Claim Making Tutorial

Due to recent changes in how Vermont Medicaid requires claims to be created and submitted, we are no longer able to use the automated claims-building features within SimplePractice (or any other EHR) for Medicaid billing. As a result, all OpenGate clinicians who bill Medicaid will now complete manual claim creation and submission on a weekly basis.

Claims must be created and submitted by 5:00 p.m. each Friday in order to be paid in the following week. While this adds a new responsibility for clinicians, the process itself is straightforward, quick (typically under five minutes), and highly repeatable once learned. The step-by-step instructions below walk you through the process in full and are designed to help you complete this accurately and confidently each week.

This page walks you through the full process of preparing and submitting insurance claims at OpenGate. Step 1 focuses on getting your sessions set up correctly before claims are generated (including required cleanup, such as removing modifiers where applicable). Step 2 provides clear, practical instructions for submitting claims to multiple insurance companies, with guidance that reflects the real workflows you’ll be using in practice. Together, these steps are designed to reduce errors, prevent delays, and make claim submission as smooth and predictable as possible.

Step 1- Prepare your sessions for claims making

Effective for all sessions on or after January 1, 2026

All clinicians must stop using modifiers for Medicaid sessions beginning January 1, 2026.

If modifiers remain attached to sessions, claims will require manual correction later, so it’s important that this is cleaned up now on the front end.

Important! You will still use the 95 telehealth modifier and the 93 phone session modifier for all claims to all payers.

There are three places you need to update:

✅ 1. Past Sessions (since Jan 1, 2026)

If you have already completed Medicaid sessions that include a modifier:

  • Go back into each affected session
  • Edit the service code
  • Remove the modifier
  • Save the session

This ensures the claim will generate correctly when submitted.

✅ 2. Client Default Services (for future bookings)

To prevent modifiers from being added automatically going forward:

  • Open each Medicaid client’s profile
  • Go to Client Default Services
  • Remove the modifier from the service
  • Save changes

This step prevents modifiers from being added to newly booked sessions.

✅ 3. Existing Recurring Appointments (calendar cleanup)

For Medicaid clients with recurring sessions already on your calendar:

  • Open the appointment on the calendar
  • Edit the service and remove the modifier
  • When prompted, select “Apply to all future sessions”
  • Save

This ensures all future appointments in that series are corrected.

🔁 Quick Summary

You are:

  • Removing modifiers from completed sessions since Jan 1, 2026
  • Removing modifiers from client default services
  • Removing modifiers from all future sessions in existing recurring bookings

Thank you for taking care of this promptly — it saves significant cleanup work later and keeps our Medicaid billing compliant and smooth.

If you run into issues or aren’t sure whether you’ve caught everything, reach out.

Part 2

How Claim Making Works at OpenGate

(Read this all the way through before beginning)

Claim submission at OpenGate currently requires two distinct workflows, depending on the insurance company. This is because SimplePractice automatically assigns the rendering provider based on whose NPI is entered in your Provider Settings, and different payers require different rendering providers.

Here’s the key distinction:

Medicaid Claims

For Vermont Medicaid, claims must be submitted with:

  • You (the supervisee) listed as the Rendering Provider, using your individual NPI
  • OpenGate listed as the Billing Provider, using the OpenGate group NPI

To make this happen in SimplePractice:

  • Your individual NPI must be entered in your Provider Settings before generating Medicaid claims

All Other Insurance Claims (BCBS, MVP, etc.)

For all non-Medicaid insurance companies:

  • Kathleen Landry (or your supervising clinician) must be listed as the Rendering Provider
  • OpenGate remains the Billing Provider as applicable

To make this happen:

  • Your individual NPI must be removed from your Provider Settings before generating these claims
  • When no supervisee NPI is present, SimplePractice defaults the rendering provider correctly to the supervisor

What This Means in Practice

Until a more automated system is available, claims must be created manually in two batches:

  1. Batch One: Medicaid Claims
    • Enter your individual NPI in Provider Settings
    • Generate and submit all Medicaid claims
    • Confirm rendering provider = you, billing provider = OpenGate
  2. Batch Two: All Other Insurance Claims
    • Remove your individual NPI from Provider Settings
    • Generate and submit all non-Medicaid claims
    • Confirm rendering provider = supervising clinician

This setup is intentional and required to meet payer-specific billing rules. Submitting claims outside of this structure will result in denials, delays, or rework.

The sections below walk you through exactly how to do this step-by-step, including screenshots and payer-specific instructions.

Claim Making SOP (Two-Batch Process)

To be completed weekly (recommended: Fridays)

Because different insurance companies require different rendering providers, all claims at OpenGate must be submitted in two separate batches: Medicaid first, then all other insurance payers.

Follow the steps below in order, every time.

Batch 1: Medicaid Claims

Step 1: Enter Your Individual NPI

  1. Go to Settings
  2. Enter your individual NPI in Provider Information
  3. Save

This step ensures you are listed as the Rendering Provider, as required by Vermont Medicaid.

Step 2: Filter for Medicaid Claims

  1. Go to Insurance
  2. Select Unbilled Appointments
  3. Under All Insurance Payers, enter the Medicaid payer identifier:
    • VTMCD (Vermont Medicaid)
  4. This will filter your list to Medicaid-only sessions

Step 3: Review Claims Before Submitting

Before creating claims:

  • Confirm no modifiers are attached to any session
  • Edit and remove modifiers if needed

Step 4: Create and Submit Medicaid Claims

  1. Select the filtered Medicaid appointments
  2. Click Create and Submit Claims
    • ⚠️ Do not select “Create Claims” only
  3. Submit

Batch 2: All Other Insurance Claims

Step 5: Remove Your NPI

  1. Return to Settings
  2. Remove your individual NPI
  3. Save

This allows SimplePractice to correctly default the Rendering Provider to your supervising clinician.

Step 6: Filter for All Non-Medicaid Claims

  1. Go back to Insurance
  2. Select Unbilled Appointments
  3. Under All Insurance Payers, select All Insurance Payers

At this point, Medicaid claims should already be completed, so this list should include all remaining insurance sessions.

Optional payer identifiers (if you ever need to filter individually):

  • Vermont Blue Cross Blue Shield: VTBLS
  • MVP: 14165
  • Cigna: Cigna
  • Other payers: type the payer name

Step 7: Create and Submit Remaining Claims

  1. Select all remaining appointments
  2. Click Create and Submit Claims
  3. Submit

Weekly Reminder

  • Complete this process once per week
  • Medicaid first, always
  • Confirm modifiers are removed before submitting claims

This workflow is required to keep claims compliant and avoid denials or manual corrections later.