What Is A Superbill & How Is It Used For Therapy?

What Determines My Reimbursement?

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

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.

Deductible

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.

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.

What If I Have Not Received Reimbursement?

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 I 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 the “Denials” section below)
• If the claim is 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 your superbill was 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 and 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.

Incorrect Billing or Diagnosis Codes

If you have an incorrect billing or diagnosis code, your claim may be denied. It is important that you talk to your therapy provider’s office to ensure you understand why your billing code is what it is, and that the appropriate corrections are made if needed.

Possible remedy: Speak with your provider about recording alternative codes or correcting the codes on the superbill you were given originally.

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 superbill 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.

Determination That Services Were Not Necessary

It is important to note that services are only covered when they are deemed medically necessary. You want to make sure that you are stating that the services you used were medically necessary.

Possible remedy: Obtain a letter, note, or script from your provider or therapist that deemed the services medically necessary.

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.