Superbills for out-of-network and cash-pay patients

A superbill is an itemized receipt that an out-of-network or cash-pay patient can send to their insurer to ask for reimbursement. RafaNest builds one from the visit, with your provider details, the CPT and ICD-10 codes, the place of service and the amount the patient paid. It is a receipt the patient submits, not a claim you file for them, and whether the insurer pays is the insurer's decision.

What RafaNest fills in for you

• Your details. Practice name, address and phone, your NPI and license number, and your tax ID with only the last four digits shown. You can add a referring provider and their NPI.
• The patient and the coverage. Name, date of birth, address, insurer, group number and relationship to the insured, with only the last four digits of the member ID shown. You enter the insurance details once and RafaNest reuses them.
• Each visit. The CPT code, the ICD-10 diagnosis codes with pointers to them, the place of service, units and fee. If you documented codes in the visit's clinical note, those take precedence over the defaults set on the service.
• Units for timed services. For codes billed per 15 minutes, such as physical therapy and acupuncture codes, RafaNest can work out the units from the visit length. Per-session codes, including the common psychotherapy codes, stay at one unit.
• Telehealth. A video visit is coded with modifier 95 and place of service 10, meaning the patient's home, unless you choose otherwise. Payers differ on telehealth coding, so it is worth checking the patient's plan.
• Several visits at once. One superbill can cover several visits for the same patient, one line each, with a total that matches what was paid.

Every superbill gets a reference number and an issue date. A saved superbill is not edited afterward. A correction is a new version that replaces the earlier one, so the patient never holds two conflicting documents without a record of which is current.

A check before it goes out

When you send a superbill, RafaNest checks it first. If the NPI, the tax ID, the CPT code or an ICD-10 code is missing, or a diagnosis is a header code that cannot be billed on its own, the send stops and lists what to fix, because a patient's claim would likely be rejected. You can still send it as it is, and that choice is logged. Softer issues, such as no practice address, no date of birth for the patient, a missing insurer name or member ID, or a code that is not in the reference list, appear as warnings and do not block the send.

Sending it to the patient

The patient receives a message with a link to the superbill in their patient portal. From there they can print it or save it as a PDF and submit it to their insurer. Check with the patient which address and form their plan wants, since out-of-network rules and forms vary by insurer.

Your part, the coding

RafaNest fills in and checks the fields, but the codes are yours. A superbill says what you documented and billed, so the CPT code must match the service you provided and the diagnosis must be one you have actually made. The superbill itself says that it is provided for possible reimbursement and does not guarantee payment. Explain that to patients up front, so nobody expects a refund that the plan does not offer.

Self-pay patients and the Good Faith Estimate

For patients who pay you directly instead of using insurance, the No Surprises Act asks for a Good Faith Estimate of expected costs before care starts. RafaNest builds one from your service prices and includes the disclosure text that CMS provides. It also asks for the details the rule requires, such as the patient's date of birth and your NPI, tax ID and address. Read Good Faith Estimates for self-pay therapy clients for who needs one and when it is due.

Superbills and Good Faith Estimates are part of the Professional plan.

New to this? Read what a superbill is and how to write one. If your practice is mostly self-pay, see how to start a cash-pay therapy practice. Coming from another system? Read how to switch from SimplePractice to RafaNest.