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Filing secondary insurance claims

Filing secondary insurance claims

In SimplePractice, you can create and submit secondary insurance claims electronically. If you’re enrolled to receive electronic Payment Reports from a primary payer, secondary claims will automatically populate the required information from primary claims. If you’re not enrolled for Payment Reports, the information can be entered manually. 

Note: SimplePractice only supports filing primary and secondary insurance claims. You can file tertiary insurance claims directly with the payer. 

In this guide, we’ll cover:

Note: For more details on common secondary claim rejections and the steps you can take to resolve them, see Common secondary claim rejections.


Adding a client's secondary insurance

To file secondary claims or record secondary insurance payments in SimplePractice, you'll first need to add the secondary insurance to the client’s profile. To do this: 

  • Navigate to the client's Overview page
  • Click Edit > Billing and Insurance
  • Scroll to Insurance info
  • Click + Insurance info

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  • Under Insurance type, select Secondary insurance

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  • Select the Insurance Payer 
  • Enter the Member ID 
  • Upload a copy of the client’s insurance card, if available 
  • Click Save 

For more information, see Setting up insurance billing for your clients.


Creating a secondary insurance claim

If a client has secondary insurance on file, you can create a secondary claim once the primary claim is in one of the following statuses: 

  • Downloaded
  • Received
  • Accepted
  • Paid
  • Denied
  • Deductible

If these conditions are met, the Create secondary claim button will display on the primary claim.

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Important: In the client's Insurance info settings, the primary payer should be listed as Primary insurance and the secondary payer as Secondary insurance. Otherwise, you won’t be able to create a secondary claim. 

Clicking Create secondary claim will generate a new secondary claim populated with the client's secondary insurance information.

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You can view all secondary claims within a specific date range by navigating to Insurance > Claims and filtering by Secondary claims.

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Note: If you need to submit a secondary claim but the primary claim was filed outside of SimplePractice, you can create and download a primary claim in SimplePractice without submitting it. You’ll then be able to create a secondary claim in SimplePractice. For more information, see Removing appointments from the Unbilled appointments list.


Entering payment information and adjustment reason codes

Secondary payers require specific information on secondary claims to determine how a primary claim was processed. This information is listed on the primary claim’s Payment Report, Explanation of Benefits (EOB), or Electronic Remittance Advice (ERA). If you’re enrolled to receive Payment Reports from the primary payer, the information from the primary Payment Report will automatically populate on the secondary claim. 

Note: Secondary payers will only accept secondary claims if the primary claim has been successfully processed by the primary payer with a finalized status of Paid, Denied, or Deductible.   

Secondary payers require the following information: 

  • The total primary insurance paid amount
  • The total remaining client responsibility
  • The date the Payment Report, EOB, or ERA was received
  • Adjustments, which are most commonly divided into:
    • Contractual obligation (CO)
      • The main contractual obligation reason code is 45 (charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement)
    • Patient responsibility (PR)
      • Deductible (reason code 1)
      • Coinsurance (reason code 2)
      • Copay (reason code 3)

Note: For additional adjustment reason codes, see the Claim Adjustment Reason Codes list. If you’d like to verify a reason code before submitting the secondary claim, submit a help request with the secure claim URL so our team can verify with our clearinghouse. 

The next section goes into how to identify each piece of information within your Payment Report, EOB, or ERA.

Important: You must have the remittance information for the primary claim prior to filing secondary claims in SimplePractice. If you aren't enrolled to receive Payment Reports and you don't have access to the EOB or ERA, contact the primary payer to determine if one can be sent or accessed through an online portal.


Reviewing a primary Payment Report, ERA, or EOB

If you're enrolled to receive Payment Reports through SimplePractice with a primary payer, they’ll send a Payment Report outlining the adjudication information for the primary claim. To view the primary Payment Report: 

  • Navigate to Insurance > Claims 
  • Locate the primary claim 
  • Click View 
  • Click Claim Details 
  • Scroll to Insurance payment report 

On the first part of the Payment Report, you’ll find the: 

  • Date received
  • Payment amount 
    • This is the total primary insurance paid amount
  • Client responsibility 
    • This is the total remaining client responsibility

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Under the Appointment section, the Paid column will list the insurance paid amount for each appointment.

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Under the Client responsibility section, the client’s copay, coinsurance, or deductible amount will be listed with the reason code.

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Under the Adjustments section, the Contractual obligation or other adjustments will be listed with the reason code.

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An explanation of each reason code will be listed in the Remarks section with the corresponding group code. 

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If you're not enrolled to receive Payment Reports, you can use the EOB or ERA received outside of SimplePractice to locate the required information. 

Important: Formatting for EOBs/ERAs vary by payer. If it isn’t possible to determine the necessary information from the EOB/ERA, contact the primary payer for clarification. You can also submit a help request so that our team can work with our clearinghouse to identify the necessary information. So that we can review the EOB/ERA, upload it to the client’s profile and include the secure client URL in the help request.


Filing a secondary insurance claim

When creating a secondary claim from a primary claim with a Payment Report, all the necessary information will automatically populate on the secondary claim form in box 8 and box 24.

Important: If the information from the primary claim automatically populated on the secondary claim, verify that all the information is correct and in the appropriate boxes using the instructions below.

If using an EOB/ERA to manually fill out the secondary claim form, enter the following information in box 8

  • The total amount paid on the primary claim in the Paid $ field
  • The total remaining client responsibility in the Remaining $ field
  • All other fields in box 8 should be left blank

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Note: Some payers require the primary claim’s Payer Claim Number in the Claim control no field in box 8. If you receive a secondary rejection with Other Payer's Claim Control Number - Required in the rejection message, edit the secondary claim to include this information. The Payer Claim Number can be found on the Payment Report, EOB, or ERA. For more information, see Using claim reference numbers.

In box 24, enter the following information: 

  • 1a 
    • The amount insurance paid for the individual appointment in the Paid $ field
    • Leave the Remaining $ field blank
    • Enter 1 in the Quantity field 
    • The date you received the EOB/ERA in the Adjudication date field

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  • 1b 
    • If the claim was billed with a modifier, enter the modifier(s) in the Modifier field
  • 1c 
    • Enter the Group code for each client responsibility and adjustment 
      • The main group code for a contractual obligation is CO 
      • The main group code for a client responsibility is PR 
    •   Enter the Reason code for each client responsibility and adjustment 
      • The main reason code for a contractual obligation (CO) is 45 
      • The main reason codes for a client responsibility (PR) are 1 (deductible), 2 (coinsurance), and 3 (copay)
    • Enter the Amount for each adjustment
    • Enter 1 as the Quantity for each adjustment

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If there are additional appointments, each appointment will have corresponding boxes in box 24. You can follow this workflow to enter the information for each appointment.

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After confirming that all the information is correct, click Submit.

Important: Box 29 should be left blank on secondary claims to avoid secondary rejections.


Common secondary claim scenarios

When submitting a secondary claim, the payment information and adjustments need to be listed based on how the primary claim was processed. In this section, we’ll cover the most common scenarios for submitting a secondary claim and the information needing to be entered for each:

Important: The examples in this section are true in most cases, but payers can have unique secondary claim filing guidelines. Some payers may also require different reason and group codes. If a secondary claim is being rejected after using the adjustments listed in one of these three scenarios, submit a help request with the secure claim URL so our team can investigate.


Client’s copay/coinsurance is covered by secondary insurance payer

In this scenario, the appointment fee is $100, the primary payer covered your in-network rate ($65), the client’s copay is being submitted to the secondary payer ($25), and the remaining amount was written-off ($10). 

In box 8, enter: 

  • 65 for Paid $
  • 25 for Remaining $

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In box 24 1a, enter: 

  • 65 for the Paid $
  • Leave the Remaining $ blank
  • 1 for the Quantity
  • The date the EOB/ERA was issued for the Adjudication date

In box 24 1b, only enter a Modifier if applicable.  

In box 24 1c, enter the adjustments as follows:

box24.simplepractice.secondaryclaim.png

In the above screenshot, the first Group Code (CO) represents the contractual obligation, and the first Reason Code (45) represents the write-off. The second Group Code (PR) represents the patient responsibility that is being covered by the secondary insurance, and the second Reason Code (3) indicates that this is their copay. If the client has a coinsurance instead of a copay, use Reason Code (2)

Tip: The amount the primary insurance paid for an appointment and the amounts of each adjustment must add up to the appointment fee (65 + 10 + 25 = 100).


Client’s deductible is covered by secondary insurance payer

In this scenario, the client’s deductible isn’t met. The appointment fee is $100, the primary insurance paid $0, there is a $25 write-off, and the client responsibility amount of $75 is being submitted to their secondary insurance plan. 

In box 8, enter: 

  • 0 for Paid $
  • 75 for Remaining $

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In box 24 1a, enter: 

  • 0 for the Paid $ 
  • Leave the Remaining $ blank
  • 1 for the Quantity
  • The date the EOB/ERA was issued for the Adjudication date

In box 24 1b, only enter a Modifier if applicable.  

In box 24 1c, enter the adjustments as follows:

deductible.simplepractice.secondaryclaim.png

In the above screenshot, the first Group Code (CO) represents the contractual obligation, and the first Reason Code (45) represents the write-off. The second Group Code (PR) represents the client responsibility that is being covered by the secondary insurance, and the second Reason Code (1) shows that this is their deductible rate. 

Tip: The amount the primary insurance paid for an appointment and the amounts of each adjustment must add up to the appointment fee (0 + 25 + 75 = 100).


Primary claim is denied as out-of-network

In this scenario, you’re out-of-network with the client’s primary insurance, and the primary claim was denied. In this case, the full appointment fee of $100 can be billed to their secondary insurance.

In box 8, enter: 

  • 0 for Paid $
  • The full appointment fee ($100) for Remaining $

box8denied.simplepractice.secondaryclaim.png

In box 1a, enter: 

  • 0 for the Paid $ 
  • Leave the Remaining $ blank
  • 1 for the Quantity
  • The date the EOB/ERA was issued for the Adjudication date

In box 1b, only enter a Modifier if applicable.  

In box 1c, enter the adjustments as follows: 

outofnetwork.simplepractice.secondaryclaim.png

In the above screenshot, the first Group Code (PR) represents the patient responsibility that is being covered by the secondary insurance. Our clearinghouse has advised using Reason Code (242) when the primary claim is denied as out-of-network.  

Tip: The amount the primary insurance paid for an appointment and the amounts of each adjustment must add up to the appointment fee (0 + 100 = 100).


Adding a secondary insurance payment

If you’re enrolled to receive Payment Reports from a secondary payer, secondary insurance payments will be automatically recorded. If you’re not enrolled for Payment Reports, you can add these manually. To do this: 

  • Navigate to the client's Billing tab
  • Click Add Insurance Payment

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Note: You can quickly locate a primary insurance payment that's already been added by navigating to the client's Billing tab and filtering by Transactions by insurance. Then, click View next to the primary insurance payment.transactionsbyinsurance.simplepractice.insurancepayments.jpg

  • On the Add Insurance Payment page, select the secondary payer from the Payer dropdown

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  • Select the Payment Method, including the check or wire number
  • Enter the Amount paid
  • Under All Appointments, filter by date and client to locate the appointment(s)
  • Enter the amount paid for the appointment in the Insurance Paid column

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  • If the client responsibility has changed, update the Client Owes to the new responsibility 
  • If there’s a remaining balance, click the wheel icon in the Write-Off column to automatically calculate the write-off
  • Click Save Payment

Medicare crossover claims

Medicare is a unique payer in that they’ll submit a secondary claim on your behalf depending on the client’s Coordination of Benefits. This is referred to as a crossover claim

We’re unable to verify if a client’s Coordination of Benefits is set up for crossover claims with Medicare. If a client has secondary insurance, we recommend reaching out to Medicare proactively to confirm if they have the secondary insurance on file and if they’ll be submitting crossover claims. 

If Medicare will submit the crossover claim, you only need to submit the primary claim. If you’re enrolled to receive Payment Reports, you may see two Payment Reports in the primary claim’s details, with one listing Secondary in the Responsibility sequence. This indicates that the crossover took place and the appointment(s) will be fully accounted for. 

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In this case, the secondary Payment Report may indicate that it’s from Medicare, rather than the actual secondary insurance payer. This is because the secondary payer sends the Payment Report through Medicare. 

To accurately record which payer the secondary insurance payment came from, you can manually edit the secondary insurance payment itself. See editing or deleting an insurance payment for more information.

If you've confirmed that Medicare won't submit a crossover claim, you can create and submit the secondary claim following the steps in Creating a secondary insurance claim.

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