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Managing billing profiles for insurance

Managing billing profiles for insurance

Adding billing profiles allows individual clinicians to determine which set of billing information will populate their claim forms. This simplifies the process of submitting claims by reducing claim errors and allowing you to spend less time manually editing claims. 

In this guide, we’ll cover:

Note: Billing profiles are only available on the Plus plan. 


Reviewing your default billing information

Before adding any billing profiles, there’s a default set of billing information that populates claims. To review this information: 

  • Navigate to Settings > Billing and Services > Insurance
  • Review the information listed under your Billing provider info 

defaultinfo.simplepractice.insurance.png

If no additional billing profiles are added, the information listed here will continue to populate all claims. This information includes:

  • First and last name (if billing as an individual)
  • Organization name (if billing as an organization)
  • Billing address
  • NPI 
    • Type 1 for individuals
    • Type 2 for organizations
  • Taxonomy code (box 33b)
  • Phone number

Additionally, billing profiles also include your TIN/EIN or SSN, which will populate box 25

To manage your default billing provider information:

  • Click Edit

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  • After making any edits, click Save profile 

Adding a new billing profile

To add a new billing profile: 

  • Navigate to Settings > Billing and Services > Insurance
  • Click Add billing profile

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  • To complete the billing profile, add the following information: 
    • Clinician
      • If you leave this blank, or select the All clinicians option, the Insurance payer will be a required field, and claims for all clinicians submitted to that payer will populate with the information entered in the billing profile
    • Insurance payer
      • If you leave this blank, or select the All insurance payers option, the Clinician will be a required field, and claims submitted to all payers for that clinician will populate with the information entered in the billing profile
    • Provider type
      • If you choose Individual, enter your name
      • If you choose Organization, enter your practice name
    • Tax ID or SSN
    • NPI 
      • If billing as an individual, this will be an individual, Type 1 NPI
      • If billing as an organization, this will be a group, Type 2 NPI
    • Taxonomy code
      • If billing as an individual, this field is required
      • If billing as an organization, this field is optional
        • If you’re not sure whether to include a taxonomy code in this field when billing as an organization, we recommend reaching out to the payer 
    • Address
  • Click Save profile

Setting a rule for billing profiles

Every billing profile requires that you set a rule. This rule will dictate when the information in that billing profile is used to populate claims. 

The two rules you can set are:

  • Which clinician the billing profile is for
  • Which insurance payer the billing profile is for

At least one of these rules must be set, and you can also use both for a single billing profile. 

You can choose an individual clinician or All clinicians from the dropdown.

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If you select a clinician, the billing profile will only determine how claims submitted for that clinician populate. 

You can choose a specific payer or select All insurance payers from the dropdown.

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If a payer isn’t listed, it's because it hasn’t been added to your Payers list. For more information, see Why can’t I search for a payer when adding a billing profile? below.

At least one rule is required in order to add a billing profile. When reviewing your billing profiles, you can reference the Rule column, which will list the clinician or payer the rule is set for. 

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If a billing profile has a rule in place for each condition, you’ll see the clinician and payer that billing profile is set to populate for. 

ruleforboth.simplepractice.insurance.png

Note: As you add billing profiles, there may be some overlap between them, as certain profiles can be added for all clinicians, and others for all payers. See What happens when information across billing profiles overlaps? below for a breakdown of how this information is prioritized when claims are being created.


Removing a billing profile

A billing profile can be deleted at any time. 

Important: Once deleted, this information can’t be retrieved. However, deleting a billing profile won’t impact any existing claims.

To delete a billing profile:

  • Navigate to Settings > Billing and Services > Insurance 
  • Locate the billing profile in question
  • Click Edit

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  • Click Delete profile

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Editing a billing profile

To edit an existing billing profile: 

  • Navigate to Settings > Billing and Services > Insurance 
  • Review the information associated with that profile

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  • Click Edit

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  • After making the edits, click Save profile

After a profile is edited, claims that have already been created won’t have those updates reflected. If a claim is in the Prepared status, or has been rejected due to incorrect billing information, you can:

  • Edit the billing profile
  • Delete the claim
  • Recreate the claim and leave it as an Original in box 22
  • Review and confirm the billing information in boxes 25 and 33
  • Submit the claim

If a claim has already been accepted for processing under an incorrect set of billing information, we recommend allowing the claim to be fully processed and denied, at which point you can submit a corrected claim. You can also reach out to the payer proactively and let them know you’d like to resubmit the claim

Payers handle claims differently, so if you’re not sure whether a claim needs to be resubmitted, we recommend reaching out to them directly for confirmation. 


FAQs


Do I need to use billing profiles?

Billing profiles aren't required to submit insurance claims. However, they’re recommended for practices that frequently make manual edits to boxes 25 and 33 of claims prior to submitting them. 

Examples of when using billing profiles is recommended include:

  • If clinicians bill using unique tax identification numbers 
  • If clinicians in a practice bill using their own, individual NPI in box 33
  • If a practice has multiple locations, and you frequently have to edit the address in box 33 of claims
  • If certain payers have specific billing requirements that differ from other payers you submit claims to

Can I add multiple enrollments for an insurance payer?

Certain payers require enrollments to submit claims through SimplePractice, and all payers require Payment Report enrollments to receive electronic Payment Reports. If you use billing profiles to populate unique billing information for certain payers, you can submit additional enrollments to those payers.  

Once the enrollments are accepted, the clinician will be able to file claims and receive Payment Reports in SimplePractice. For more information, see Submitting multiple enrollments per payer.


How many profiles can I add?

There’s no limit to how many billing profiles can be added. 


Should I include a payer when adding a billing profile?

Associating a billing profile with a specific insurance payer is optional. If no payer is selected, the information entered in that billing profile will populate all claims submitted for that specific clinician. 

Including a payer with a billing profile is recommended in cases where a very specific set of information needs to be used only for that payer. For example, if a clinician bills several payers, but only one of those payers requires they bill under their organizational NPI, a billing profile is recommended.


What happens when information across billing profiles overlaps?

As you add billing profiles, there are times when some of the information will overlap. For example, you may have one billing profile set to populate for all clinicians, and another set to populate for all insurance payers. At the same time, you may also have a billing profile that has a specific clinician and a specific payer for its rule. 

When multiple billing profiles exist, information populates claims based on the following order: 

  • If there’s a billing profile that matches both the clinician and payer, this will overrule any other billing profiles
  • If the above isn’t found, but there’s a billing profile that matches the clinician assigned to the appointment, this billing profile will be used to populate the claim
  • If there isn’t a billing profile for the specific clinician, but there’s one for the payer assigned to the client, this billing profile will be used to populate the claim
  • If no billing profiles can be found for the clinician or the payer, the claim will populate with your your default billing information.

Which team members can add a billing profile?

Clinicians with entire practice access, practice managers, and practice billers are able to add billing profiles.


Why can’t I search for a payer when adding a billing profile?

Before a billing profile can be added, the payer must be added to your Payers list. To do this:

  • Navigate to Settings > Insurance
  • Click Search available payers

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  • Enter the name of the payer
  • Click + Add

Once the payer is saved to your list, you’ll be able to add a billing profile for it.


Which sections of a claim are populated by a billing profile?

Billing profiles determine how boxes 25 and 33 are populated. These boxes can be found at the bottom of a claim and contain required billing information.

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