To create insurance claims directly in your SimplePractice account, you'll first need to add the client's billing and insurance information. Making sure that your clients' information is entered properly from the start will minimize claim rejections and help you avoid lengthy calls with insurance payers later on.
After you've added a client, you can manage all of their information by clicking Edit under their name while viewing their profile.
This guide will walk through the settings for the following client information:
- Demographic Info
- Billing Type
- Insurance Info
- Insurance card on file
- Authorization Tracking
- Insurance Claim/CMS Fields
- Client’s Default Service
Payers will require that a client's demographic information is listed on claims and that it matches exactly what the payers have on file.
To meet these requirements, make sure every insurance client has all of the following information stored in their profile under Edit > Client Info and be sure to verify that the information is accurate:
- First and Last name
- List the client's name exactly as shown on their insurance member ID card
- Phone number
- Date of birth
- This can differ from the client's gender identity - please 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 go directly to the client's insurance information.
All of your clients that you bill through insurance must have their Billing Type set to Insurance. To do this:
- Navigate to the client's Overview page
- Click Edit > Billing and Insurance
- Select Insurance as the Billing Type.
- Scroll down and click Save Client.
To enter a client's insurance plan information, go to the client’s Overview page > Edit > Billing and Insurance. Scroll down to Insurance Information and click +Insurance info. All of the fields with a red asterisk are required.
Important: Prior to selecting the payer ID for your clients, please review this guide: Adding insurance payers and selecting the correct payer ID. Payer IDs and payer names can be specific to the clearinghouse and the connection that clearinghouse has established.
Here are the pieces of the insurance information you’ll need to enter:
- Insurance type
- Primary insurance is automatically selected
- To enter secondary insurance or EAP, scroll down and click + Insurance Info again and select the corresponding insurance type
- Insurance 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 insurance payer
- Member ID
- List the full member ID number including any prefixes or suffixes
- Don't include any spaces or dashes in this field
- Who is the Primary Insured?
- If the client is under someone else’s plan, make sure to select the correct relationship and enter the Primary Insured's information
- If the client is a minor, make sure to enter the insurance information in their profile, select Client's Parent under Who is the Primary Insured? 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 that information based on what's entered in the client's settings
After the primary insurance information is entered, you can scroll down and click + Insurance Info to record any additional insurance plans, such as a secondary insurance or EAP. Be sure to Save any changes.
Tip: Insurance plans and requirements can often change suddenly. 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 lapse of coverage.
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 Information settings.
Note: If your client has a coinsurance, meaning that they are financially responsible for a set percentage of the contracted rate, you will need to manually calculate the dollar amount due in order to use this feature. 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 owes amount 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 copay amount in the remittance information, you can make the necessary corrections using Appointment level billing changes. 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 copay amount due, the information we receive from the payer will automatically correct the client owes amount, to streamline your workflow.
If your client has an annual deductible, you can record the total amount of the deductible in this field to give you a sense of how many appointments they will be responsible for out-of-pocket. However, it's important to note that the system won't be able to track the remaining deductible amount because clients may be billing their insurance for services held by other providers.
Tip: See Billing clients who haven't met their deductible to learn more.
Insurance card on file
We highly recommended uploading copies of the front and back sides of your clients’ insurance member ID cards. In the case of a claim rejection, the client's member ID card will be the starting point for determining what needs to be corrected. The front side will contain important information about the client's specific insurance plan, while the back side will list important claim filing information that's specific to the payer.
To upload a member ID card:
- Scroll to the bottom of the client's Insurance information settings until you see a box that says Front of Insurance Card with a blue document icon
- Click Browse to upload a copy of the ID card, or drag a file from your computer directly into this box
- Repeat these steps to upload the Back of Insurance Card
Note: You can upload either 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.
Tip: Download the SimplePractice Mobile app to upload member IDs cards directly from your mobile device.
Certain insurance plans will require prior authorization in order for a client to be eligible for coverage.
To add a prior authorization number to your client's Insurance Information, click +Authorization number and list the starting date in the Valid from field. Storing this information will trigger the system to auto-populate the prior authorization number into box 23 of the client's claims.
Note: See Using Authorization Tracking for more information about this feature.
Insurance Claim/CMS Fields
Check Show additional claim fields to enable the additional fields that are available to auto-populate onto your claims:
- Accept Assignment
- By default, Accept Assignment? will be set to Yes. This indicates that the insurance payment should go to the provider. When performing courtesy billing, you can change this to No to have the payment to go to the client instead.
- Referring provider
- Some insurance payers require the referring physician’s NPI in box 17. Select the dropdown to choose the appropriate option, 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
Client’s Default Service
To set a Default Service for the client, click the dropdown and select the Client’s Default Service. The default service code will auto-populate when you create a new appointment for this client. It will also auto-populate into box 24d of the claim form. You can change this setting at any time.
Tip: To learn more about setting a default service code and rate, see How to set a custom service code rate for a client.