If a claim was submitted to the incorrect payer for a client's insurance plan, you may receive a rejection right away, or you may find that the claim gets stuck in the Accepted state. In either case, you'll need to create a brand new claim so that it can be submitted to the correct payer in the appropriate format. In this guide, we'll cover how this can happen, and we'll go over the steps you'll need to take to submit the claim properly:
- Scenarios leading to a claim being submitted incorrectly
- Updating a client’s insurance information
- Creating an updated claim
- Correcting insurance payments that were added in error
Scenarios leading to a claim being submitted incorrectly
When filling out intake documentation, clients may accidentally enter an incorrect payer ID that’s not associated with their insurance provider. It’s also not uncommon for clients to switch to a new insurance plan without notifying their provider of the change. In either of these cases, claims will continue to populate with the payer ID that was initially entered in the client’s file. Because the payer ID is used to route the claims to the insurance payer, if it’s listed incorrectly, the claim won’t reach the appropriate insurance payer for processing.
Another scenario we see is when clients have both primary and secondary insurance policies. In these cases, the order in which their claims need to be processed matters and is referred to as their Coordination of Benefits (COB). If a claim is submitted directly to the secondary insurance payer without first being processed by the primary payer, it can lead to rejections, denials, or accidental payments.
Any of these cases result in the claim being submitted incorrectly for the client’s insurance plan and will either be automatically rejected, or accepted for processing and then later denied.
When this happens, you’ll need to submit a brand new claim with the client’s corrected information. In the next section of this guide, we’ll go over how to update a client’s insurance information so a new claim can be created and submitted properly.
Updating a client’s insurance information
In order to resubmit a claim so that it goes to the correct payer, you’ll first need to update the client’s insurance information. This way, all future claims you create will populate with the accurate payer information and will get routed to the appropriate insurance payer for processing.
To do this, first navigate to the client’s Overview page > Edit > Billing and Insurance and update the payer that’s on file in their Insurance Information:
Note: If you're unsure which payer to select, see our guide on adding insurance payers and selecting the correct payer ID.
If the client’s primary and secondary insurance policies were entered out of order, determine which is their correct primary policy and select Primary insurance:
You can then designate the policy that was previously marked as primary as their Secondary insurance.
Once their information is correctly entered, scroll to the bottom of the page and click Save Client. The payer that’s selected will populate box 1 of all claims for this client moving forward.
Important: When updating a client’s insurance information, we recommend saving their prior information as Other and adding the new one as Primary insurance. This way, you’ll have a record of it and will still be able to add, edit, and delete insurance payments that have appointments associated with the old insurance.
Creating an updated claim
In SimplePractice, only one primary claim can exist for an appointment. When a claim is submitted to an incorrect payer, you’ll first need to delete the existing claim so that the date of service can be billed to the correct payer.
To do this, locate the claim in the client’s Billing page and click the trash icon:
Important: Before deleting a claim, we recommend downloading a copy and saving its clearinghouse reference number. Many of our customers choose to store these in the client’s file for their records. You can learn more about storing client documents here: How do I store client documents?
After the original claim is deleted and the appointment is no longer linked to it, you’ll need to create a new claim from the client’s Billing page by clicking New > Claim/CMS1500. This new claim will populate with the client’s updated insurance information and can be submitted for processing.
Note: All new claims are automatically marked as Original in box 22. You’ll need to leave this field as-is because it’s a new claim going to a payer who hasn’t seen it yet.
Correcting insurance payments that were added in error
Rather than rejecting or denying a claim that was submitted incorrectly, insurance payers may issue a payment in error. Once the error is noticed, payers often recoup incorrect payments by either requesting a check or withholding the overpaid amount from a future payment.
If you’ve been paid for a claim that was submitted to an incorrect insurance payer, we recommend proactively reaching out to the payer directly to clarify their preferred method of recouping the overpayment. This will help to avoid any complications down the line.
If the payer withholds the overpaid amount from a future payment, this will be reflected in any payment reports (ERAs/EOBs) that are received and no additional action is needed on your part.
If the payer is requesting a check, you can record this retraction in your account by adding a negative insurance payment. To do this:
- Click Add Insurance Payment in the client’s file
- Enter the negative amount of what was initially paid in the Amount and Insurance Paid fields:
- Click Save Payment to record the retraction
You can learn more about adding insurance payments here: Adding insurance payments.