Out of Network Billing

Billing Fee for Service and Out of Network Clients

Cases often arise where you need to bill the client directly for services and have them remit payment directly to you.  The two most common scenarios are when the client does not have insurance benefits (known as fee-for-service billing), or the client does have insurance, but you are not contracted with the insurance payer (known as out-of-network billing).

In either fee-for-service or out-of-network billing, you’ll want to be able to render an invoice to the client, keep track of their account balance, post payments against their account and provide various kinds of documentation and forms necessary for them to file a claim with their insurance company (in the case of out-of-network billing).

This document provides an overview of best practices for either fee-for-service or out-of-network billing with My Clients Plus.

Out-of-network Billing Options

In out-of-network billing, your client has insurance coverage, but is responsible for billing the payer and receiving reimbursement. Your obligation is to provide them the documentation necessary for them to file the claim.

My Clients Plus provides you three basic options in support of out-of-network billing:

  1. Insurance super bills. These invoices provide your clients the information they need to complete file a claim with their insurance company.  Things like the CPT and/or diagnosis codes are listed on the super bill.
  2. Paper CMS-1500 forms. You have the option of generating a completed CMS-1500 form on behalf of the client so that they can mail it to the insurance company.
  3. Submit the claim electronically on their behalf. You can submit the claim on behalf of the client and receive electronic status information on the claim (this is possible for those insurance payers that don’t require electronic billing pre-enrollment). The client would still be responsible to follow up with the insurance company should that be necessary.

The Setup

To begin using My Clients Plus, you must first complete the following Setup Screens.  Once these screens are completed, you will not need to enter this information again…the system will remember it for you.

Practice Setup – this is where you put all your practice information such as tax ID, NPI, office address and billing address.

Bill Code Setup – many codes are already set up for mental health, but you may want to add other codes and need to update the billed charges to your normal and customary rate.

Diagnosis Code Setup – several codes are pre-loaded, but you can add any additional codes as necessary.

Insurance Setup – this is used if you will be providing a CMS form for your client or if you are going to submit the claims electronically on their behalf.

Client Setup – this is where you enter the client’s demographic information.

Client Setup:

  1. The Client Invoice Option gives three choices:
  • Standard – basic client invoice
  • Insurance Super Bill – standard client invoice + diagnosis code and Provider information. 
  • Account Statement Format –most detailed client statement typically used when billing insurance.

The Insurance Super Bill option is the recommended setting for Fee-for-service and Out of Network billing.

The client insurance information should NOT be entered in the Client Setup at this point in the process if you wish to create a CMS form as an out-of-network provider.

Creating the Insurance Superbill

To create the Insurance Superbill, you must enter the Client Session and invoice it. Select your client at the top in the client drop down, then click on Daily Activity - Client Session and choose the date of service from the calendar. Click on Add New Session.

Client Session

Choose the appropriate:

  • Billing Code
  • Diagnosis Code
  • any Paid at Session amount
  • If you are going to add units, bill code modifier or additional diagnoses codes to a CMS form, you may click on the appropriate entry blocks.
  • Click Save once completed.

Invoice Clients and Insurance

In the menu panel, click on Daily Activity - Invoice Clients and Insurance, or Client and Insurance Invoices on the dashboard. The sessions that you have entered and saved in Client Sessions will be listed on the Review Billable Sessions screen.

You will note under the “Bill To” column that it should say PvtPay-Superbill if you are creating an Insurance Superbill.

  • If there is a green icon and a check in the box on the left of the client session, then the session is ready to bill.
  • Click on Generate Invoices and Insurance Forms to generate the Insurance Superbill.

Once the Client Session is generated, the system will create a PDF file that you may open to view and print the Insurance Superbill. The Insurance Superbill contains all the information that the client needs to submit a claim to their insurance payer or flexible spending account for reimbursement.

Creating the CMS form

If you wish to give your client a ‘Value Added’ service, you can then either create a paper CMS form for the client or submit the claims electronically for the client (for those insurance payers that don’t require pre-enrollment. The list of insurance payers that require pre-enrollment are available in our main website under EDI Enrollment Forms at the bottom.)

To provide this ‘ Value Added’ service for your clients, simply click on the $ icon by the client name at the top of the screen. 

Click on the “Generate Out-of-Network Claims” located at the top of the Account Activity. This will open up a selection screen where multiple DOS may be selected to create the claim based on the date range selected in the Account Activity by Client. If a claim has already been created for a DOS, the DOS will be listed, but there will not be a selection box available next to it.

The first time you are generating claims on behalf of your client, you will need to enter their insurance information, either paper or electronic. Click on the clients name to view the insurance information.

Choose one of the insurance payers that you previously set up in the Code Setup - Insurance Companies either as a paper insurance payer or an electronic insurance payer or you may choose to set it up now by clicking on the green +.

Choose the appropriate insurance payer and complete the additional information needed, including:

  • Insured’s ID
  • Insured’s name and address
  • Insured’s birthday

Once the insured’s information is completed, simply click Save. Back on the Generate Out of Network Claims screen, select the dates you wish to generate, then click on Generate Invoices and Insurance forms.

The system will create a PDF file of the paper or electronically submitted claim so you can review it (for electronic claims, it has submitted the claims electronically for you).  If you would like to print a copy of it, you may simply open it and then click on File/Print in Adobe.

Note when CMS forms are submitted in this manner that there is no “Signature on File” in block 13, so the insurance payers will reimburse the client AND the “Accept Assignment” is marked “No”.

Balances Due You Report

You can review the status of the electronically submitted claims in the Balances Due You/Electronic Claims Status Report. Once an electronic claim is generated as Out-of-Network, it will be listed at the bottom of the Balances Due You report. 

When claims are first submitted, the electronic billing status icon will  be a blue ! which means it is being processed by the clearinghouse.

Once the clearinghouse has processed the electronic claims, the icon will turn to a green check if it is passed on to the insurance payer or a RED X if it is rejected for any reason.  In this example, the claim shows that it was rejected.

When you move your mouse over the electronic billing icon, a Claim Status box will pop up giving you the latest electronic message. In this particular example, the client and provider is incorrect (as we used dummy information for the example claim submission).

When the claim submission has been successfully submitted to insurance and you no longer need the claim, you can simply click on the electronic billing icon to delete this electronic claim submission from your records.

The client session, and all of that data, remains stored in your account. It is only the electronic listing on the Balances Due You report that is deleted.

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