What is a superbill and why do you need it?

What is a superbill? 

A superbill is a detailed invoice or receipt used in medical billing. It provides a comprehensive breakdown of services provided by a healthcare provider to a patient, along with associated costs. Superbills are typically used in the billing process for healthcare services that may be reimbursed by insurance companies.

The information on a superbill includes details such as the date of service, the healthcare provider's information, the patient's details, a list of services provided (including medical codes), the cost of each service, and any applicable diagnostic codes. This document serves as a record of the patient's visit and the services rendered, facilitating the reimbursement process with insurance providers.

Patients can use superbills to submit claims to their insurance companies for reimbursement or to apply for healthcare benefits. Additionally, healthcare providers use superbills as part of their administrative process to keep track of services rendered and financial transactions.

How does a superbill payment work?

Typically, superbills are provided to patients and insurance companies that are out of network. 

If a provider is out of network, they are not connected to your insurance carrier. That means treatment and sessions may not be covered by insurance. 

As such, your provider won’t submit for payment to your insurance company. Instead, you can request to be reimbursed by your insurance company for a part of your costs. A superbill is your key to doing this.

You can contact your insurance provider to learn if you have out-of-network benefits. Medicare recipients do not have out-of-network benefits. It is important to know what your benefits are before beginning treatment. Also, ask if you’ll need prior authorization for out-of-network services.

If your insurance provider confirms that you have out-of-network benefits, you may be reimbursed for some of the costs you paid out of pocket.

How superbill math works

Your insurance company will process your reimbursement according to the details of your plan. Based on your insurance carrier’s policies and your plan, several factors determine how much you may be reimbursed. This is how the math is determined:

1.  Determining the "amount allowed" by insurance companies: Insurance companies set a price for what they believe physical therapy costs. So if you pay $175 for your initial physical therapy evaluation and for instance, your insurance sets the price at $125, you will be reimbursed only that $125. The additional $75 will not be reimbursed or calculated as part of your deductible, insurance, or co-pay.

2. Determining your out-of-network deductible: Most people have a deductible, which means they need to pay a certain amount (or the deductible) before insurance kicks in anything. Deductibles exist for out-of-network and in-network benefit. So if you have a $1,000 deductible, you have to spend that much out of pocket before insurance pays anything. Submitting Superbills for out-of-network benefits adds to your deductible, but they will only track the "amount allowed" not your actual cost. 

3. Determining Co-insurance and Co-Pays: Co-insurance is a percentage and co-pay is a flat fee. So if you have a 20% co-insurance from your insurance whose "amount allowed" is $100, you will get reimbursed $80 per session. If you have a co-pay of $10, you will be reimbursed $90. 

When you put all these factors together, here’s an example of what you might expect to be reimbursed by your insurance company for a PeteHealth physical therapy initial evaluation:

• You paid PeteHealth the out-of-pocket $175 fee for an initial evaluation and submitted a superbill to your insurance carrier.
• Your insurance company decides the amount allowed for this service is $125, which is the maximum they will consider for reimbursement.
• Your plan determines that your coinsurance is 20% for this physical therapy evaluation (or $25).
• You have met your deductible for the year and are therefore eligible to be reimbursed.
• When processed, your insurance carrier will reimburse you $100 for your therapy session.

In most cases, your insurance company won’t reimburse 100% of what you paid to your provider. Depending on where you live and your provider’s fees, this can be much higher.

Who creates the superbill?

The provider you are receiving services from creates the superbill. They may offer superbills regularly. But, you will need to talk to your provider to find out when you should expect to get your superbill. 

A provider can agree with the patient to give them a superbill or not. But, they don’t have to provide one.

Do I have to ask my provider for my superbill, or do they send it automatically?

Your provider will choose how you receive your superbill. First, it is important to know if your provider is willing to and can provide you with a superbill. You can ask your provider about the process for using superbills during your consultation. 

The provider has options for how they give out superbills. Your provider may have an electronic medical record that sends out a superbill. They may also have a system that gives patients access to download the superbill through a portal. 

What information is required on a superbill?

Insurance carriers have specific requirements for how they want treatment providers to complete superbills. If any information is missing, the insurer may deny the claim or follow up to get more information before they send payment. 

Here are some common items that are typically included on a superbill: 

• Patient contact information: This may include name, address, date of birth, phone number, and any unique identifiers requested by the insurer. 
• Provider information: This may include the provider’s name, location of practice, state license number, phone number, and email address. The provider should also include their 10-digit National Provider Identification (NPI) and employer identification number (EIN) for tax purposes.
• Your diagnosis: Your insurance company needs to know why you needed physical therapy services. So, a superbill needs to include your diagnosis in the form of an ICD code. The International Classification of Diseases (ICD) diagnostic code shows what a patient is being treated for and helps the insurance company validate that treatment is medically necessary.
• CPT code: The Current Procedural Terminology (CPT) code is used by healthcare providers to describe specific medical and diagnostic services that a patient receives. This tells insurance companies what kind of services you receive, such as an initial evaluation with a physical therapist.
• Dates of service: The provider should include all dates they worked with the patient. If there are multiple dates of service on the superbill, the most relevant procedure code should be listed by each date.
• Itemized list of costs: The service amount should be included next to each procedure code. The total balance should reflect the costs of all services performed. The service provider should also include any out-of-pockets costs that were paid by the patient.
• Referrer identification: The provider or other type of treatment provider must include the contact information of the healthcare provider that may have referred the patient (if applicable).

You can ask your insurance company for a list of what is required on a superbill before submitting it. And if anything is missing, you can ask your provider to update your superbill.

What do you do with your superbill once it’s filled out?

If your provider provides you with a completed superbill, you can submit it to your insurance provider. Your insurance provider should give instructions on how to submit a superbill. Follow the guidelines and call your insurance provider if you have any questions. 

Below are some common ways to submit your superbill: 

• Upload through insurance company portal (look for a “submit claims” option)
• Mail in your completed information
• Send a fax

Once your superbill has been accepted, the insurance carrier will send payment. Most of the time, your insurance company will reimburse you directly.

Is there a time limit in submitting my superbill for reimbursement?

Yes, but it depends on your insurance provider. It is important to check with your insurance carrier for their specific time frame. These guidelines can also be set by state health insurance laws. Typical time limits can range for 90 days to a year.

What happens if my insurance company denies my superbill?

If your insurance company denies your superbill, first find out why. Your insurance company must explain why your claim was denied. Look for the reason in your explanation of benefits (EOB).

There can be many reasons why your superbill claim was denied. These can include:

• Missing information on the superbill
• Incorrect billing or diagnosis codes
• Claim was submitted outside the time limit
• Lack of coverage for submitted services
• Determination that the services aren’t medically necessary

If your claim for reimbursement is denied, you have several options. If your superbill or claim was missing information, you may need to resubmit a corrected claim. Then, your insurance company can reprocess it.

You can also appeal a denied claim. Your insurance company must let you know the process for appealing the decision. First, you’ll appeal to your insurance company. This formally asks your health plan to reconsider your claim. 

If your insurance carrier denies your claim again, you may have the option to appeal to your state’s insurance regulators. This allows you the opportunity to have your claim reviewed by an independent party.

Key Takeaways

• A superbill is a detailed invoice, typically used in the billing process for healthcare services that may be reimbursed by insurance companies.
• Your insurance company will process your reimbursement according to the details of your plan. 
• If your claim is denied, you can re-submit or appeal your claim. 

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