Optional: set up insurance billing
Electronic claims and eligibility checks are for US practices on a paid plan. Set up your billing foundation, add client insurance details, connect appointments to coverage, then submit and track claims, in four phases.
- A US practice on an active Plus or Advanced plan. Electronic claims and eligibility checks are switched off during the free trial.
- Credentialing with each payer, which is handled outside Carepatron
- Stripe connected, if you want clients to pay their share online (lesson 4.1)
Phase 1: the foundation
Before any claim can go out, you need six things in place:
- Credentialing with each payer, handled outside Carepatron. A payer won't pay a provider it hasn't credentialed.
- A billing profile: Settings → Insurance → Payers → Add billing profile, with your organisation or practitioner name, NPI, and tax number.
- Payers added on the same tab: Add payer to search the clearinghouse list, or New manual payer.
- Enrolment with each payer. Claims, eligibility and ERA (electronic payments back) are enrolled separately, and each payer shows as fully, partially or not enrolled. You can start enrolling once you're on a paid plan.
- Practitioner NPIs added under Your team, on each team member's details.
- Billable services with their CPT code in the Code field, at Settings → Scheduling → Services.
Stripe (Lesson 4.1) is optional here: you only need it if you want clients to pay their share online.
Phase 2: client insurance details
- Open the client's record → Insurance tab → Claim settings → Edit → Client billing method → Insurance.
- Add the policy: insurance type, payer, member ID, group ID, plan ID, deductibles, co-pay or co-insurance, cover level, plan type, plus the policy holder and a photo of the insurance card.
- Click Check eligibility to confirm active coverage. Carepatron notifies you when the report is ready; click View report for benefits, deductibles, and exclusions.
- Review them before the first appointment.
For new clients, add the Insurance policies form element to your intake form (Lesson 2.3). When the client submits it, Carepatron creates the policy and runs an eligibility check at no charge. A successful check marks the policy Verified.
Phase 3: connect appointments to insurance
Per appointment:
- Open the appointment and go to its Billing tab.
- In the Insurance section, check the payer card shows coverage (Check coverage, or Recheck).
- In Services, check each line's code, units, modifiers, diagnosis (ICD-10) and place of service.
- Use Create invoice to bill the client's share, if they have one.
The code comes from the service and the place of service from the location, so most of this fills in for you. The appointment is where you fix the exceptions.
Phase 4: submit and track
On the appointment's Billing tab, choose Create claim from the footer menu. It appears once the appointment is billed to insurance. You can also use New claim on Billing → Claims. Click Submit electronically; Validate, in the same menu, checks the claim for missing details first.
Track claims in Billing → Claims; open any claim for its status, history, comments and follow-ups. Statuses include Draft, Validated, Submitted, Rejected (clearinghouse error: fix and resubmit), Denied (payer decision: appeal with the payer, outside Carepatron), Accepted, Paid, Processed, and Closed. For secondary insurance, open the paid primary claim → Create secondary claim → select the secondary policy.
Tick these off in your own workspace before moving on.
Five insurance billing setups.
These are examples. Insurance is detailed, so start from the closest one.
Two payers (BCBS + Aetna), ERA enrolled, eligibility check the day before each appointment. Co-pay invoiced same-day.
Six practitioners, each with their own NPI added under Your Team. Billing profile is the organisation, not individuals.
Video locations set to place of service 02 (or 10 for telehealth in the client's home), so every telehealth claim carries the right code.
Insurance for in-network services. Cash invoice with no claim for self-pay clients. Same workspace, different billing methods per client.
Primary claim submits, ERA arrives, secondary claim created with the leftover balance, submits to secondary payer.
Where is insurance billing available?
Electronic claim filing and eligibility checks are US-only. Practices outside the US can still store client insurance policies, set coverage and co-pay amounts, split billing items between the client and the insurer, and record insurance payments by hand.
What does a billing profile need?
An NPI, a tax number type and a tax number. They're required, so you can't save the profile without them. Add or edit profiles under Settings → Insurance → Payers.
Can I submit claims while enrolment is pending?
Yes, while a payer's claims enrolment is processing you can submit claims to it. If the payer shows Enrollment required or Rejected, electronic claims to that payer won't go through until you enrol.
How long does an eligibility check take?
Usually not long, though some payers take a few minutes. Checks run in the background and Carepatron notifies you when the report is ready. Click View report for details on coverage, benefits, deductibles.
What's the difference between a rejected and a denied claim?
Rejected = clearinghouse or system error (missing field, wrong format). Fix it and resubmit. Denied = payer decision (not medically necessary, wrong code, out of network). Appeal outside Carepatron, with the payer directly.
Are there CPT or diagnosis code requirements?
Yes, every claim needs CPT codes per service rendered and at least one diagnosis (ICD-10) code per appointment to support medical necessity. Add the CPT code to each service in the Code field at Settings → Scheduling → Services.
Which Carepatron plans include insurance?
Electronic claims and eligibility checks need an active Plus or Advanced plan with a payment method saved. They're switched off during the 14-day trial, even though the trial is on Advanced. Client policies, payers and recording insurance payments work on every plan, and US practices can create claims and print CMS-1500 forms on any plan.
How much does claim submission cost?
Per-claim pricing: roughly $0.25 per claim for the first 199 claims per month, decreasing with volume (down to $0.19 at 1000+ claims). Full pricing: [Insurance pricing](https://help.carepatron.com/en/articles/11748935-insurance-pricing).