How To Create a Clean Superbill: 5 Common Mistakes to Avoid

If you provide out-of-network mental health services, you likely know how important a superbill for therapy is. It’s your client’s ticket to receiving insurance reimbursement, but only if it’s filled out correctly.

Even small errors can result in delayed payments and rejected insurance claims, which is frustrating for all involved.

Here, we’ll break down five common mistakes therapists and billing teams make when creating superbills, and how to fix them. These tips can help you improve your billing process and support your clients’ access to care. Plus, we’ll include a few reasons why more therapists are shifting towards offering superbills.

Why Superbills Are Becoming More Common in Therapy Practices

Being part of an insurance network typically brings steady referrals and expanded access, but it can also come with challenges: low reimbursement rates, frequent delays, administrative strain, and sometimes rigid oversight into treatment decisions.

That’s why some therapists are choosing to step away from insurance panels and operate as out-of-network providers. It gives them greater autonomy over their time and treatment plans.

Offering a superbill for therapy can be a practical way to maintain this autonomy while still supporting client access. With a superbill, clients request reimbursement for out-of-network services from their health insurance company even when the therapist doesn’t bill insurance directly.

While it doesn’t guarantee reimbursement, a superbill bridges the gap. It gives clients the ability to tap into out-of-network benefits, especially as most insurance companies now have clear (if not always seamless) processes for clients to submit a superbill.

At other times, clinics may be in-network with most insurance providers but out of network for the occasional client. Even in-network providers may need to generate a superbill if a client unexpectedly receives care that falls outside their insurance plan’s network coverage.

Mistake 1: Missing or Incomplete Provider Information

It might sound obvious, but forgetting to include full therapist information is more common than you’d think. Every superbill must list:

• The provider’s full name and credentials
• Mailing address of the practice
• National Provider Identifier (NPI)
• Tax ID or Employer Identification Number (EIN)

Most insurance companies require this to verify the provider and determine eligibility for out-of-network benefits. Without it, the claim may be denied before it even hits the review queue.

Use EHR software like ClinicTracker that auto-fills provider information and ensures all required fields are populated.

Mistake 2: Incorrect or Vague Diagnosis and Procedure Codes

Every superbill for therapy includes:

• Diagnosis code (ICD-10)
• Procedure code (CPT or HCPCS)
• Optional: Modifier codes (especially for telehealth or unusual circumstances)

These codes are how the insurance company understands what service was provided and why. If you use incorrect or outdated codes (or skip them entirely), the claim won’t match payer systems.

Mistake 3: Missing Patient Information Details

Missing details about the patient can also trigger denials or delays. The superbill should include:

• The patient’s details, including full name and date of birth
• Insurance information (plan name, policy number)
• Accurate session dates and duration
• Fees charged and amount paid

Some insurance plans have filing window deadlines. If you miss them because of going back-and-forth over paperwork, the client may lose reimbursement eligibility.

To avoid issues, have a standardized process. Generate superbills from your EHR or online portal so all patient fields are populated automatically.

Mistake 4: Using One-Size-Fits-All Templates

A generic superbill template off the internet might not meet all payer requirements, especially if you serve multiple insurance providers or offer a mix of services. Different insurers require different documentation. For example, Medicaid services often have stricter coding and billing requirements. A poorly matched template may not meet those standards.

Customize your superbills based on payer requirements and service types. ClinicTracker allows you to generate templates based on your specific needs. 

Mistake 5: Failing to Educate Clients on the Process

The best superbill in the world won’t get reimbursed if the client doesn’t know how to use it.

Instead of walking each client through the steps, include a short, pre-written note or email template when you deliver the superbill. It can simply say:

“Here’s your superbill to submit to your insurance provider. You’ll typically need to send it through your member portal or by mail. If you’re unsure how, call the member services number on your insurance card and they can walk you through it.”

This small gesture saves time in the long run and helps the client to request reimbursement confidently, without adding to your plate.

Tip: Don't Skimp on Therapy Notes (Especially If You're an Out-of-Network Provider)

It’s a common misconception: “Since I’m out-of-network, the insurance company won’t need to see my notes, right?”

Not quite.

As soon as a client submits a superbill and asks their health insurance company for reimbursement, the door is open for the insurance provider to request a clinical review. They may want to see your session notes to determine if the diagnosis and treatment justify reimbursement, especially for multiple visits or higher-cost care. 

That’s why accurate, defensible documentation is essential. Even if you're not submitting claims yourself, your notes may become part of the review process later.

How ClinicTracker Helps With Better Documentation

With Clinical Scribe, you can capture detailed clinical documentation in real time, without spending hour after hour writing notes. 

The AI-assisted tool helps you clearly document every session and supports your diagnostic codes, just in case the insurance company comes asking. That means you stay focused on care while Clinical Scirbe takes care of the paperwork, providing high-quality documentation that supports both clinical work and the billing process. 

Connect with our team to learn more!