Superbill Template for Therapy (Printable Sample)

Below is a complete, filled sample therapy superbill rendered exactly as it should appear when a client takes it to their insurer for out-of-network reimbursement. Every field that an insurer checks is populated. Replace the bracketed/sample values with your own practice and session data — the structure and the required elements stay the same.

Riverside Behavioral Health, LLC — 482 Park Avenue, Suite 210, Austin, TX 78701 | (512) 555-0144 | Billing Tax ID (EIN): 47-1234567

Services Rendered

Diagnosis key: (A) F41.1 = Generalized anxiety disorder; (B) F33.1 = Major depressive disorder, recurrent, moderate.

Total charges: $850.00 | Total paid by patient: $850.00 | Balance: $0.00

Provider attestation: I certify that the services above were rendered as documented in the clinical record. Signature: Dana Okafor, LCSW | Date: 06/17/2026

Note how every line ties documented session length to the correct time-based CPT (45 minutes → 90834, 60 minutes → 90837), points each procedure to a specific ICD-10 with a diagnosis pointer, and carries the place-of-service code (11 office, 10 telehealth in the home, 02 telehealth away from home) plus the telehealth modifier 95 on virtual sessions. In our reviews of denied out-of-network claims, the missing piece is almost always one of these four columns — a blank NPI, a generic diagnosis, a CPT that does not match documented time, or an absent POS code.

Use this as the build specification for your blank template. A superbill that is missing any of these fields is the single most common reason a client's out-of-network reimbursement is reduced or denied.

1. Provider / practice block

• Practice (facility) legal name and address
• Rendering provider name + credentials (LCSW, LMFT, LPC, PhD, PsyD, MD)
• Rendering provider individual NPI (Type 1) — the most-missed field; the tax ID alone is not enough
• Billing/organization NPI (Type 2) when the practice bills under a group
• Tax ID (EIN, or SSN for sole proprietors)
• Provider taxonomy code (optional but speeds adjudication)

2. Patient block

• Patient legal name, date of birth, sex
• Patient address and phone
• Insurance payer name, member ID, group number
• Subscriber name and relationship to patient (if the patient is not the subscriber)

3. Encounter / service lines (one row per session)

• Date of service (DOS)
• Place of service (POS) code
• CPT or HCPCS code
• Plain-English description of the service
• ICD-10-CM diagnosis code(s), primary first
• Diagnosis pointer linking each procedure line to its supporting diagnosis (A/B/C/D or 1/2/3/4)
• Units of service
• Modifier(s) where applicable (95 for telehealth, 25, 59, add-on codes)
• Charged fee per line

4. Totals and attestation

• Total charges, total paid by patient, balance
• Statement that the patient paid in full (out-of-network workflow)
• Provider signature (electronic equivalent acceptable) and date

The diagnosis pointer is the field practices forget most often after the NPI. Without it, the insurer cannot tell which diagnosis supports which session and may deny the line for medical necessity. For the full anatomy of the form across all specialties, see what is a superbill.

Therapy superbills live or die on matching the documented session length to the correct time-based CPT code. Below is the quick-reference for the psychotherapy and behavioral health codes that appear on most therapy superbills. Reimbursement figures are illustrative; the CMS Physician Fee Schedule (PFS) allowable varies by year, locality/MAC, and provider type (a non-physician practitioner is paid at a percentage of the physician rate), and commercial out-of-network allowed amounts are set by the patient's plan — always verify against your contract and the current PFS.

The time-based codes use CPT midpoint ("time threshold") rules: a session must reach at least the lower bound of the band to bill that code. Documenting 50 minutes supports 90834, not 90837 — billing 90837 for a 50-minute session is a downcoding/audit exposure. Add-on codes (the + codes) are never billed alone; they attach to a primary service. For the full 90834-vs-90837 decision and audit exposure, see 90834 vs 90837 psychotherapy billing.

When a therapist is out-of-network, the client pays in full and then recovers the covered portion from their own insurer using the superbill. Here is the exact path to give your clients.

Step 1 — Pay in full at the session. The provider does not bill the insurer; the client pays the full fee and the superbill shows a $0.00 balance.

Step 2 — Receive a complete superbill. Issued at checkout or through the client portal, populated exactly like the sample above — individual NPI, specific ICD-10, time-matched CPT, units, modifiers, POS, fees, signature, and date.

Step 3 — Get the insurer's out-of-network claim form. Most payers post a member-reimbursement or out-of-network claim form on their portal. The client attaches the superbill to that form.

Step 4 — Submit through the member portal or by mail. Some payers accept a portal upload; others require mail. The client attests they paid the provider directly.

Step 5 — Insurer adjudicates against out-of-network benefits. The plan applies the out-of-network deductible, coinsurance, and any allowed-amount cap, then reimburses the client (not the provider) for the covered portion. The client receives an EOB and a check or direct deposit. Out-of-network reimbursement commonly takes four to eight weeks.

Before the client pays — verify benefits. The single biggest disappointment is a client who submits a clean superbill and learns their plan has no out-of-network benefit at all (common on HMO and many narrow-network plans) or a deductible they will never meet. A front-end insurance eligibility verification that confirms out-of-network mental health benefits, the deductible, and the allowed-amount basis sets accurate expectations and prevents the awkward post-session surprise.

A downloadable PDF/DOCX version of this template is a useful follow-up asset for clients; the printable sample table above is the ranking and reference version.

The diagnosis is what an out-of-network insurer uses to judge medical necessity, so the ICD-10 code on a therapy superbill matters as much as the CPT. The single most common medical-necessity failure is an 'unspecified' code (the .9 family) when the documentation supports something more specific.

The Z-code caveat: couples/relationship work coded only to a Z-code (for example Z63.0) is frequently treated as not medically necessary by insurers, because Z-codes describe circumstances rather than a billable disorder. If a clinical disorder is present and documented, code to that disorder. Code to the highest specificity the record supports — that is the difference between a reimbursed superbill and a denied one.

Behavioral health is delivered virtually more than almost any other specialty, and the place-of-service code is the field that trips up the most therapy superbills. Getting POS wrong on a telehealth session is a frequent reason a payer reduces or denies reimbursement.

Modifier 95 identifies a synchronous audio-video telehealth service and is appended to the CPT on virtual sessions (some payers also accept/require modifier 93 for audio-only — verify the plan). The combination most therapy clients need is 90834 or 90837 + POS 10 + modifier 95 for a routine telehealth session from home. Putting POS 11 (office) on a telehealth session — a common copy-paste error — will often deny. Telehealth payment parity and the exact POS expectation vary by payer and can change year to year, so confirm the current rule with each plan. For the office-based POS distinctions, see POS 11 vs POS 22, and for the telehealth pair specifically, POS 02 vs POS 10.

Even a perfectly formatted superbill can come back denied when it is converted into a claim or adjudicated against out-of-network benefits. These are the named CARC/RARC codes that show up most on behavioral health and the fix for each.

The recurring theme: match documented time to the CPT, use a specific ICD-10, include the individual NPI and POS, and never bill an add-on code without its primary. Practices that scrub these four things before issuing the superbill see the fewest client reimbursement disputes. For high-volume out-of-network practices, mental health billing services can own superbill generation, benefit verification, and the denial follow-up end to end.