Submitting a Superbill to your insurance provider is a common process when you’ve paid out-of-pocket for healthcare services, particularly if those services are out-of-network, meaning they were provided by a healthcare provider not contracted with your insurance company. Out-of-network benefits allow for partial or full reimbursement of these costs. Each insurance plan is a little bit different, so it is advised to call the number on the back of your insurance card for specifics regarding your plan’s requirements. In this post, we list general guidelines, along with examples of how to submit Superbills for Providence Health Plan (Premera) and Tricare Select.
First let’s take a quick look at Out-of-Network Benefits:
Out-of-network benefits refer to the coverage that your health insurance plan provides when you receive care from a healthcare provider or facility that does not have a contract with your insurance company. Here’s how they work:
Network Basics:
- In-Network Providers: These are doctors, hospitals, and other healthcare providers that have agreed to a negotiated rate with your insurance company.
- Out-of-Network Providers: These are providers who have not agreed to the negotiated rates with your insurance company.
How Out-of-Network Benefits Work:
- Limited Coverage: Your insurance may cover a percentage of the costs (like 50-70%) after you meet a separate out-of-network deductible.
- Claim Submission: For out-of-network care, you may need to submit a claim to your insurance company yourself (this is called a Superbill). They will review the claim and reimburse you for a portion of the costs according to your plan’s out-of-network benefits.
- Pre-Authorization: Some plans require pre-authorization for out-of-network services.
General How To
1. Get a Referral to start PFPT
- Your insurance plan may or may not require a referral
2. Pay Upfront and Obtain a Superbill
- Request a Superbill from us: Ask us for a Superbill for each appointment (this is NOT the same as a receipt). This is a detailed document that includes necessary information for insurance reimbursement.
- Ensure Completeness: The Superbill should include:
- Your full name and insurance ID number
- Provider’s name, address, and National Provider Identifier (NPI)
- Dates of service
- Detailed descriptions of services rendered
- CPT (Current Procedural Terminology) codes
- ICD (International Classification of Diseases) diagnosis codes
- Total amount paid
3. Get a Claim Form (if required)
- Check with Insurance: Visit your insurance company’s website or call customer service to see if they require a specific claim form to be submitted along with the Superbill.
- Complete the Form: Fill out the claim form accurately, ensuring that all information matches the details on the Superbill. Fill in all boxes with Superbill information, do not just rely on insurance to check your Superbill. Not doing this may result in your claim being denied.
- Attach Documentation: Attach the Superbill to the claim form. You may also be required to attach an invoice or receipt. If the claim form or receipt isn’t required, just submit the Superbill.
4. Submit to Insurance
- Methods of Submission:
- Online: Many insurance companies allow you to submit claims through their online portal. Log in to your member account, locate the claims section, and follow the instructions for uploading your Superbill and claim form.
- Mail: If mailing, send the documents to the address specified by your insurance provider. This address is usually found on the claim form or the back of your insurance card. Be sure to keep a copy for your records.
- Fax: Some insurers accept faxed submissions. Use the number provided by your insurer and keep the fax confirmation for your records.
5. Track Your Claim
- Confirmation: After submitting, check for any confirmation from your insurance company (via email, online account, or mail).
- Follow Up: If you haven’t received confirmation or heard back within a few weeks, contact your insurance provider to check the status of your claim.
6. Receive Reimbursement
- Reimbursement Process: If approved, the insurance company will process your reimbursement according to your plan’s benefits. The payment may be sent via check or direct deposit, depending on your preferences and what the insurer offers. This may take 15-30 business days.
- Explanation of Benefits (EOB): You’ll receive an EOB from your insurance company explaining how much was covered, how much you were reimbursed, and any remaining balance.
7. Keep Records
- Documentation: Keep copies of the Superbill, claim form, and any communication with your insurance provider. These records may be important if there are any issues or discrepancies with your claim.
By following these steps, you can efficiently submit a Superbill and seek reimbursement for your out-of-pocket healthcare expenses. Be sure to follow any specific guidelines or requirements set by your insurance provider to ensure a smooth process.
Example Guide to Submitting a Superbill to Providence Health Plan with Premera Insurance:
1. Get a Referral to start Physical Therapy at Empowered Physical Therapy
- Your insurance plan may or may not require a referral.
- Your referral does not need to specify “pelvic floor physical therapy”
2. Pay Upfront and Obtain a Superbill
- When you receive PT services from us, you’ll need to pay for these services upfront. Premera requires this payment as part of the reimbursement process.
- Request a Superbill from us (this is NOT the same as a receipt). Ensure it includes your details, provider’s information, date of service, CPT codes, ICD codes, and the amount paid.
2. Fill Out a Claim Form
- Some insurance companies, including Premera, may require you to fill out a claim form. You can usually download this form from the Premera website or request it by calling their customer service.
- To find the form: go to http://providencehealthplan.com and click on “Member Resources.”
- Click “Individuals & Families”
- Download the “Medical Claim” form and fill out all questions (do not leave any empty just because the information is on the Superbill, this may result in a denied claim).
- Example of Medical Claim Form
3. Submit the Claim
- You can submit your claim and Superbill to Premera through one of the following methods:
- Online: Log into your Premera member account and go to messaging. Start a new message under subject “Customer Service” and sub-subject “Medical Claims & Benefits” with the subject line of “ATTN: Claim.” Upload the Superbill and claim form and an invoice/receipt for the appointment.
- Mail: Send the completed claim form and Superbill to the address provided on the claim form or on the back of your insurance card.
- Fax: If Premera accepts fax submissions, fax the documents to the number listed on their website or your insurance card.
4. Keep Copies
- Make copies of the Superbill, claim form, and any other documentation you are submitting. This will be useful if you need to follow up on your claim.
5. Follow Up
- After submitting, you may want to follow up with Premera to ensure they received your claim and to check the status of the reimbursement. You can do this by calling their customer service or checking your claim status online.
6. Receive Reimbursement
- If the claim is approved, Premera will reimburse you according to your plan’s benefits. The reimbursement check will usually be mailed to you, or direct deposited if you have set up that option.
This entire process may take 15-30 business days. For the most accurate and specific instructions, you may want to visit the Premera website or contact their customer service directly, as procedures may vary slightly depending on your plan.
Example Guide to Submitting a Superbill to Tricare Select:
1. Get a Referral to start Physical Therapy
- Under Tricare Select, ask your primary care provider (PCM) or another authorized healthcare professional for a referral to Empowered Physical Therapy (your referral does not need to specify “pelvic floor physical therapy”)
2. Choose Empowered Physical Therapy as your Certified Out-of-Network Provider
- We’re certified out-of-network providers with Tricare Select and you have the freedom to choose us for your care.
3. Pay Upfront and Obtain a Superbill
- When you receive PT services from us, you’ll need to pay for these services upfront. Tricare Select requires this payment as part of the reimbursement process.
- Request a Superbill from us (this is NOT the same as a receipt). Ensure it includes your details, provider’s information, date of service, CPT codes, ICD codes, and the amount paid.
4. Complete a TRICARE Claim Form
- Download the TRICARE Claim Form (DD Form 2642) from the TRICARE website. Fill out the form completely and accurately.
5. Attach the Superbill
- Attach the Superbill to the completed TRICARE Claim Form. Make sure all the information matches.
6. Submit the Claim
- Mail: Mail the completed claim form and Superbill to TRICARE
- TRICARE West Region
Claims Department
P.O. Box 202112
Florence, SC 29502-2112
www.tricare-west.com
- TRICARE West Region
- Online: At the time of writing this, we cannot find where to access the TRICARE Online Patient Portal. Please let us know if you have the link!
7. Keep Copies
- Make copies of everything you submit for your records. This will be important if you need to follow up on your claim.
8. Follow Up
- Check the status of your claim by contacting your regional TRICARE claims processor or by checking your TRICARE Online account.
9. Receive Reimbursement
- If the claim is approved, TRICARE will reimburse you based on your plan’s benefits. The payment will typically be sent via check or direct deposit. Tricare Select typically covers around 80% of the allowed amount for out-of-network PT services.
For more specific guidance or to address any unique circumstances, visit the TRICARE website or contact your regional TRICARE office.