Superbill template

A superbill is an itemized receipt you give a client who paid you directly, so they can ask their insurance plan to pay back part of the cost. It is the client who sends it in. Whether the plan pays anything depends on the plan, the service and the codes on the form. Below is a blank template you can print, then what goes in each field.

Superbill

Statement date: ____________

Provider

Practice or practitioner name:
Credentials and license number (state):
Practice address and phone:
NPI (and group NPI, if you bill as a group):
Tax ID (EIN, or SSN if you have no EIN):

Client

Client name:
Date of birth:
Address:
Insurance plan and member ID (optional):

Diagnosis codes (ICD-10)

1:
2:
3:

Services

Date of servicePlace of serviceCPT / HCPCS codeModifierDiagnosis (1-3)UnitsFee
Total charged:
Amount paid:
Date paid and method:
Balance due:
Provider signature:
Date:

Provider details

Plans may want to see who provided the service and that they are licensed. Use the name and NPI you are listed under in the national NPI registry, and the tax ID you bill under. If you don't have an NPI yet, you can apply for one for free through NPPES. Only use an SSN if you have no EIN: an EIN is free from the IRS, and the superbill goes wherever your client forwards it. NPI registry search · NPPES.

Codes

Diagnosis codes are ICD-10 codes, and service codes are CPT or HCPCS codes. Use only codes that match what you did and what is within your license and scope of practice. Your profession's association and your state board are the right places to check which service codes apply to your work. A plan may also need a diagnosis from the client's own doctor.

Place of service and telehealth

Place of service is a two-digit code for where the visit happened. Three common ones:

  • 11: office.
  • 10: telehealth, with the client at home.
  • 02: telehealth, with the client somewhere other than home.

Some plans also ask for a modifier, such as 95, on video visits. Rules differ by plan, so check with the plan or your billing guidance. CMS: telehealth place of service codes.

Things that can get a superbill sent back

  • A missing NPI, tax ID or signature.
  • No diagnosis code, or a service line with no diagnosis linked to it.
  • One total for several visits instead of a line per date of service.
  • No proof the client paid (amount, date and method).
  • A name or date of birth that doesn't match the plan's records.

A superbill holds health information, so send it the way you would send any other client record, and give it to the client, who decides whether to send it to the plan.

If you work with people in cancer care

Alongside lists dietitians, acupuncturists, massage therapists, counselors and other practitioners who work with people in or after cancer treatment. When a session on Alongside is complete, you can issue the client a superbill from it. Your NPI and tax ID come from your profile, you add the codes and place of service, and you can void it if something was wrong. Joining is free today, you set your own rates, and we verify your license before you can accept patients. We are adding Illinois practitioners first. See how joining works or create your practitioner account.

This page is general information. It is not billing, coding, legal or tax advice, and it doesn't mean any plan will pay. Check the plan's rules and your own billing guidance. Alongside is not affiliated with CMS or any insurance plan.