A superbill is an itemized receipt healthcare providers, like therapists, give to patients who have paid for services upfront. This document is a detailed invoice that contains specific medical and billing information required by insurance companies. Patients use the superbill to submit a claim directly to their health insurance provider to seek reimbursement for out-of-network services they have received. This process is used when a therapist does not have a contract with the patient’s insurance plan, making the patient responsible for the full fee at the time of service.
Required Elements of a Superbill
A superbill is more detailed than a standard receipt and must contain accurate, mandatory information about both the provider and the patient for an insurance claim to be accepted. This includes the provider’s full name, professional credentials, physical practice address, and contact information.
The provider must also include their unique 10-digit National Provider Identifier (NPI) number, along with their Tax Identification Number (TIN) or Employer Identification Number (EIN). The superbill must also clearly list the patient’s full name, address, date of birth, and their insurance policy information for proper identification and claim processing.
The service details rely on specific standardized codes. Current Procedural Terminology (CPT) codes describe the exact service provided, such as “90834” for a 45-minute individual psychotherapy session. International Classification of Diseases (ICD-10) codes are also required to classify the patient’s diagnosis, which establishes the medical necessity for the treatment. Each date of service, the corresponding CPT and ICD-10 codes, and the fee charged for that session must be clearly itemized.
Submitting the Superbill for Patient Reimbursement
The first step in seeking reimbursement is for the patient to thoroughly understand their out-of-network benefits by contacting their insurance company. Patients should inquire about their specific out-of-network deductible amount, the percentage of costs the plan covers after the deductible is met, and any limits on the number of sessions allowed. Knowing these details helps set realistic expectations for the amount the patient may receive back.
After paying their therapist’s full fee and receiving the completed superbill, the patient must gather any additional forms required by their insurer, often found on the company’s member portal. The superbill and the completed insurance claim form are then submitted to the insurance company, typically through an online portal, via postal mail, or by fax.
The insurance company reviews the submitted claim to determine if the services are covered under the plan’s out-of-network benefits. If the patient has not yet satisfied their out-of-network deductible, the claim may be approved, but no reimbursement check will be issued. Once the deductible has been met, the insurer will process the claim and send the patient an Explanation of Benefits (EOB) document detailing the decision and the calculated reimbursement amount. Patients should actively track the claim status through their insurance portal.
Superbill Versus Direct Insurance Claims
The superbill process is different from a direct insurance claim, primarily due to the contractual relationship between the provider and the insurance company. When a therapist is “in-network,” they have a contract with the insurer and agree to accept a pre-determined, discounted rate for their services. In this scenario, the therapist handles the administrative work of submitting the claim directly, and the patient is only responsible for a co-pay or co-insurance amount.
When a therapist is out-of-network, they have no contract with the insurance plan and are not bound by the insurer’s fee schedule. They charge the patient their full, standard fee upfront. This shifts the administrative burden of seeking reimbursement onto the patient, who must submit the superbill to the insurer.
The superbill allows patients to utilize their out-of-network benefits, which are typically found in PPO plans, even when seeing a provider who does not accept their insurance. Unlike a direct claim, the payment from the insurer goes to the patient, not the provider, because the patient has already paid for the service in full.