Many of us pay an exorbitant amount for healthcare, between monthly premiums, HSA or FSA amount that is deducted from a paycheck or COBRA payments. We then attend a therapist session and pay out-of-pocket. After the payment, the next question is, “How can my healthcare reimburse me for the sessions?” The process for insurance to consider reimbursement is through the submission of a Superbill.
What Is a Superbill?
A Superbill is a receipt for a session with an out-of-network counselor allowing the patient to submit to their health insurance. A Superbill may be requested by a patient of a mental health professional; psychiatrist, psychologist, or licensed social worker, when the patient pays out-of-pocket for the qualified medical expense. Reimbursement will be determined by the individual healthcare policy at the time the claim is received.
A Superbill is a statement of service(s) from a provider. The statement reflects the date(s) of service (DOS), the service code or CPT code, the diagnosis code(s) and the billed amount from the rendering provider, along with their credentials. See Figure 1 sample of a superbill below:
Superbills may be referenced by several names, but they all must contain the elements necessary to be processed by the healthcare insurance company.
Other names for a Superbill include:
- Claim form
- Encounter ticket
- Fee ticket
- Invoice of service(s)
- Receipt of service(s)
- Statement of service(s)
What Must Be Included on a Superbill?
Along with different names for the Superbill, each may be formatted differently. Ultimately, each must contain the required details for a successful claims submission.
Patient & Provider Information
The Superbill needs to reflect the behavioral/mental health professional who performed the therapy. As the Superbill serves as a claims form submitted to insurance by the patient, it must have the prime identifiers of the rendering provider, as well as specific details about the patient.
The Provider’s information is labeled in yellow:
- Provider’s first and last name
- Provider’s NPI number and/ or tax identification number
- Office location where services took place
- Provider’s phone number
- Provider’s email address
- Referring provider first and last name (if applicable)
- Referring provider’s NPI number (if applicable)
“An NPI is a unique 10-digit number used to identify healthcare providers. All healthcare providers who are HIPAA-covered entities, whether individuals or organizations, must obtain an NPI.” Learn more about HIPPA covered entities here.
The patient information includes the patient demographic information the provider has documented. As the therapist is not credentialed with your insurance, they may not have the patient’s insurance information that is required for a Superbill. The patient’s member ID will need to be included on a cover letter, when the claim is forwarded to insurance.The patient information is labeled in blue:
- Patient first and last name
- Patient address
- Patient phone number
- Patient date of birth
Service Dates, Codes, & Fees
The Superbill must contain the necessary information detailing the therapy session: The diagnostic code (DX), date(s) of service (DOS), and the fee for each service date.
Details for the therapy sessions is highlighted in red in the list below:
The service date elements are labeled in red:
- Date of Service
- Procedure Code (CPT)
- Diagnosis code (DX)
- Modifiers (if applicable)
- Units or minutes
- Fee charged
How Do I Request a Superbill?
Most providers do not openly offer a Superbill, but will provide it upon request. With the Superbill in hand, it can be forwarded to your healthcare insurance.
How Do I Submit a Superbill?
Each insurance company has unique policies. Therefore, it’s best to call your individual insurance company to obtain your plan benefits. The call to insurance will take 10-20 minutes to verify benefits and submit a Superbill. This time is well spent on the front-end to realize the benefits and expectations of submitting a Superbill to your insurance.
On the back of your healthcare insurance card, call the phone number for “Members” or “Members Services” with your insurance card in hand and the ability to take notes.
To make sure your submission will be accepted:
- Verify out-of-network benefits
- Verify how to submit a Superbill
- Confirm your home address with your healthcare insurance (especially if a check will be issued)
Below are two examples of the back of the insurance card:
In the call to “Member Services,” make sure they have your correct address on file. The healthcare company obtains the address directly from the sponsoring employer. To change the address with healthcare insurance, the policyholder will need to update the address through the Human Resources Benefits Specialist from the employer who sponsored the plan. The individual in the household that works with the employer will need to follow the employer policies to update the address at work and for the healthcare insurance.
What to Ask Your Insurance Company Before Submitting Your Superbill
As most insurance companies are passing more of the out-of-pocket expenses to their members, understanding your healthcare insurance is part of financial well-being. Each time you use your healthcare insurance there is a financial responsibility—as a paying member to healthcare insurance, you can call for an explanation of benefits (EOB). Especially when submitting a Superbill for an out-of-network provider, the benefits can be non-existent or can be dramatically different from your in-network benefits.
Call the healthcare “Members Services” line and ask the questions below:
Ask the representative, “What are my out-of-network healthcare benefits for behavioral health in an out-patient setting?” Take notes of the answers to the following questions:
- Is pre-authorization required? (if applicable)
- Co-payment? (if applicable)
- Deductible? (if applicable)
- Today’s accumulation for deductible? (if applicable)
- Co-insurance? (if applicable)
- Timely filing
If pre-authorization is required, ask the representative to get this started. Many times, they will need to transfer the patient to the person who can grant the authorization. They will ask the patient’s name, date of birth, and member number, along with the name and address of the mental health professional who will provide the therapy.
After the information is completed, the representative will give the member the authorization number that is stored in the insurance database. The authorization will provide a time frame: example 8/1 through 12/31 and/or a total number of visits allowed during the time frame.
Next ask, “I have a Superbill, how do I submit?” Each healthcare company has various ways to submit a Superbill. Most will have one of the below options or all three:
1. Fax Superbill to Insurance
Insurance will provide a fax number to transmit the Superbill. Please do not send from public fax or work fax, as the receipt of fax will include your original fax with Personal Healthcare Information (PHI).
Items to fax include:
- A cover letter is needed to include the patient name and member identification number
- The Superbill.
2. Mail Superbill to Insurance
Insurance will provide an address to mail the Superbill. Along with the superbill, a cover letter is needed to include the patient name and member identification number.
3. Upload Superbill Through Your Insurance Company’s Portal
Your insurance company may have a portal that you can use to upload the Superbill. The portal is the insurance company’s website that requires a username and password. This is the most secure way to transmit your Superbill, and the most timely.
When speaking to the representative, ask if the web portal requires an invitation from them to get started. If not, ask for the web address for the insurance portal. Typically, to create an account an email address will be required, along with a password.
Items to upload via the insurance portal include:
- A cover letter—include the patient name and member identification number
- The Superbill
In Network vs. Out-of-Network Claims
An in-network provider has been reviewed and has contractual obligations with an insurance company. In-network providers in the contract have pre-negotiated rates with the insurance company.
Conversely, out-of-network providers have not been reviewed, do not have contract or terms of fees. Often out-of-network claims are processed separately than in-network claims, with a higher copayment or deductible, based on the individual policy.
Your Insurance Will Determine How Your Superbill Is Processed & Paid
The information received when verifying your healthcare benefits will determine how the Superbill will be processed and any subsequent reimbursement. The primary factors are whether the policyholder has a copayment or a deductible, along with timely filing.
Copayment is the simplest: The reimbursement will be the allowed amount for each service, minus the copayment. As the member is responsible to pay out-of-pocket (the copayment), this amount will be deducted from the payment.
When a policyholder has a deductible, reimbursement needs to be determined by insurance. This is calculated from the amount of the deductible and the accumulations for each therapy session applied. After the deductible is reached, insurance will issue payment, minus the coinsurance. The member is responsible to pay the coinsurance out-of-pocket, which will be deducted from the payment.
Timely filing is the time limit that an insurance company allows for a claim to be submitted. For example, a payer has a 90 day timely filing. This means that all Superbills must be submitted within 90 days of the date of service. Claims that are older than 90 days submitted to insurance, will be “Denied” for being outside timely filing.
What Can I Expect After Submitting My Superbill?
When a claim is received by insurance, most insurance companies will make a determination in two weeks. If reimbursement is due after the claim is processed, most insurances have a specific day of the week when checks are mailed. When the claim is processed accurately and applied to the deductible, no payment is forthcoming.
I Submitted My Superbill & Received No Payment?
Generally, the Superbill will be processed within two weeks. After this time, with a copy of the Superbill in hand, call the “Member Services” number on the back of your healthcare card.
Ask the question, “What is the status of the claim submitted?” The representative will ask for dates of service and the total amount of the charges. Total amount is the accumulation of all the dates of service to include the date range on each page of a Superbill.
Insurance will inform you of the status of the claim(s) at the time of the call: Denied, in process, or completed:
- If a claim is denied, this is the time to ask the representative for the Denial reason, while on the phone. (see Denials reasons)
- In Process, the claims are currently in the process of being completed. Insurance is still completing the process of reviewing the claim(s) against the policy. Insurance has yet to make a final determinization on the claim(s). More time is needed for the insurance claims adjuster to “Finalize” the claim.
- Completed, means the claim is “Finalized.” Finalized claims have two determinations:
- 1) Money will be issued
- 2) The amount for each claim was applied to the patient’s deductible, meaning no reimbursement will be issued to the insurance member.
- Finalized Claim(s) payment will then be issued to the patient: Ask the representative for the dollar amount for each DOS and the total check amount.
- How will the money be issued, by check or EFT?
- When will the money be issued?
- If mailing, confirm the mailing address?
- Finalized Claim(s) to the patient deductible with no payment issued: Ask the representative information on how the claim was determined. Insurance will list the amount for each date of service and the amount that was applied to the deductible. To understand the healthcare policy, ask for the total amount of the deductible and its accumulations.
- Deductible Accumulations are the collection amount assigned to each therapy session. These accruals allow the total deductible to be obtained. After the deductible is met, then insurance will pay (minus the coinsurance, if applicable.)
My Superbill Was Denied – Now What?
In the case your claim(s) is denied, it is recommended to call insurance for them to explain the reason for the denial.
Possible reasons for your Superbill to be denied include:
Prior Authorization Was Required But Not Obtained
The Superbill was received and no prior authorization is on record. The insurance policy requires authorization to be obtained by the client, prior to the counseling session. No prior authorization was obtained, causing the claim(s) to be “Denied” on submission.
Possible remedy: Call “Member Services” with the Superbill “in-hand,” ask about the status of the claim. If the claim was denied for “no prior authorization,” ask if they can “back-date” the authorization, if possible. Either way, it would be beneficial to obtain a new authorization for future care with the provider of choice.
Date(s) of Service Was Outside the Timely Filing of Claims
The Superbill was received by insurance after the ninety-day period of the Date of Service. Any claims that are beyond the time frame of 91 days will be “Denied for timely filing.”
Possible remedy: Call “Member Services” with the Superbill in-hand and ask about the status of the claim. Ask the representative if they can reconsider your Superbill, especially, if you are within 30 days of the timely filing date.
Information on the Superbill Was Incomplete or Illegible
The insurance carrier is stating that the Superbill received was not legible or did not include the required components on the form.
Possible remedy: Call “Member Services” with the Superbill in-hand and ask about the status of the claim. If they state that the form was incomplete or illegible, the representative will state the reason with what is missing or illegible. For example, the Provider’s NPI or name are not present on the form, or the service code is not present on the form.
With the information the representative relays on the phone, examine the copy to see if the elements are present on the Superbill—maybe the insurance company received a bad copy. If they received a bad copy of the Superbill, it can be re-submitted by different means: Fax, mail, or insurance portal. In the case that the information was not present on the Superbill, take notes of the missing data and ask your provider for a Superbill with all the elements needed for successful submission.
No Out-of-Network Coverage
The Superbill is submitted to insurance and denied because the policy has no coverage for those providers that are not paneled to service the insurance members.
Possible remedy: Call “Member Services” with the Superbill in-hand and ask about the status of the claim. If the claim is denied for no out-of-network coverage, ask for a “Single Case Agreement,” which is a contract allowing the specific provider to treat the insurance company’s member or insured for a qualified number of sessions and/or date range. Many “Single Case Agreements” may be renewed at the discretion of the insurance company.
When an Insurance Company Will Not Accept a Superbill
Any insurance coverage inquiries require a call to “Member Services.” This inquiry will be in regards to the claims for an individual provider.
If the claims are present in the insurance company system, the questions are different:
- How did the claim(s) finalize?
- How much was assigned for each Date of Service?
- To whom was the money sent—the patient or the provider?
In the case that no claims are present with insurance, ask how to submit the claims to insurance, either by the patient or the provider. Within this inquiry, ask how you can submit a Superbill to insurance. If the representative is being difficult, it may be best to hang up and call again with the hope of getting a better-informed representative with your insurance.
If all your calls are fruitless, contact your Human Resources Benefits Specialists from your employer. Your HR specialist represents your employer group with the insurance company, and they do their best to keep your employer happy in a highly competitive insurance industry.
Other Potential Superbill Formats
While Superbills must contain the key pieces of information listed above, they are not always in the same format. Here are a couple of examples of what Superbills can look like, with the same identifiers marked as in the above example (click to expand).
The purpose of submitting a Superbill to your healthcare for potential reimbursement is logical. However, the determination of the Superbill is based on the individual healthcare policy. Understanding your healthcare benefits on the front end is the best way to optimize your chances of a successful Superbill submission.
For Further Reading
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- Take a closer look at Talkspace vs BetterHelp
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