it.
  7. If you call the payer and they report that your rejected claim was never received, this is because the service rep you're speaking with does not have access to this claim. It was rejected by the payer's electronic system before the claim was entered into the adjudication process. Read about Invalid Subscriber ID messages from the payer to learn what to do next. 

 

Common coding issues that cause rejected or denied claims:

An invalid Subscriber ID

Payers will frequently reject claims if the patient's policy information is not coded correctly on the claim form. These are the items most payers check when verifying a subscriber ID:

  • Client Name
  • Client Date of Birth
  • Client Address
  • Primary insured information

Payers can immediately reject claims on the basis of an invalid subscriber ID for the slightest coding variations:

  • Omitting a space or hyphen in the client's subscriber ID
  • Including a space or hyphen in the client's subscriber ID
  • Using the client's nickname instead of the full legal name (Tom vs. Thomas)
  • Omitting the "Jr." or "Sr." Suffix in a patient's name
  • Omitting the primary insured's information (Spouce, parent, etc.)
  • Including the primary insured's information
  • Omitting the client's Group ID
  • Including the client's Group ID
  • Using a different patient address than the one on file with the payer

Any of these things can cause a payer to report an invalid Subscriber ID meaning they do not recognize the client as an insurance policy holder.  

In this case, it's best to contact the payer directly to find out how they want you to code the claim with the correct subscriber information.

If the payer reports that they did not receive the claim

When you contact the payer it is possible that the service rep will tell you that the online claim was never received. This means that the rep does not have access to the claim.

When a rep does not have access to a claim, it's typically because the payer's initial electronic review of the claim determined that you have coded the patient's subscriber information incorrectly and the claim was rejected before it reached the adjudication process. In this case you will need to ask the payer's service rep how you should code a claim for this specific client instead of asking the rep why this particular claim was rejected.

This information about how to code the client's subscriber info will help your claim clear this initial hurdle the payer has set up and you can have your claims accepted into the payer's ajudication process.

If the payer reports that the client information is correct

When you contact the payer, it may not be enough to just ask the payer rep to confirm the client's name, subscriber ID, and date of birth. If the payer rep reports that the client info you have is correct then you'll need to ask the payer to tell you in detail which boxes on the CMS claim form they require you to fill out and how they expect the information to be coded in each of those boxes. (subscriber ID with or without hyphens, primary insured info, box 11 to be filled out or not, etc.) 

Make sure you confirm with the payer rep how box 1a through box 11 should be coded for this client. The payer's online claim processing system is rejecting or denying the claim because of some coding variation in one or more of these boxes. 

An invalid billing code

Many payers have strict policies about what billing codes they will and will not reimburse. The payer's customer service resps will be able to explain to you the details of these policies and instruct you how to code your claim so it can be reimbursed.

Invalid Provider (Entity) Information

Most payers only require providers in private practice to enter provider information in box 33 of the CMS claim form. But, this is not always the case. If the payer rejected or denied your claim because of an "Entity" or "Provider" issue, this means they would like you to code your provider information differently on claims.

The payer representatives will be able to tell you which information you should put in the appropriate boxes on your CMS claim forms. Be sure to ask the payer rep specifically how you should code each of these boxes on the claim form:

  • 17, 17a, and 17b
  • 24j
  • 25
  • 27
  • 32, 32a
  • 33, 33a, and 33b

If the payer reports that they did not receive the claim

When you contact the payer it is possible that the service rep will tell you that the online claim was never received. This means that the rep does not have access to the claim.

When a rep does not have access to a claim, it's typically because the payer's initial electronic review of the claim determined that you have coded the provider information incorrectly and the claim was rejected before it reached the adjudication process. In this case you will need to ask the payer's service rep how you should code a claim for this specific client instead of asking the rep why this particular claim was rejected.

This information about how to code your provider information will help your claim clear this initial hurdle the payer has set up and you can have your claims accepted into the payer's adjudication process.

 

For additional help contact a biller

For additional help with billing questions and advice on how to code claims, we recommend you contact a professional biller. Only a professional biller will be able to research your specific coding requirements with an insurance payer.

At SimplePractice, we do not employ any professional billers to advise you but we know that some SimplePractice members have appreciated working with Michael Williams of MCM- South Medical Billing Service. He specializes in billing for mental health practices.

Here is his contact information if you would like to reach him:

Michael Williams, Jr.
Office: (770) 680-5386
Fax: (678) 317-2216
mwilliams@mcmsouth.com

MCM- South Medical Billing Service, LLC
3375 Centerville Hwy #392606
Snellville, GA 30039

 

Please be advised that SimplePractice is not responsible or liable to you in any way for the acts and omissions of any professional billers we may recommend and you must conduct your own investigation and due diligence prior to engaging any such professional billers.  If you hire any professional biller recommended by SimplePractice, you alone assume the risk and are responsible for the acts and omissions of such professional billers.  SimplePractice does not receive any commission, fee or other compensation for recommending any professional billers to third parties.

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