Superbill Template for Out-of-Network Therapy

A superbill template is an itemized out-of-network (OON) statement a licensed US therapist gives a client so the client can seek reimbursement. The client has already paid the practice. Give the client a completed superbill template after they have paid, not a second invoice. Licensed US mental-health clinicians and the billing staff who support them complete this document. Clients ask their plan how and when to file.

The pack names every required box, shows one fictional outpatient example, and keeps psychotherapy notes off the statement. Use the CPT codes for therapists guide to choose the service family. The statement only records the service you already chose.

Educational resource for licensed US mental-health clinicians and the billing staff who support them. CPT descriptors, place-of-service rules, NPI enumeration, and payer OON benefits change. Verify current requirements before you issue a statement. This is not a claim form, not legal advice, and not a reimbursement guarantee.

Superbill versus invoice versus CMS-1500

Define the document before you fill it.

Document	Who it is for	What it is
Superbill	The client, then the client’s plan	Itemized OON statement after payment
Invoice or receipt	The client	What they owe or already paid you
CMS-1500 / 837P	The payer	A practice-to-payer claim

The client already paid. This is not a bill and not a practice-to-payer claim. Use insurance billing for therapists for in-network eligibility, clearinghouse submission, remittance, and denials. Give an OON client the completed statement after payment.

What belongs on a superbill template

Walk the blocks in order. Identity, NPI, tax ID, POS, CPT, and amount paid have to match the chart and payer records.

Practice block. Legal practice name, the official practice or service address that matches enrollment and payer records, phone, EIN or tax ID, and the organization NPI-2 when the practice uses one. A home-based practice may list that home address when it is the enrolled location.

Provider block. Rendering clinician name, credentials, license number plus state, and the individual NPI-1. NPI-1 is the Type 1 enumeration for an individual. NPI-2 is the Type 2 enumeration for an organization. Confirm the NPI and provider or entity match in the NPPES NPI Registry. CMS describes Type 1 and Type 2 in its NPI fact sheet.

Client block. Legal name as it appears on the plan, date of birth, member ID, and payer name. List the diagnosis as an ICD-10 code. A short diagnosis title is optional. Do not paste the clinical formulation.

Service table. One row per date of service: date, place of service (POS), CPT, modifier, ICD-10 pointer, fee, amount paid.

Close. Totals, provider signature, date, and a one-line statement that this is not a bill and not a guarantee of payment.

Scroll the visual sideways to view the full diagram

NPI, tax ID, POS, and amount paid

• NPI-1 versus NPI-2. Put the rendering clinician on NPI-1. Add NPI-2 only when the organization is on the statement. Confirm the NPI and provider or entity match in NPPES. NPPES is a registry lookup, not a checksum test.
• EIN versus SSN. The tax ID on the statement must match the practice W-9 and payer records. A sole proprietor may use an SSN when it is the tax ID on the practice’s W-9 and payer records. The digits still have to match.
• POS. CMS place of service codes distinguish office (11) from telehealth. Use POS 10 when the client was at home, POS 02 when telehealth was elsewhere, POS 11 for in-office care.
• Modifier. Add 95 or a payer-required GT only when that plan still requires a telehealth modifier on a real-time video row. Pair video rows with the CPT 95 modifier for telehealth. Check the plan before you print 95 as a default.
• Amount paid. Enter what the client actually paid, not the fee you wish had posted.

CPT on the row must match documented time and service family. Use psychotherapy CPT time rules to distinguish 90834 from 90837. The statement only prints the code you already selected.

Worked outpatient therapy example

Illustrative only. Names, NPIs, and member IDs are fake. Verify current CPT descriptors and payer rules before you copy a row.

Practice. Cedar Hollow Therapy, PLLC, 100 Example Ave, Austin, TX 78701. EIN 00-0000000. Practice NPI-2 0000000000. Phone (512) 555-0100. Email billing@example.org.

Provider. Alex Rivera, PhD. License LP 00000, Texas. Individual NPI-1 0000000001.

Client. Jordan Lee. DOB 01/01/1985. Member ID EX-000000000. Payer: Example Health Plan. ICD-10 F41.1.

The first row is in-office 90837. The second is telehealth 90834 with POS 02 and modifier 95 as one common commercial pairing. Fee and amount paid match because this client paid in full at the visit. These rows are illustrative only. Verify current CPT descriptors and payer rules.

Common denial drivers

Preventable OON problems on this document are identity and field mismatches: names, NPI, POS, modifiers, CPT and time, and amount paid.

• Name mismatch. Nickname on the statement, legal name on the plan.
• Missing or wrong NPI. Blank NPI-1, swapped NPI-1/NPI-2, or digits that do not match NPPES.
• Wrong POS. Office code on a video hour, or home telehealth billed as POS 02 when the payer wants POS 10.
• Missing telehealth modifier. Video row with no telehealth modifier when that payer still requires 95 or GT.
• CPT and time mismatch. 90837 on a 40-minute note is a timed-psychotherapy error. 90837 on a documented urgent crisis assessment, safety work, resource mobilization, and disposition is a service-family error that belongs on 90839. Code choice follows the crisis service delivered, not duration alone.
• Unpaid versus charged. Fee listed as paid when the client still owes the balance.

Fix the row and reissue the statement before the client files.

What never goes on the statement

Keep the chart in the chart.

• Psychotherapy notes and extra clinical narrative
• A mailing-only address that does not match enrollment when the payer expects the enrolled service location
• Nicknames, preferred names that do not match the plan, or informal email handles as the legal name
• 42 CFR Part 2 protected substance-use narrative or records when Part 2 applies
• A diagnosis lecture, rule-out paragraph, or risk narrative

ICD-10 supports medical necessity without dumping the note. When Part 2 applies, keep protected SUD narrative in the chart. Do not put it on the statement.

How often to issue

Issue a completed superbill per session when POS or modifier can change. A monthly recap is workable when every row still carries its own date, POS, CPT, modifier, ICD-10 pointer, fee, and amount paid.

Write the cadence in the financial policy. Do not improvise it in the waiting room. Tell the client, once, that the practice cannot promise what the plan will pay.

How documentation support fits

Emosapien helps the clinician produce a signed, therapy-shaped note so the CPT and ICD-10 on the statement match the chart. The therapist still chooses codes, fees, and whether to issue the document. The product does not file out-of-network claims, run eligibility, or replace a clearinghouse.

Use the printable pack

The printable pack is four US Letter pages: fillable statement, required-field checklist, worked example, and a short client instruction sheet. The fields above are the same fields in this superbill template PDF. Do not treat the PDF as a CMS-1500.

Treat the pack as educational. It is not a claim form, not legal or reimbursement advice, and not a crisis service.

References

• American Medical Association. Current Procedural Terminology (CPT) code set.
• Centers for Medicare & Medicaid Services. Place of Service code set.
• Centers for Medicare & Medicaid Services. National Plan and Provider Enumeration System (NPPES) NPI Registry.
• Centers for Medicare & Medicaid Services. NPI fact sheet (Type 1 individual and Type 2 organization).