Filing primary claims in SimplePractice

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

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

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:

1. Navigate to the client’s Billing tab
2. Locate the appointment in question
3. Click Manage > Edit details
4. Set the Type to Insurance
5. 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. 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 enter your individual NPI:

1. Navigate to Settings > Profile > Clinical info
2. Click Edit next to Clinician details

3.  Enter your individual NPI number
4.  Click Save

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:

1. Navigate to Settings > Client billing and insurance > Insurance documents
2. Enter your Organization NPI
3. Click Save changes

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:

1. Scroll down to your default Billing provider info
2. Click Edit next to your Default set of information

3. Choose the Organization option

4. If you’re only billing under your individual NPI, choose Individual
5. Click Save profile

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.

Note: Billing profiles can be used to populate claims with different sets of information based on the payer or clinician. If no billing profiles are added, your default billing provider information will populate all claims. To learn more, see Managing billing profiles for insurance.

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:

1. Click New > Claim/CMS1500

2. 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

3. 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.