To submit claims for a client, you'll first need to add their demographic and insurance information. Making sure this information is entered properly from the start will minimize claim rejections.

You can manage a client’s information by clicking Edit on their profile. 

Note: You can also request that a client enter their demographic and insurance information through the Client Portal. For more information, see Sending the Demographics form. 

This guide will walk through the settings for the following client information:

• Demographic info
• Billing Type
• Insurance info
• Copay/Coinsurance
• Deductible
• Effective start and end dates
• Insurance cards
• Authorization tracking
• Insurance Claim/CMS Fields
• Client’s Default Services

Demographic info

Payers require that a client’s demographic information be listed on claims and that it matches what they have on file. To meet these requirements, make sure every insurance client has the information below stored accurately in their profile under the Client Info tab. 

• Legal first name and Legal last name 
  • List the client's name exactly as shown on their insurance member ID card
• Phone number
• Address
• Date of Birth
• Sex 
  • As this can differ from the client's gender identity, select the client's sex that's on file with their insurance policy

Tip: If any of the necessary pieces of demographic information are missing, a notice in your Unbilled appointments page will remind you to enter this information. Hover over the exclamation point to see what information is missing and click Add info to navigate to the client's profile. 

Billing Type

Clients can be assigned Self-pay or Insurance as their billing type. In order to submit claims for a client, their billing type must be set to Insurance. To do this:

• Navigate to the client's profile
• Click Edit > Billing and Insurance
• Select Insurance as the Billing Type

• Scroll down and click Save Client 

After updating this, the client’s future appointments will be set to Insurance. If a client’s prior appointments need their billing type to be updated to Insurance, see Changing individual appointment types. 

Insurance info

You can enter a client’s insurance information in their Billing and Insurance settings. To do this:  

• Navigate to the client’s profile 
• Click Edit > Billing and Insurance 
• Scroll down to the Insurance info section
• Click + Insurance info

• Fill out the payer and member information 
  • All fields with a red asterisk are required 

• Click Save 

Important: Because payer names and payer IDs can vary by clearinghouse, a payer’s name or ID may be different from what you’ve used in a previous EHR. For more information on selecting a payer ID, see Adding insurance payers and selecting the correct payer ID. 

The following pieces of information are required: 

• Type
  • Primary insurance is automatically selected
  • For additional payers, you can select Secondary insurance or Other  
• Primary policy holder 
  • If the client is under someone else’s plan, such as a parent or spouse, select the correct relationship and enter the primary insured's information in the available fields
  • If the information is the same as the client's, click Same as client to automatically populate what's entered in the client's settings

• Payer 
  • Search the available payers by typing the payer ID number or the entire name of the payer as it appears on your client's insurance member ID card
  • Select the insurance payer with the payer ID and name that best matches the client's member ID card
  • Review our guide for tips on Selecting the correct payer ID
• Member ID 
  • List the full member ID number including any prefixes or suffixes
  • Don't include any spaces or dashes in this field

After the primary insurance information is entered, you can click + Insurance info to record any additional insurance plans, such as a secondary insurance or EAP. 

You can update a client's insurance information at any time by locating the plan in their Billing and Insurance information and clicking Edit. 

Tip: Insurance plans and requirements can often change unexpectedly. We always recommend verifying benefits and eligibility before your first appointment with a client and again at the start of a new year. This can help to avoid claim denials and unexpected client balances due to a change of coverage.

Copay/Coinsurance

If your client is responsible for a copay or a coinsurance, you can list the dollar amount that they will owe for each appointment in the Copay/Coinsurance field of their Insurance info settings. 

Note: If your client has a coinsurance, meaning that they are financially responsible for a set percentage of the contracted rate, you’ll need to manually calculate the dollar amount due. For example, if your client has a 20% coinsurance, and you have a contracted rate of $80, you will need to enter $16 in this field (.2 x 80 = $16).

Listing this information will trigger the system to auto-populate the client responsibility for the client's upcoming appointments. After an invoice is created for an appointment, the client owes amount will be reflected in their Client balance. This allows you to collect the client's portion of the bill before the claim is processed.

If you find that a claim is processed and the payer outlines a different client responsibility in the remittance information, you can make the necessary corrections using an Appointment level billing change. This can often be the case if the client has an annual deductible.

Tip: If you're enrolled for Payment Reports and a claim was processed with a different client responsibility than initially entered, the information we receive from the payer will automatically correct the client’s responsibility.

Deductible

If your client has an annual deductible, you can record the total amount of the deductible to give you a sense of how many appointments they’ll be responsible for out-of-pocket. The deductible amount can be entered in the Deductible field of the client’s Insurance info settings. 

Important: This field is only for your records and doesn’t automatically update or track a client’s remaining deductible. 

For a walkthrough on how to manage clients with a deductible, see Billing clients who haven't met their deductible.

Effective start and end dates

If you know the start and end dates of a client’s insurance plan, you can enter them in the client’s Insurance info settings. 

This is helpful if you need to keep a record of a client's prior insurance coverage. When adding a new plan, we recommend saving a client’s prior plan as Other and adding their new one as Primary insurance going forward. 

Note: Primary and secondary claims will always populate with what’s designated as a client’s Primary insurance and Secondary insurance, respectively, even if the effective end date has passed. If you need to submit a claim for an insurance payer listed as Other, you’ll need to temporarily set it as the client’s Primary insurance to create the claim. 

Insurance cards

We highly recommended uploading copies of the front and back of your clients’ insurance member ID cards in their Insurance info settings. In the case of a claim rejection, these will be the starting point for determining what needs to be corrected. 

The front side of an insurance card contains important information about the client's specific insurance plan, while the back side lists important claim filing information that's specific to the payer.

To upload a member ID card: 

• Click browse under Front of insurance card to upload the front of the card, or drag a file from your computer directly into this box

• Repeat these steps to upload the Back of insurance card
• Click Save

Note: You can upload PNG, JPEG, or PDF files. If you upload PDF files, you won’t have a “preview” option, but you’ll still be able to view the file by clicking it.

Alternatively, you can have a client enter their insurance information and upload their insurance card through the Client Portal. For more information, see Adding optional fields on the Demographics form. 

Tip: Download the SimplePractice Mobile app to upload member IDs cards directly from your mobile device.

Authorization tracking

Certain insurance plans require prior authorization for a client to be eligible for coverage. To automatically populate a prior authorization number in box 23 of a client's claims, you can enter it in the Authorization tracking section of a client’s Billing and Insurance settings.

Note: For an overview of this feature, see Using Authorization Tracking.

Insurance Claim/CMS Fields

Some payers require additional fields on claims. To enable these fields: 

• Navigate to the client’s profile 
• Click Edit > Billing and Insurance  
• Scroll to Insurance Claim/CMS Fields 
• Check Show additional claim fields 

These fields include:

• Accept Assignment? 
  • This indicates that the insurance payment should go to the provider and is set to Yes by default 
  • When courtesy billing, you can change this to No to have the payment to go to the client instead
• Referring provider
  • This populates the referring physician’s NPI in box 17
  • If a payer requires this field, select the dropdown to choose the appropriate provider type, the referring provider’s name, and their NPI 
• Include secondary insurance info on primary claim?
  • This will only be an option if the client has a secondary insurance entered
  • Select Yes or No if you’d like this information to populate the primary claim
  • Only include this information if the primary payer requires it as it can lead to claim rejections if included unnecessarily 

After entering the applicable information, click Save Client at the bottom of the page. 

Note: Most payers don’t require these fields. If you’re not sure whether to include them, we recommend reaching out to the payer. 

Client’s Default Services

You can set a default service code to automatically populate for a client when creating their appointments. To do this, you can select a default code in the Client Default Services section of the client’s Billing and Insurance settings. 

Note: For an overview of this feature, see Setting a default service code and custom rate for a client.