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Filing secondary insurance claims

This guide covers everything you need to get started creating and filing secondary insurance claims within SimplePractice. Below you'll find the information about:

Note: For more details on common secondary claim rejections and the steps you can take to resolve them, see Common claim rejections: What they mean and what actions you should take.


Adding a client's secondary insurance

If your client has a secondary insurance and you plan to file secondary claims or record secondary insurance payments in SimplePractice, you'll first need to add their secondary insurance to their profile.

  • Navigate to your client's profile and click Edit > Billing and Insurance tab.
  • Click +Insurance Info.
    clientdetails.simplepractice.insuranceinfo.png
  • Under Insurance Type, select Secondary Insurance.
    clientdetails.simplepractice.secondaryinfo.png
  • Fill out all the other relevant information and whenever possible, upload the front and back sides of the client's insurance card. See uploading a client's insurance card to learn more.
  • Click Save.

Creating a secondary insurance claim

Within SimplePractice, you're only able to create a secondary claim after you've successfully created a primary claim. The Create Secondary Claim button won't appear on the primary claim unless the client has a secondary insurance on file and until the primary claim is in any of the statuses below:

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

If your primary claim is in one of the above statuses, you'll see the Create Secondary Claim button appear on the primary claim:

insurance.simplepractice.createsecondaryclaim.png

By clicking the Create Secondary Claim button, a new secondary claim will be generated with the client's secondary insurance information populated on the claim form.

insurance.simplepractice.secondaryclaim.png


Entering information to successfully file a secondary claim

To successfully file a secondary claim within SimplePractice, you'll need a primary claim that has been successfully processed by the payer. This means the primary claim has been given a finalized claim status of Paid, Denied, or Deductible.

Note: The claim in SimplePractice doesn't necessarily need to reflect the paid, denied, or deductible status as you will be able to create and submit a secondary claim when the primary claim is in any of the claim statuses listed in the previous section of this guide, but to successfully file a secondary claim electronically, you need the primary claim to be finalized and processed by the primary payer.

If your claim is in one of these finalized statuses, you'll need an Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA) from the payer or a SimplePractice payment report to complete the next steps.

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, you'll need to reach out to the primary payer and either request one be sent via mail/fax or see if they have an online portal to retrieve the remittance advice online.

Using the primary EOB, ERA, or payment report, you'll need to list the necessary remittance information on the secondary claim for it to process successfully. This information is used by the secondary payer to process the claim at the appropriate rate. Without listing this information, the secondary payer won't be informed of how the primary payer processed the claim. The required information is detailed below:

  • Primary insurance paid amount
  • Remaining client responsibility
  • The date the EOB, ERA, or payment report was received
  • Adjustments, which are divided up into:
    • Contractual Obligation (CO)
      • The main contractual obligation reason code you'll be using will be 45
    • Patient Responsibility (PR)
      • Deductible (reason code 1)
      • Coinsurance (reason code 2)
      • Co-pay (reason code 3)

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


Reading a SimplePractice payment report or Explanation of Benefits (EOB)/Electronic Remittance Advice (ERA)

Example Payment Report:

If you're enrolled to receive payment reports, once the payer has finished processing a claim, they will send a payment report to your SimplePractice account outlining the claim's finalized status.

Take a look at the example payment report below and you'll see the necessary information needed to file a secondary claim outlined in blue:

insurance.simplepractice.paymentreport.png

  • Primary insurance paid amount - $58
  • Remaining client responsibility - $35
  • Date the payment report was received - 02/18/2020
  • Adjustments are as follows:

To view any adjustments, hover your cursor over the ? icon. This will display the reason code in parentheses:

paymentreport.simplepractice.adjustments.png

Contractual Obligation:

  • Group Code - CO
  • Reason Code - 45
  • Amount - $47

Patient Responsibility:

  • Group Code - PR
  • Reason Code - 3
  • Amount - $35

Example EOB:

If you're not enrolled to receive payment reports, you should either receive an EOB in the mail or electronically receive ERAs through an online provider portal or through another clearinghouse.

Important: Formatting for EOBs/ERAs can vary from payer to payer. If you're having trouble distinguishing the necessary information on an EOB/ERA, please reach out to the primary payer to help clarify the pieces of information that you need. You can also write into our Insurance Team and we'll be happy to reach out to our clearinghouse to help identify the necessary information.

insurance.simplepractice.eob.png

  • Insurance paid amount - $15.92
  • Remaining client responsibility - $87.25
  • Date EOB was received - 04/07/2020
  • Adjustments are as follows:
    • Contractual Obligation
      • Group Code - CO
      • Reason Code - 45
      • Amount - $36.83
    • Patient Responsibility
      • Group Code - PR
      • Reason Code - 1
      • Amount - $83.27
    • Patient Responsibility
      • Group Code - PR
      • Reason Code - 2
      • Amount - $3.98

Once you've identified the information you need to successfully file a secondary claim, the next section of this guide details where to list this information on the enhanced secondary claim form.


Filing a secondary insurance claim

If the primary claim you're using to create a secondary claim has a payment report, all the necessary information will auto-populate onto the secondary claim form. When you create a secondary insurance claim, you'll notice some updates to two specific boxes:

  • Box 8:
    secondaryclaim.simplepractice.box8.png
  • Box 24:
    secondaryclaim.simplepractice.box24.png

Note: Please leave box 29 blank, when filing secondary claims electronically in SimplePractice, our clearinghouse has advised to leave this field blank.

If the secondary claim auto-populated with your primary payment report information, you'll want to verify that all the information is correct and in their appropriate boxes using the information learned from the previous section and the details below. If you're using an EOB or an ERA to populate the secondary claim form, please review the details below to verify the correct placement of the primary EOB/ERA information.

In Box 8, enter the two pieces of information in their respective fields:

  • The total amount paid on the primary claim in the Paid $$ field
  • The total remaining client responsibility in the Remaining Amount field

In Box 24, enter in the rest of the information in their respective fields:

  • 1a:
    • The amount insurance paid for that date of service in the Paid $$ field
    • The Quantity will always be 1
    • The date you received the EOB, ERA, or payment report in the Adj Date field
  • 1b:
    • Enter the billed code in the CPT/HCPCS field
    • If the claim was billed with a modifier, enter the modifier(s) in the Mod field
  • 1c:
    • Enter in all adjustments in their respective fields with a Quantity of 1

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


Adding a secondary insurance payment

When you receive payment from a secondary insurance payer, the process of adding the payment is no different than manually adding an insurance payment from a primary payer.

  • Navigate to the client's Billing tab and click Add Insurance Payment.

clientpage.simplepractice.addinsurancepayment.png

  • On the Add Insurance Payments page, make the following adjustments:
    • From the Payer dropdown, select the correct secondary payer.
    • Under Allocate payments to appointments below:
      • Filter the date range to the date of the appointment.
      • Select the correct client from the Client dropdown.

  • Once you've found the appointment, you can select the Payment Method including, the check or wire number, and the amount paid by the insurance.

insurancepayment.simplepractice.secondary.png

If the client responsibility changes for the appointment after receiving the secondary insurance payment, you can update the Client Owes amount and allocate the secondary insurance payment to the Insurance Paid column. If there's an unpaid amount remaining that needs to be written off, you'll need to manually calculate the amount and enter it in the Write-off field.

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