SimplePractice makes it easy to submit claims electronically. You can create and submit claims individually, or in batches, so long as the minimum information within your client and account settings is entered. 

In this guide, we’ll cover: 

• Entering the minimum information required for claims
• Setting your service rates
• Filing claims with both your organization NPI and individual NPI
• Creating and submitting claims
• Reviewing claim statuses
• Running claim reports
• FAQs

For a full walkthrough of how to set up your account for insurance billing, see Getting Started Guide: Insurance.

Note: Submitting secondary claims in SimplePractice is a separate process. See Filing secondary insurance claims for a detailed walkthrough.

Entering the minimum information required for claims

If any of the following information is missing from a client’s file, you’ll receive an error when trying to create a claim: 

• First name
• Last name
• Date of birth
• Gender 
  • This is required by insurance payers for billing
• Address
• Phone number
• Insurance information, including:
  • The payer ID
  • Member ID

Note: If you’re unsure which payer ID to use, see Adding insurance payers and selecting the correct payer ID.

If any of the following information is missing from your account settings, you’ll receive an error when trying to create a claim: 

• Provider name
• NPI
  • If you use a solo and group NPI, see Filing claims with both your organization NPI and individual NPI.
• Tax ID or Social Security Number
• Billing provider address

Additionally, a diagnosis code is required before being able to create a claim. For more information on adding a diagnosis code, see Adding a diagnosis & treatment plan to a client's chart.

If you’re still unable to create a claim after entering all of the above information, make sure the date of service has Insurance set as its billing Type. To do this:

• Navigate to the client’s Billing tab
• Locate the appointment in question
• Click Manage > Edit details
• Set the Type to Insurance

• Click Save

Setting your service rates

When setting your service rates, bill your full appointment fee on claim forms, even if that amount exceeds your contracted rate. The reason for this is that insurance payers will pay your contracted rate and will write-off the remaining balance. 

If you’re not enrolled to receive Payment Reports, this remittance information will be outlined in the Explanation of Benefits (EOB) sent by the payer after they’ve processed the claim. If you’re enrolled to receive Payment Reports, the insurance payment will be automatically posted to your account, and the write-off recorded. For a walkthrough on how to submit enrollments to receive Payment Reports, see Submitting enrollments to file claims and receive Payment Reports. 

Filing claims with both your organization NPI and individual NPI

If you have two NPIs, you’ll want to enter these credentials into the correct fields so they populate on claims as needed for successful filing. To do this:  

• Navigate to Settings > Profile & Security > Clinical
• Enter your individual NPI Number under Clinician Information

• Click Save Information

Note: Each clinician that will be billing insurance in a group practice will need to enter this in their respective account. 

After you’ve entered your individual NPI, enter your organization NPI. To do this: 

• Navigate to Settings > Billing and Services 
• Enter your Organization NPI

• Scroll down and click Save

Make sure to also enter the Tax ID associated with your organization NPI. 

Now that both NPIs are entered, you’ll want to set your account to populate claims with both NPIs. To do this:

• Navigate to Settings > Billing and Services > Insurance
• Locate the billing profile in question
• Click Edit

Note: To learn more about how to manage your billing profiles, see Managing billing profiles for insurance.

• Choose the Organization option
  • If you’re only billing under your individual NPI, choose Individual

After adjusting this setting, if billing as an Organization, claims will populate with the rendering provider’s individual NPI in box 24j, and the practice’s organization NPI in box 33. 

Creating and submitting claims

Claims can be created from a client’s Billing page, or from your Unbilled appointments page.

Note: The Unbilled appointments page allows you to create and submit claims for multiple clients in batches. You can also use this page to filter unbilled appointments by insurance payer, clinician, or by whether or not their progress notes are locked. For additional information on how to use this page, see Creating batch claims.

To submit a claim from a client’s Billing page: 

• Click New > Claim/CMS1500

• Select each of the dates of service you’d like to include on the claim
  • Up to 6 dates of service can be included on a single claim
• Click Create Claim

This will create the claim and put it in a Prepared status. You can click Save and review the claim, or click Submit to send it to the payer. 

Reviewing claim statuses

Once you’ve submitted a claim electronically, its status will update based on information our clearinghouse receives from the payer. 

You can review the status of your claims by navigating to Insurance > Claims and using the available filters.

There are many different statuses that can be assigned to a claim. For a full breakdown of each status and what action is needed respectively, see Checking a claim status: The different phases of an insurance claim.

Running claim reports

There are several reports you can run to stay on top of your insurance claims. You can view these reports under Analytics > Reports > Insurance:

For a full breakdown of these reports and how to use them, see Understanding your insurance reports.

FAQs

Below, you’ll find answers to commonly asked questions about filing primary claims, including: 

• What additional fields can be enabled?
• Why can’t I edit the payer ID on a claim?
• Do payers require I include box 32 on claims?

What additional fields can be enabled?

After entering the minimum required information needed to submit a claim, there are additional fields that can be enabled as well. To enable these fields:

• Navigate to the client’s Overview page
• Click Edit > Billing and Insurance
• Scroll down to Insurance Claim/CMS Fields
• Select Show additional claim fields

• Complete the fields you want to populate onto your claim forms
• Click Save Client

The fields you’ve completed will populate specific boxes on claim forms. The information and the box they’ll populate are listed below: 

• Box 9: Include secondary insurance info on primary claim?
  • This option will only be present if you have already saved the primary and secondary insurance information in the client's profile. 
• Box 10: Is patient's condition related to:
  • Employment?
  • Auto Accident?
  • Other Accidents?
• Box 14: Date of current illness or injury.
• Box 16: Dates patient unable to work.
• Box 17: Referring provider.
• Box 18: Hospital dates related to services.
• Box 20: Outside Lab and Lab Charges.
• Box 27: Accept Assignment?
  • If No is selected, the payer will send reimbursement directly to the client. This option should only be used if you’re courtesy billing.

Most payers don’t usually require these fields. Check with the payer if you’re not sure whether to enable one of the additional fields.

Why can’t I edit the payer ID on a claim?

A payer ID is the primary piece of information our clearinghouse uses to process claims. Each payer that has an electronic filing connection will have a unique payer ID assigned to it. Other clearinghouses may use their own payer IDs, so it’s important that when filing claims from your account, you only use the payer ID assigned in SimplePractice. 

Once a claim is created, the payer ID in box 1 is tied to it and can’t be edited. If a claim hasn't been submitted electronically yet, and you need to change the payer ID, you can delete and recreate the claim after you’ve adjusted the client’s Insurance information. 

If the claim was already submitted, and the wrong payer ID was used, see What should I do if I submitted a claim to the wrong payer?

Do payers require I include box 32 on claims?

Box 32, the service facility location, is specific to each payer. Because most payers don’t require it, we recommend excluding it unless explicitly requested that it be included.   

Important: If the NPIs populating in box 32a and 33a are identical, the service facility location shouldn’t be included, as the claim can be rejected by the payer due to having duplicate data. 

If required, here’s how to include box 32 on claims: 

• Navigate to Settings > Billing and Services > Insurance
• Check Include on Claim Form under Service Facility Location (Box 32)

• Click Save

Selecting this option will automatically populate box 32 of your claims with the address of the location you assigned to the client when scheduling their appointment.