Superbill Template for Therapists: What to Include

What Is a Superbill?

A superbill is a detailed receipt that an out-of-network mental health provider gives to a client so the client can submit it to their insurance company for reimbursement. It is the primary vehicle through which clients with out-of-network benefits recover a portion of their therapy costs.

Unlike a standard receipt, a superbill contains all the information an insurance company needs to process a claim: provider identification (NPI number, tax ID, credentials), client information, date of service, procedure codes (CPT), diagnosis codes (ICD-10), fees charged, and place of service. It functions as a pre-formatted insurance claim — the client submits it instead of the provider.

For therapists in private practice who are out-of-network with insurance companies, the superbill is one of the most important financial documents you produce. It directly determines whether your clients can access their out-of-network benefits and recoup a portion of the fees they pay you. A complete, correctly formatted superbill leads to smooth reimbursement. An incomplete or incorrectly coded superbill leads to denied claims, frustrated clients, and potential loss of referrals.

Superbills also serve as financial and clinical records. They document the services provided, the diagnostic basis for treatment, and the fees collected. In the event of an audit, your superbills should be consistent with your progress notes, treatment plans, and appointment records.

When You Need It

You should provide a superbill in the following situations:

• Out-of-network clients seeking insurance reimbursement — This is the primary use case. Clients who have out-of-network mental health benefits can submit superbills to receive partial reimbursement (typically 50-80% of the insurer's "usual and customary" rate, after meeting their deductible)
• Self-pay clients who later discover they have coverage — Clients who initially pay out-of-pocket may later request superbills when they learn they have unused mental health benefits
• Employee Assistance Program (EAP) documentation — Some EAP arrangements require superbill-style documentation
• End-of-year documentation — Many clients request superbills at year's end for tax purposes (HSA/FSA reimbursement) or to submit accumulated claims before the filing deadline
• Clients using health savings accounts (HSA) or flexible spending accounts (FSA) — Superbills serve as proof that the expense qualifies as a medical service
• When transitioning a client from in-network to out-of-network — If you leave a panel, clients continuing with you as out-of-network will need superbills going forward

Key Components

Every superbill must include the following elements to be processed by an insurance company:

Provider Information

• Full legal name and professional credentials (e.g., PhD, PsyD, LCSW, LMFT, LPC)
• National Provider Identifier (NPI) number — the 10-digit unique identifier assigned to healthcare providers
• Tax Identification Number (TIN) — either your EIN for a practice entity or your SSN if operating as a sole proprietor
• Practice name (if applicable)
• Practice address and phone number
• State license number

Client Information

• Full legal name (as it appears on the insurance card)
• Date of birth
• Address
• Insurance company name
• Insurance member/subscriber ID number
• Group number (if applicable)
• Relationship to subscriber (self, spouse, child)

Service Information

• Date of service for each session
• CPT code for the service provided
• ICD-10 diagnosis code(s) — primary and secondary
• Place of service code (11 for office, 10 for telehealth in patient's home, 02 for other telehealth)
• Modifiers (95 for telehealth, if applicable)
• Fee charged for each service
• Amount paid by client
• Units (typically 1 for psychotherapy codes)

Summary Information

• Total charges
• Total amount paid
• Balance (if any)
• Provider signature (or electronic equivalent)

How to Create a Superbill Step by Step

Step 1: Set Up Your Template

Create a superbill template in your practice management system or as a standalone document. Most EHR systems (SimplePractice, TherapyNotes, Jane App, IntakeQ) have built-in superbill generators. If using a custom template, ensure it includes every required field listed above. Set up the template once and populate it per client and session.

Step 2: Verify Client Insurance Information

Before generating a superbill, verify the client's insurance information. Confirm the member ID, group number, subscriber name, and insurance company name match what is on their insurance card. Incorrect insurance information is the most common reason superbill claims are denied. Ask clients to provide a copy of their insurance card at intake.

Step 3: Enter Accurate Service Codes

For each session, enter the correct CPT code based on the service delivered and the actual time spent. If you provided 45 minutes of individual psychotherapy, use 90834. If the session was conducted via telehealth, add modifier 95 and use the appropriate place-of-service code (10 for the client's home). Cross-reference your progress note to ensure the CPT code matches the documented service.

Step 4: Apply Current Diagnosis Codes

Use the ICD-10 codes from your current treatment plan. If the diagnosis has changed since the last superbill, update the codes. Ensure the diagnosis codes on the superbill match the codes in your clinical documentation — consistency across records is essential.

Step 5: Record Accurate Fees and Payments

List the full fee charged for each service and the amount the client paid. If you offer a sliding scale, list the actual fee charged, not your standard rate. The amount paid should reflect what the client actually paid on the date of service.

Step 6: Review Before Issuing

Before giving the superbill to the client, review every field. Check that dates are correct, CPT codes match the service provided, ICD-10 codes are current, and the fee total is accurate. Errors require reissuing the superbill and can delay the client's reimbursement.

Step 7: Provide to the Client in a Timely Manner

Issue superbills regularly — monthly or after each session, depending on client preference. Some clients prefer to accumulate superbills and submit them quarterly or annually. Remind clients of their insurer's timely filing deadlines. Many plans require claims to be submitted within 90 days to one year from the date of service.

Step 8: Keep Copies

Retain copies of all superbills issued as part of your financial records. In the event of a dispute, audit, or client complaint, you need documentation of exactly what was provided to the client. Most practice management systems store superbills automatically.

Common Mistakes

Missing NPI number or Tax ID. Insurance companies cannot process a claim without the provider's NPI number and Tax ID. These two identifiers are mandatory for claim adjudication. If either is missing, the superbill will be returned or denied. Double-check that both are on your template.

Using outdated diagnosis codes. ICD-10 codes are updated annually. If you assigned a diagnosis at intake using a code that has since been revised, updated, or replaced, your superbill may be denied. Verify that the codes you use are current for the year of service.

Listing the wrong place-of-service code. Place-of-service code 11 (office) and code 10 (telehealth — patient's home) have different reimbursement rates with many insurers. Using code 11 for a telehealth session is incorrect and constitutes a billing error. Match the POS code to where the service was actually delivered.

Not including the client's subscriber information when the client is a dependent. If the client is covered under a spouse's or parent's insurance plan, the subscriber (policyholder) information must be included on the superbill. The member ID on the claim must match the subscriber's records, and the relationship to subscriber must be specified.

Providing superbills with inconsistent information. If your superbill lists F33.1 as the diagnosis but your progress note documents adjustment disorder symptoms, the inconsistency creates a problem if the insurer requests clinical records. Diagnosis codes, CPT codes, and fees on the superbill must match your clinical and financial records exactly.

Failing to explain the superbill to clients. Many clients have never seen a superbill and do not know how to submit one. Take time during the first session to explain what a superbill is, how out-of-network reimbursement works, what information will be shared with their insurer (including their diagnosis), and how to submit claims. Some practices provide a one-page instruction sheet alongside the superbill.

Charging different fees for the same service without documentation. If you charge some clients $200 and others $150 for the same CPT code, you need a documented sliding scale policy that justifies the fee variation. Fee inconsistencies without a written policy can create audit exposure. Maintain a fee schedule and a written sliding scale policy.

Not disclosing that a diagnosis will appear on the superbill. Some clients are unaware that submitting a superbill means their mental health diagnosis becomes part of their insurance record. This must be part of your informed consent process. Discuss the implications before the client decides whether to use their out-of-network benefits.