Get started with insurance billing

OptiMantra’s robust insurance billing system allows you to manage your full insurance workflow in one place. 

• Check eligibility for new patients by modality and service time

• Easily submit and track claims with just a few clicks after entering services and diagnosis codes in your chart note

• Handle copay collection at the time of visit

• Reconcile your insurance payments, and automatically generate a second superbill when insurance payments are entered, ensuring accurate documentation for analytics and patient balances

• And more…
   

This article covers the following: 

• The Basics: How Insurance Billing Works 
  • Skip this if you're already comfortable with insurance billing!
• Set Up Insurance Billing - Credentialing & EDI/ERA/EFT
  • 1.  Complete your Credentialing
  • 2. You're Already Connected to Office Ally's Clearinghouse!
  • 3. Enroll in EDI-ERA-EFT
• Set Up Insurance Billing in OptiMantra
  • 1. Set up Contact List
  • 2. Set Up Insurance Billing Providers
  • 3. Add CPT (Service) Codes
  • 4. Optional - Upload Patient Insurance Info (in Bulk)
• Further Training
  • Tips for Successful Insurance Billing

We also offer individualized and group training for all aspects of insurance setup and billing. Please note each successfully submitted claim costs $0.25.

The Basics: How Insurance Billing Works 

Insurance billing is how healthcare providers get reimbursed by a patient’s insurance for covered services, using standardized codes to submit claims. In OptiMantra, this process is fully integrated into your workflow—enabling accurate claim generation, efficient submission, and direct tracking of claims, remittances, and denials. Effective billing ensures your practice gets paid and helps patients maximize their benefits. 

Here's how the typical insurance billing cycle works

1. Patient Registration and Verification in OptiMantra eligibility check

   • When a patient schedules an appointment, the practice collects their personal and insurance information. 

   • Verifying insurance coverage before the visit ensures that services are covered by the patient's plan and reduces the likelihood of claim rejections and denials. 

   • Ensure your patient’s demographics within OptiMantra match their insurance carrier card to ensure clean claim submission!

2. Service Documentation and Coding in your OptiMantra charting

   • During the patient visit, the provider documents the services rendered. 

   • Each service is then translated into standardized codes: ICD (International Classification of Diseases) codes for diagnoses and CPT (Current Procedural Terminology) codes for procedures. 

   • Accurate coding is crucial for clean claim submission and proper reimbursement.

3. Claim Submission  in OptiMantra

   • After coding has been added, a claim is created and submitted to the insurance company. The claim includes the patient’s info, provider details, CPT codes, diagnosis codes, and the billed charge amount for each CPT.

   • Claim submission happens directly in OptiMantra! We will send the claim to your selected clearinghouse, which scrubs it and then passes it on to your designated payer.

4. Claim Processing  by the Clearinghouse and Insurance Companies, with updates for you in OptiMantra

   • The clearinghouse scrubs the claim for any errors and then submits it to the insurance company if no errors are observed. The insurance company further reviews the claim, checks for errors, verifying patient eligibility, and ensuring the services are covered.

   • The insurance company will process the claim and either approve the claim in full, approve it partially, or deny it entirely. 

     1. If the claim is denied, the EOB or remittance advice should be reviewed to understand the reason for the denial or underpayment, to understand the necessary steps to correct and resubmit the claim.

   • As claims are updated, the status will show up in OptiMantra, so you can make necessary corrections and resubmit claims. 

5. Clearinghouse Rejections and Claim Denials

   •  If a claim is sent to a clearinghouse and kicked back due to errors, this is referred to as clearinghouse rejection.

     1. Common reasons for clearinghouse rejections include mismatched patient demographics, ineligible coverage for the billed date of service, provider credentialing or NPI mismatches, invalid payer IDs, missing or invalid procedure or diagnosis codes, and duplicate submissions.

   • If a claim is sent to an insurance carrier and the carrier refuses to pay all or part of the claim, this is referred to as a claim denial. 

     1. Common reasons for claim denials include coding errors (CPT, diagnosis codes, place of service, modifiers), services deemed not medically necessary, coordination of benefits issues (e.g., covered by another payer), missed timely filing deadlines, and missing prior authorizations or referrals.

6. Reimbursement directly to you, then update OptiMantra and bill any remaining balances directly in the system

   • If the claim is approved, the insurance company reimburses the provider based on the agreed rates in the provider’s contract with the insurer. 

   • The patient is then billed for any remaining balance not covered by insurance, such as co-pays, deductibles, or co-insurance.

Attached to this article is the Insurance Billing Setup Checklist, which guides you through each step outlined in this article. Use this checklist alongside the article to ensure you complete every step of the billing setup process.

Set Up Insurance Billing - Credentialing & EDI/ERA/EFT

There are two steps required outside of the OptiMantra software: Credentialing and EDI/ERA/EFT setup. While OptiMantra cannot complete these steps on your behalf, we’ve outlined clear, step-by-step instructions below to help you. 

Note: Attached to this article is the Credentialing Tracking Spreadsheet, designed to help you stay organized while managing your credentialing. 
 

 1.  Complete Your Credentialing

This step must take place before you can begin insurance set up within OptiMantra

Before you can get started, you'll need to register for the NPI database and get credentialled with insurance companies (this is registering with the insurance companies who will review your qualifications and then add you to their network). 

Please note that OptiMantra cannot complete credentialing for you. 

• Obtain your National Provider Identifier (NPI) number(s) before starting the credentialing process. If you are a solo provider, apply for an individual NPI. If you operate a group practice, you’ll also need a separate NPI for the group/practice.

  •  To apply, visit the National NPI Registry at https://nppes.cms.hhs.gov and complete the application.

  • If you run a group practice or have multiple employees providing care, you may need an organizational NPI.

    • These are sometimes referred to as NPI Type 1 (individual) and NPI Type 2 (organization).

• Contact each insurance company you plan to bill and ask what’s required to join their network of eligible providers.

  • Keep track of which NPI (individual or organizational) you use during credentialing with each insurer.

  • It is highly recommended to use a spreadsheet to track key details, including:

    • Insurance company name
      

    • NPI used for credentialing
      

    • Main contact person
      

    • Date credentialing was approved
      

    • Claims address
      

    • Payer ID
      

    • Any additional relevant information

2. You're Already Connected to Office Ally's Clearinghouse!

The Clearinghouse receives claims submitted through OptiMantra and forwards them electronically to the insurance payers you've credentialed with. 

And - great news! - your OptiMantra account is already connected to Office Ally! No other to dos here.

→ Please do not create a separate Office Ally account. All claim submissions must go through the integrated Office Ally account in OptiMantra to ensure full functionality. 

Key points:

• Billing is completed in OptiMantra - and Office Ally and OptiMantra communicate directly, so billing activity is visible in OptiMantra. 
  • A clearinghouse account is also established to provide access to the full claim history. This is particularly useful for timely filing, as OptiMantra only displays the most recent submission, whereas the clearinghouse maintains a record of all submissions.
  • Contact Office Ally directly for EDI, ERA, or EFT setup (more on that below).
• We also work with Jopari Clearinghouse for motor vehicle accidents (MVA) and workers’ compensation (WC) claims. Send us a ticket if you would like to get connected! 
• You'll notice some references to Change Healthcare (CHC)'s clearinghouse - this integration is only available for a handful of clients who were set up before their 2024 shutdown. 
  • We don’t recommend using the CHC option at this time. 

3. Enroll in EDI-ERA-EFT

Before submitting any claims in OptiMantra, providers must complete the EDI (Electronic Data Interchange) enrollment process for each insurance payer they intend to bill. This is essential to enable electronic claim submissions.

In addition, to receive payments and remittance information directly in OptiMantra, providers must also enroll in:

• EFT (Electronic Funds Transfer) – to receive claim payments directly to your bank account
   

• ERA (Electronic Remittance Advice) – to receive electronic remittance reports

Enrolling in ERA and EFT helps speed up reimbursements (vs. mailed paper checks), streamline payment posting directly in OptiMantra, and reduce manual entry and payment errors

Please note: Each payer has its own enrollment requirements, which may vary by state. Be sure to follow the specific EDI, EFT, and ERA setup instructions for:

• Payers listed under your state

• Payers listed in the All States section, accessible via the EDI Enrollment link below

• Be sure to complete and follow up on the enrollment process with each individual payer, where required, before submitting claims.
   

Follow the instructions on Office Ally’s website by clicking the blue links labeled “EDI Enrollment” and “ERA/EOB” below to complete the required pre-enrollment steps for each.

• EDI Enrollment/Submissions: 

  • Some payers—like Medicare, Medicaid, and Blue Cross Blue Shield—require EDI pre-enrollment before accepting electronic claims.

  • Office Ally provides state-specific, pre-filled forms with their information. Follow all instructions exactly before submitting claims.

  • Most early claim denials result from incomplete or incorrect enrollment, so review forms carefully and keep copies on hand.

• ERA/EOB & EFT:

  • Some payers require pre-enrollment to activate Electronic Remittance Advices (ERA/835) — the digital version of an Explanation of Benefits (EOB). These documents detail the billed amount, payment, patient responsibility, and any denials or adjustments.

  • To receive payments via EFT (Electronic Funds Transfer) directly to your bank account, most payers also require a separate setup.

    • Office Ally provides pre-filled ERA/EFT forms where applicable.

    • Some EFT forms must be obtained directly from the insurance company.

  • Note: Enrollment may take 14–45 days. If switching from another clearinghouse or EMR, you may need to fax an ERA Transfer Request Letter (see end of article). As of late 2023, Office Ally may require separate enrollment per payer, so contact them first to confirm the correct process.

Set Up Insurance Billing in OptiMantra

Once you’ve taken care of your credentialing and ERA/EDI/EFT setup, you will follow the below steps to setup insurance billing within OptiMantra. 
 

1. Set up Contact List
 

You will need to set up your insurance payer list in OptiMantra.

To get started, visit: Settings > Business > Contact List > Choose “Insurance (Payer)” under Type and add all the insurance companies that you plan to bill, whether they are in or out of network. 

Note: You can also view and update your contacts under Settings > Insurance > Contact list. The contact lists are the same.

• Enter the full name of the insurance company in the “First Name” field,

• Add the claim mailing address in the address fields. 

  • While the address isn't required for insurance claims, it is necessary for lab requisitions. The claims address is listed on the insurance card, but you can also obtain it online. 

• Add the Office Ally Payer ID in the “Payer ID” field, just below the “Phone” field. 

  • The payer ID can be located on the insurance card or by visiting Office Ally’s website: Payers List

  • You can also access this URL via the blue “Ref” button next to the “Payer ID” field on the insurance tab in the patient’s profile (see screenshot below). 

• The “Office Ally Eligibility ID” field should be filled out to utilize eligibility checks. 

  • The Realtime ID box will fill automatically when you select the appropriate CHC Payer ID from the drop down list.

• Be sure to mark the “Contact Type” in the bottom middle column as “Insurance (Payer)” when saving the contact!

 

At any point, to view your full payers list, set the type to "Payer", when you start typing in the Name, and OptiMantra will pull up all existing records.
 

2. Set Up Insurance Billing Providers
 

In Settings > Business > Location(s): Please enter your business information accurately, as it will appear on the CMS-1500 claim form.

• The address listed here must match the address used when setting up credentialing.

• The phone number must match the phone in the NPI registry for your credentialing. 

• The NPI number listed here should be the organization NPI (if you have one)

• A CLIA number is required to perform and bill for in-office lab tests. It is issued by CLIA, the federal program that regulates laboratory testing in healthcare practices.

In Settings > Business > Provider Settings >  Edit Profile: Make sure your name, credentials, and address exactly match the information used during your insurance credentialing. 

• The NPI listed here must be your individual NPI.

• Your federal tax ID must be entered for billing insurance. 

  • You may also need to provide insurance companies with a W-9 form to verify your legal right to use the associated Tax ID number.

In Settings > Insurance > Insurance Billing Providers: Please click on Add New Billing Provider to add a provider that will bill for rendering services.

• The Title field can be utilized to help you distinguish provider profiles and it doesn't show anywhere.

• It is very useful to create an insurance billing provider profile with your organization NPI and another one with your individual NPI (the rest of the information will be the same on both profiles).

• If you are licensed under multiple provider types (e.g., NP and LAC) and bill under different taxonomy codes or license requirements, you may need separate billing profiles. Some insurance companies require separate credentialing for each provider type.

→ After you have the Insurance Billing Providers and Locations set up, please go to your Settings > Provider Settings > Edit Profile and select the Default Billing Location and the Default Billing Provider.  

• Choose the billing location and billing provider that will be most frequently used.

  • At the bottom of the CMS-1500 claim preparation form, you'll find buttons to switch the billing location or billing provider if the default options are not correct for the specific insurance company’s billing requirements.
     

3. Add CPT (Service) Codes

Go to: Settings > Services  > Services (Fee Schedule) to enter the appropriate CPT code in the service box for any services that you plan on billing insurance for.  

• You can use the HCPCS/CPT code box to search by code or begin typing the name of the service to find the correct code.

• Only the CPT code appears on the claim form, so the service name you use for internal billing purposes does not affect the claim.

• The service name will appear in the chart note and on Superbills for self-pay patients. If a patient plans to submit the Superbill for insurance reimbursement, you can include the CPT code in the service name for clarity.

• In the Services box, you can set default Modifiers and/or Place of Service for any service you use frequently.

Quick Side Note - If You Have Different Self-Pay vs. Insurance Pricing…

• For insurance-billed services, the price for each CPT code must be consistent across all patients - set the price at or above the highest amount any insurance company will reimburse. 

  • You can write off any unpaid balance or, if you're out of network, bill the patient. 

  • In-network agreements often require you to write off the difference.

• You can offer a discount to self-pay patients who don’t have insurance coverage, even if it's for a service with the same CPT code. However, you should not charge insured patients more than the discounted rate you offer to self-pay patients, unless you have a consistent, documented self-pay discount policy. 

  • Charging different rates for the same CPT code without such a policy may be considered an insurance compliance violation.

• The AMA requires registration to use CPT codes, but we haven’t set this up yet. We plan to implement an organization-wide registration and charge each provider the annual fee of $68.
   

4. Optional - Upload Patient Insurance Info (in Bulk) 

Our OptiMantra team can help you by bulk uploading your patient insurance information - please send us your patient insurance information as part of your demographics data upload in a ticket.

This information will then live under each patient’s profile in the insurance billing tab:

You can also ensure that all new patients are prompted for insurance information by configuring your Patient Portal settings. 

• Under Settings > Communications > Patient Portal and Kiosk, you’ll leave the box “Hide Insurance Tab” unchecked in the "Required For All Clients" box (see screenshot below).
   

 

Live Training and Support

Our billing experts are here to help with accurate setup, transmission errors, and payment posting issues. 

For questions, create a ticket within OptiMantra by clicking “Create Ticket” at the top of your home screen. Your ticket will be routed to an insurance billing specialist for assistance

• We offer drop-in insurance billing sessions via Zoom every Tuesday and Thursday, led by our billing experts. Feel free to join at any time during these sessions.

• Tuesday sessions are held from 11 AM to 12 PM PST (2 PM to 3 PM EST). 

  • General insurance billing information and setup (click for signup)

• Thursday sessions are held from 11 AM to 12 PM PST (2 PM to 3 PM EST). 

  • A Q&A format to assist with any questions (click for signup) 
     

• If you’re transferring ERA setup from another program using Office Ally, you may need to complete a separate application for each insurance company. For the most up-to-date information, please contact Office Ally directly at 360-975-7000.
   

Tips for Successful Insurance Billing

• Stay Organized: Maintain accurate and up-to-date patient records and ensure all insurance details are verified before providing services. Ensure that the patient is eligible and the services that will be provided are covered under their plan. Approximately 35% of all claim denials are due to registration and eligibility errors.

• Use a Reliable Billing System: Invest in reliable medical billing software to streamline the process, reduce errors, and track claims accurately. (You’re already doing this!)

• Stay Informed: Keep up with changes in insurance policies, coding updates, and state and federal billing regulations to avoid claim rejections and denials.

• Follow Up: Regularly monitor submitted claims and promptly address any issues or denials. Electronic claims typically process within 30 business days, and paper claims within 45 days. If no response is received within these timeframes, contact the insurance provider to verify receipt and check claim status. Also, be aware of timely filing limits for different payers (e.g.: Medicare has a 1-year timely filing limit).