Note: If you're not currently a SimplePractice customer and are considering signing up for an account, make sure to take a look at how we streamline insurance billing.

SimplePractice streamlines the process of creating and filing secondary insurance claims. Please note, at this time 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:

• Adding a client's secondary insurance
• Creating a secondary insurance claim
• Entering payment information and adjustment reason codes
• Reading a SimplePractice Payment Report or Explanation of Benefits (EOB)/Electronic Remittance Advice (ERA)
• Filing a secondary insurance claim
• Common secondary claim scenarios
• Adding a secondary insurance payment
• Medicare crossover claims

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.

The order in which a client's claims need to be processed is referred to as your client's Coordination of Benefits (COB) and it's important their insurance information is entered based on their Coordination of Benefits. If you're unsure of the order that a client's claims need to be processed, reach out to the payer directly to confirm their Coordination of Benefits. 

• Navigate to your client's Overview page
• Click Edit > Billing and Insurance
• Scroll to their already entered insurance information
• Click +Insurance Info

• Under Insurance Type, select Secondary Insurance

• Fill out the relevant information, including the payer and Member ID
• If possible, upload a photo of the front and back of the client's insurance card.
  • See uploading a client's insurance card to learn more.
• Click Save Client

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.

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.

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

Tip: If a primary claim has already been filed outside of SimplePractice but you need to submit or prepare a secondary claim, you can still create and download a primary claim in SimplePractice without submitting it. This will meet the system requirements so that you can then create a secondary claim in SimplePractice. See Creating and printing a CMS 1500 (HCFA) claim form for more information. 

Entering payment information and adjustment reason codes

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 most commonly divided up into:
  • Contractual Obligation (CO)
    • The main contractual obligation reason code you'll be using will be 45 (charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement)
  • Patient Responsibility (PR)
    • Deductible (reason code 1)
    • Coinsurance (reason code 2)
    • Co-pay (reason code 3)

Tip: For additional adjustment reason codes, view this list. If you are ever unsure or want to verify prior to submitting the secondary claim, reach out to our Customer Success team.

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)

If you're enrolled to receive Payment Reports, once the payer has finished processing a claim, they'll send a Payment Report to your SimplePractice account outlining the claim's finalized status.

In the Payment Report below, the necessary information needed to file a secondary claim is outlined in blue:

• 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:

Contractual Obligation:

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

Patient Responsibility:

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

If you're not enrolled to receive Payment Reports, you should receive either 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 in to our Insurance Team and we'll be happy to reach out to our clearinghouse to help identify the necessary information.

• 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.

Important: You'll want to verify that all the information is correct and in their appropriate boxes using the instructions below.

When you create a secondary insurance claim, you'll notice some updates to two specific boxes:

Box 8:

Box 24

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

If you're using an EOB or an ERA to manually fill out 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

Note: Some payers will require the Payer Claim Number of the primary claim in the Claim Control No field. If you receive a rejection which states "Other Payer's Claim Control Number - Required" in the rejection message, please update the secondary claim to include the payer claim number of the primary claim in box 8. The payer claim number can be found on the Payment Report or EOB.

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 unless you're billing in units. If you're billing in units, the Quantity will equal the number of units on the corresponding service line from the primary claim 
  • The date you received the EOB, ERA, or Payment Report in the Adjudication Date field
  • If the claim was billed with a modifier, enter the modifier(s) in the Modifier 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.

Common secondary claim scenarios

When submitting a secondary claim, you'll need to list the payment information and adjustments based on how the primary claim was processed. The most common scenarios for submitting a secondary claim, and the information needing to be entered for each, include the following examples: 

• Client’s copay/coinsurance is covered by secondary insurance payer
• Client’s deductible is covered by secondary insurance payer
• Primary claim is denied as out-of-network

Note: In each hypothetical scenario below, the appointment fee is $100.  

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

In this scenario, 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 the Paid $ and 25 for the Remaining $:

In Box 24 1a, enter 65 for the Paid $, 1 for the Quantity, and the date the EOB was issued for the Adjudication Date. Leave the Remaining $ blank and only enter a Modifier if applicable.  

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

In the above screenshot, the Group Code (CO) represents the contractual obligation, and the Reason Code (45) represents the write-off. The Group Code (PR) represents the patient responsibility that is being covered by the secondary insurance, and the Reason Code (3) shows 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 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 is not met. The primary insurance paid $0, there is a $25 write-off, and you are submitting the client responsibility amount of $75 to their secondary insurance plan. 

In Box 8, enter 0 for the Paid $ and 75 for the Remaining $:

In Box 24 1a, enter 0 for the Paid $, 1 for the Quantity, and the date the EOB was issued for the Adjudication Date. Leave the Remaining $ blank and only enter a Modifier if applicable.  

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

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

Tip: The amount the primary insurance paid 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 so that it can be billed to their secondary insurance.

In Box 8, enter 0 for the Paid $ and the full appointment fee for the Remaining $: 

In Box 24 1a, enter 0 for the Paid $, 1 for the Quantity, and the date the EOB was issued for the Adjudication Date. Leave the Remaining $ blank and only enter a Modifier if applicable.  

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

In the above screenshot, the Group Code (PR) represents the patient responsibility that is being covered by the secondary insurance, and 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 and the amounts of each adjustment must add up to the appointment fee (0+100=100).

Important: The examples used above will be 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, reach out to our customer success team and we can verify the information. 

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

Tip: 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. There, click View on the primary insurance payment:

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

• Filter the date range to the date of the appointment(s)
• Select the Payment Method, including the check or wire number
• Enter the Amount paid
• Allocate the Amount to the Insurance Paid field

• Click Save Payment

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

Medicare crossover claims

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

We’re unable to verify if a client’s Coordination of Benefits is set up with Medicare. We recommend reaching out to Medicare proactively if a client has a secondary policy. When contacting Medicare, you’ll want to confirm that they have the client’s secondary insurance information on file, and if they plan to submit a crossover claim. 

If Medicare will submit the crossover claim, then no action is needed on your part. 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 Payment Responsibility Sequence: 

This indicates that the crossover took place and the appointment(s) will be fully accounted for. 

When this takes place, the secondary Payment Report may indicate that it’s from Medicare, rather than the actual secondary insurance payer. This is because the information in the Payment Report comes directly from Medicare and the system recognizes Medicare as having issued the payment. 

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

If you've confirmed that Medicare won't submit a crossover, then you'll need to create and submit the claim as you would any other secondary claim.