A PPO pays you back for an out-of-network visit only when your superbill carries the same facts a clinic would put on a CMS-1500 claim: the rendering clinician’s 10-digit NPI, the practice’s tax ID, the place of service, each CPT code with its modifier and diagnosis pointer, the total charge and the amount you already paid. This generator lays those out in CMS-1500 box order, marks Box 27 Accept assignment = NO so the check goes to you, and can add a signed cover letter for your plan’s claims department.
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Superbill #:
Issued: November 10, 2026
Itemized Medical Superbill — Out-of-Network Patient Receipt
Boxes are numbered to match the CMS-1500 (02/12) claim form so a claims processor can key them directly. This is a provider receipt, not the CMS-1500 form.
Billing & rendering provider
Billing provider (Box 33)
Federal tax ID / EIN (Box 25)
Group NPI (Box 33a)
Rendering clinician (Box 31)
Rendering NPI (Box 24J)
Taxonomy (Box 33b, ZZ)
Service facility location (Box 32)
Billing phone (Box 33)
Patient & insured
Patient name (Box 2)
Date of birth (Box 3)
Relationship to insured (Box 6)
Patient address (Box 5)
Insured name (Box 4)
Insurance plan (Box 11c)
Member ID (Box 1a)
Group # (Box 11) · Account # (Box 26)
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Diagnosis codes (Box 21 · ICD Ind. 0 = ICD-10-CM)
Ptr
ICD-10-CM
Description
A
B
C
D
E
F
Services rendered (Box 24)
24A Date
24B POS
24D CPT
Mod
Description
24E Ptr
24G Units
24F Charge
Paid
Box 28 total charge · Box 29 amount paid
Box 27 · Accept assignment
YES ✕NO
Box 28 · Total charge
Box 29 · Amount paid
Balance due
Payment method
Date paid
The patient has paid this provider directly. This provider is out of network and does not accept assignment. Please issue any reimbursement to the insured; Box 13 is intentionally left unsigned.
Membership exclusion: any membership, retainer or concierge access fee is not listed and is not submitted for reimbursement. Only the itemized clinical services above are claimed.
Box 31 · Signature of physician or supplier
Date
Private superbill template organized by CMS-1500 (02/12) item numbers; not an official CMS or government form. Codes are chosen and verified by the treating clinician. Coverage, allowed amounts and reimbursement are decided by the patient’s health plan.
Organized by CMS-1500 (02/12) item numbers; CMS Place of Service code set · Educational clinical/administrative template via IntegrativeGyn.com — not medical, legal, or tax advice.
01What a PPO needs to see on an out-of-network superbill
When you submit a superbill yourself, a claims processor re-keys it into the same fields a clinic would fill on the CMS-1500 claim form. If a field is missing, the claim usually comes back as “incomplete” or is denied, and you lose weeks. Most rejections trace to the same short list, so the generator prints each item next to its CMS-1500 box number:
CMS-1500 box
What goes there
Why a plan rejects without it
24J
Rendering clinician’s 10-digit NPI
The plan cannot confirm a licensed clinician gave the care
25
Practice EIN (federal tax ID)
Needed to identify the billing entity
33, 33a, 33b
Billing provider, group NPI, taxonomy with qualifier ZZ
Taxonomy tells the plan the specialty, such as 207V00000X obstetrics & gynecology
24B
Place of service: 11 office, 10 telehealth at home, 02 telehealth elsewhere
Visits are priced differently by place of service
21 and 24E
ICD-10-CM codes lettered A–L and a pointer letter on every service line
Each CPT code has to be tied to a diagnosis
24D
CPT or HCPCS code and modifier
Missing modifiers 25 or 95 cause line denials
27, 28, 29
Assignment NO, total charge, amount paid
Shows you paid, so the plan pays you
Table 1 · Box numbers follow the CMS-1500 (02/12) form. Requirements vary by plan; your plan’s member claim form is the final word.
The generator covers six diagnosis lines (A–F), which is enough for almost any gynecology visit; the CMS-1500 itself allows up to twelve. Diagnosis pointers are letters, not codes: line 1 of Box 21 is A, line 2 is B. A line can point to up to four letters, and the first one should be the main reason for that service.
If you have not chosen a clinic yet, the 2026 clinic pricing benchmark found that 19 of 26 clinics with published prices work out of network, on cash or on a membership — so a clean superbill is often the only way to get part of your money back.
02Diagnosis pointers, modifier 25 and telehealth codes
Three coding details cause most line-level denials on integrative gynecology superbills. The generator warns you about each one as you type.
A same-day counseling visit needs modifier 25
Some clinics bill a problem-oriented visit such as 99204, 99205, 99214 or 99215 and, on the same date, preventive counseling with 99404 (about 60 minutes of risk-factor counseling). Put modifier 25 on the problem-oriented visit code. It tells the plan that the visit was significant and separately identifiable from the counseling. Without it, many plans pay only one of the two lines. Coverage of 99404 itself varies widely, so check your plan’s preventive benefits.
Prolonged time goes only on the top-level visit
99417 adds each extra 15 minutes of total time to a 99205 or 99215 visit — under CPT rules, from 75 minutes for 99205 or 55 minutes for 99215. Billed with any other visit level, it is usually denied. Medicare uses a different code, G2212, with its own time thresholds, so a Medicare-style superbill will look different.
Telehealth: place of service and modifier 95
A video visit from your home is POS 10; a telehealth visit while you are somewhere other than home is POS 02. Many commercial PPOs also want modifier 95 (synchronous audio-video telemedicine) on the CPT line, while Medicare and some plans rely mainly on the place of service. If your plan’s telehealth policy is unclear, ask member services which they expect before you submit.
Codes are your clinician’s decision, not yours: the superbill has to match what was documented in your chart. If a code looks wrong, ask the clinic to correct it rather than editing it yourself. To see how much a given mix of codes might return, run it through the insurance & superbill estimator with a prolonged-time unit and same-day 99404.
03Box 27 = NO and Box 29: getting the check sent to you
When you pay an out-of-network clinic in full, the reimbursement belongs to you. Two parts of the claim tell the plan who gets paid:
Box 27, Accept assignment: the generator always marks NO. The clinic is not taking payment from your plan and is not agreeing to the plan’s allowed amount.
Box 13, insured’s authorization of payment to the provider: leave it unsigned. Signing it asks the plan to pay the clinic, which you have already paid.
Box 29, Amount paid: the generator totals what you paid on each line. When it equals Box 28, the superbill prints “paid in full”, which is what most plans need before they reimburse you.
Some practices charge a membership or retainer on top of visit fees. That fee usually buys access, not a coded medical service, so plans generally do not reimburse it. The generator prints a short note saying membership fees are excluded, which keeps the claim clean and avoids a denial of the whole superbill.
You can still pay for the visit from an HSA or FSA. Just claim each dollar once: if the plan later reimburses part of a visit you paid from your HSA, that part was not your out-of-pocket expense. For supplements, labs or devices your plan never covers, the HSA/FSA letter of medical necessity generator builds the matching paperwork, and the insurance, superbill & HSA/FSA guide explains how the two fit together.
What reaches you is not the clinic’s fee. The plan pays a share of its own allowed amount for each code, after your out-of-network deductible, so even a perfect superbill may return much less than you paid.
04How to submit: cover letter, claim form and deadlines
Pick a quick template close to your visit — a 60-minute perimenopause consult, a PCOS visit with same-day counseling, a telehealth thyroid follow-up or an endometriosis visit with ultrasound. It fills realistic codes you can replace.
Copy the clinic’s details exactly: legal name, service address, EIN, the rendering clinician’s NPI and taxonomy. Most clinics will give you these on request; you can also look an NPI up in the federal NPPES registry.
Enter each service line with its date, place of service, code, modifier, pointer, units, charge and what you paid. Fix every warning the tool shows.
Turn on the cover letter if you are mailing or uploading the claim. It restates your member ID, asks the plan to credit your out-of-network deductible and to send reimbursement to you, and lists your enclosures.
Attach your plan’s own member claim form. Many plans require it with every superbill. Add proof of payment, sign, and submit through the member portal or by mail.
Watch the deadline. Plans set a filing limit counted from the date of service. Look it up on your member portal and submit well before it.
Prefer to write by hand? Click Clear All Fields and print: every box prints as a blank line, so your clinic can complete and sign it. If you want to know what your plan is likely to pay before you book, the consult form below can match you with a clinic that issues superbills routinely.
This page is educational and is not medical, legal, billing or tax advice; your clinician decides the codes, and your health plan decides what it reimburses.
SourcesPrimary federal sources
Every statutory element and clinical prompt on this form traces to these primary sources, each checked live (HTTP 200) on November 10, 2026.
A superbill is an itemized receipt from a clinic that has not billed your insurance. It lists the clinician, the practice tax ID, the diagnosis codes, each service with its CPT code, the charge and what you paid. You send it to your PPO yourself, usually with the plan’s member claim form, to be reimbursed under your out-of-network benefits. It is not a CMS-1500 claim form, but it carries the same information.
Can I fill out my own superbill?
You can prepare it, but the codes and details must match what your clinician documented, and plans expect it to come from the practice. Use this generator to lay out the information, then ask the clinic to check the codes and sign the Box 31 line. A superbill with invented or altered codes can be denied and may be treated as a false claim.
Why does Box 27 say NO?
Box 27 asks whether the provider accepts assignment, meaning whether it takes payment from the plan. An out-of-network clinic you have already paid does not, so the box is marked NO and the insured’s payment authorization in Box 13 is left unsigned. That tells the plan to send any reimbursement to the insured rather than to the clinic.
Will my plan reimburse membership or retainer fees?
Usually not. A membership fee generally buys access to the practice rather than a coded medical service, so it has no CPT code to put on a claim. Most plans reimburse only the itemized visits, tests and procedures. The generator prints a note excluding membership fees so the rest of the superbill is not rejected. Ask your plan in writing if you are unsure.
Does this tool send my information anywhere?
No. The superbill is built in your browser as you type. Nothing is saved, sent to a server or added to the page link. If you click the consult button, only a summary — the document type, the care category and how many service lines are listed — is attached to the request form, and only if you then choose to send that form.
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