Billing operations

How billing works end-to-end

Before working the individual tabs, it helps to see the whole pipeline. Hero EMR is built so that money follows the chart on its own: every hand-off below happens automatically, and the system only asks for a person when it hits something it can’t fix itself.

1. A visit is signed. Billing starts the moment the clinician signs and closes the encounter (see Sign & close) — there is no separate “send to billing” step.
2. Charges are priced. The visit’s E/M and CPT codes become charges, priced by your layered billing setup — organization defaults, service overrides, negotiated rates, and per-patient exceptions.
3. A claim is built and checked. For insured visits Hero EMR assembles the claim and runs readiness checks, so coding, demographic, and policy problems surface as fix before send issues in your queue instead of as payer rejections weeks later.
4. Claims batch to the clearinghouse. Ready claims go to the clearinghouse (Office Ally) as 837P batches. The clearinghouse answers with acknowledgements — a 999 for the file and a per-claim 277CA verdict — confirming each claim actually arrived and was accepted for processing.
5. The payer adjudicates — and the money posts itself. The payer decides what it pays, what it writes off, and what the patient owes, then sends back an electronic remittance (an 835 / ERA file). Hero EMR ingests it automatically and posts the payments and contractual write-offs to each claim.
6. What’s left becomes patient responsibility. Only after adjudication does the remainder — copay, coinsurance, deductible — move onto the patient’s balance, where statements and collections take over. Patients are never billed amounts insurance is still deciding.

Open and navigate the Billing Command Center

Day-to-day money work happens in the Billing Command Center — one workspace for pre-visit readiness, claims, payment posting, patient balances, and recurring-revenue programs. The header shows your organization name and the active payment-model label (Insurance, Pure Cash, DPC, Hybrid Insurance + Cash, or Not Set), and the whole workspace adapts to that model and to each user’s permissions — so two staff members can legitimately see different tabs.

1. Open the workspace. Staff whose permission profile includes any billing permission get a dedicated Billing button in the top toolbar — and staff with only billing permissions land here directly after login. Admins reach the same page from the Admin toolbar menu → Billing. Other parts of Hero EMR deep-link in too: the calendar’s appointment window can jump straight to a visit’s billing records, opening the Claims Pipeline focused on that encounter (see the calendar).
2. Learn the sidebar groups.
   • Operations — Dashboard (the Billing Monitor, the pipeline-health view covered in Monitor billing health), Pre-visit (the upcoming-visit readiness worklist — see Visit readiness), Claims Pipeline, Payments, Patient AR, and Reports, which offers Quick Reports with date-range and group-by controls, a Generate Report button, and one-click CSV / Excel / PDF export. IDR — a narrow out-of-network dispute workflow under the No Surprises Act — appears here only if your practice enables it under Additional Features.
   • Programs — the APCM program, covered in APCM billing; it likewise appears only when enabled.
   • Configuration — Payment Model, Collections & Fees, Service Menu, Subscriptions, Charge Fees, Negotiated Rates, Claim Submission, Billing Identity, Auto Modifiers, and Simulator. This is the setup material covered in Billing setup — except Subscriptions, the day-to-day membership workflow documented in Memberships. If you switch tabs with unsaved Collections & Fees edits, an Unsaved changes dialog asks before discarding (Keep editing / Discard).
3. Understand why tabs differ per person. Tab visibility follows the payment model first — Pure Cash and DPC practices don’t see Claims Pipeline or Negotiated Rates by default — and is then filtered by each staff member’s billing permissions (assigned in staff permission profiles). A staff member with no matching permission sees No billing tools are available for this staff profile. Admins can reveal every tab with the sidebar footer toggle Show all tools / Use model defaults.

Monitor billing health (the Billing Monitor)

The Dashboard tab is the Billing Monitor — one live picture of the organization’s billing pipeline over a window you pick (7d / 30d / 90d, plus Refresh). Instead of hopping between tabs to ask is billing healthy?, you read one strip left to right and click whatever looks wrong.

1. Read the lifecycle strip. Eight linked stages mirror the end-to-end pipeline: Signed → Charges → Claims → Submitted → Acknowledged → Adjudicated → Posted → Patient balance, each with its count or dollars for the window. Every stage is clickable and jumps to the tab that works it — the claim stages open the Claims Pipeline, the money stages open Payments or Patient AR.
2. Work the exception chips. Chips appear under a stage only when something there needs attention, colored by severity and stamped with the age of the oldest problem (oldest Nd). A clean strip means a clean pipeline — there is nothing to dismiss. Each chip deep-links to the tab where you fix it; the table below shows what can surface where.
3. Scan the Billing Inbox rollup. The Billing Inbox panel summarizes the alert rail without leaving the workspace: an N active badge, one chip per alert type and severity (for example charge ar drift 17), and the newest alerts with timestamps. Open billing inbox jumps to the main Inbox’s Billing folder (see Inbox queues), and the same active count shows as a red badge on the Dashboard tab in the sidebar — visible from anywhere in the workspace.
4. Read the money row. Three cards along the bottom: Insurance AR (awaiting payer) — submitted claims awaiting the payer, aged 0-14 / 15-30 / 31+ days; Patient AR with its aging buckets; and Collected in window split into insurance and patient collections, with a footer showing ERA ingestion health — how many remittance runs landed in the window, by source and status, and when the last one ran.
5. Expand the Revenue Overview for trends. The classic collapsible Revenue Overview (titled Collections Overview for pure-cash and Membership Overview for DPC practices) now sits collapsed at the bottom of the tab, with period buttons from 7 days to Year to date, summary cards such as Insurance Billed and Outstanding AR, a Claim Status Pipeline chart, and an AR Aging breakdown.

Behind the monitor, automated checks sweep the whole pipeline nightly — unbilled insured visits, self-pay balances, stale in-flight claims, claim-integrity problems (duplicates, void confirmations, orphan charges, bookkeeping drift), payment-posting problems, and statement, refund, and batch failures — and file each finding as a billing-inbox alert. The chips and the rollup are two views of that same alert rail.

Work the pre-visit billing readiness queue

The Pre-visit tab is the Upcoming Visit Readiness worklist — every scheduled visit in the next 14 days (by default), built to catch eligibility and insurance problems before the patient arrives. It used to lead the Dashboard tab; it now has its own sidebar tab, unchanged in behavior, so the Dashboard can be the Billing Monitor. The header shows the date range plus Filters, CSV, and Refresh buttons.

1. Scan the chip strip. Summary chips count Upcoming, Missing elig., Stale elig., COB missing, Open problems, and In progress, plus payer-class chips for Medicare, Medicaid, Private, and Unknown. Filters narrows by Start date, End date, Payer search (Aetna, BCBS…), Provider, Visit type, Payer class, and eligibility status (Any eligibility).
2. Run eligibility checks. Each row’s Eligibility check action queues a live eligibility verification with the payer (via Office Ally) for the patient’s primary policy — you’ll see Eligibility check queued. Rows without an active primary policy are rejected with an error. Checks run in the background, so results don’t appear instantly; Refresh after a few minutes.
3. Flag what needs a human. Flag billing problem opens a dialog asking “What needs human resolution before this visit?” with Reason, Priority, and Notes fields; flagged visits later show a Resolve problem action. Both actions require billing AR permission (tooltip: Requires billing AR permission).
4. Open the detail drawer. Clicking a row opens a drawer with Visit & patient, Eligibility, Insurance policies, Coordination of benefits, Work items, Billing messages, and Billing notes — notes are visible to billing staff only.

Review charges and run the claims pipeline

Charges created when a visit is signed and closed (see Charges & E/M) flow into the Claims Pipeline, which moves them from review through submission to resolution. The tab has four views — with clickable summary stats (needs review, ready, active batches, follow-up, stuck 25+ days) that jump you to the matching slice.

1. Review new charges. Ready to Submit splits into Needs Review — charges carrying issue badges such as coding or demographic problems — and Ready to Send. Fix the issue, then use Mark ready on the charge’s work item in the Action Center.
2. Create a batch. In Ready to Send, tick charges (or Select all) and pick the Claim submission channel: Office Ally SFTP, Availity SFTP, or Manual portal — unconfigured channels show - setup required. Click Create Batch for an integrated channel, or Create Claim File for manual (“Creates a downloadable 837P file for external portal upload.”).
3. Track what’s in flight. The In Flight view lists batches with per-batch actions: Download 837P, submit to the channel, Mark manual portal upload complete, and Check acknowledgements — TA1/999 acknowledgements show as Received or Pending in the claim detail. Expanding a batch shows a per-claim 277CA roster: every claim in the batch with an Accepted, Rejected, or Awaiting 277CA badge, the payer’s status message, and a Fix link that jumps straight to that claim’s Action Center item — a legend decodes the codes (277CA ack codes: A1/A2 accepted · A3-A8 rejected (A4 = not found)). A claim moves through Draft, Ready, Submitted, Acknowledged, and In Process, then resolves to Paid, Denied, Partial, Pended, Appealed, or Closed. Claims with no activity for 25+ days raise an amber banner with a Review oldest stuck claims filter.
4. Work the Action Center. The Action Center is a smart-sorted worklist across six lanes (table below). The lane cards across the top show each lane’s count, dollar total, and the age of its oldest item (oldest Nd) — so a lane that’s quietly aging stands out at a glance — and each claim row carries a readiness badge (Ready, or N issues — fix before send) telling you whether it’s safe to resend before you even open it. Search by Search patient, claim #, payer, code…, sort by Smart sort / Newest update / Highest dollars, and narrow with My items, Include snoozed, or Group by lane. Selected claims take bulk Snooze 7d / Flag; each item also offers Flag, Note, Assign me, Snooze, Mark ready (charges), and Mark uploaded (manual batches).
5. Resolve a claim. Expanding a claim shows Exact Problems (denial and rejection issues with codes, financial impact, and appeal deadlines — denial codes are decoded into plain language by a glossary the server builds from your payers’ actual responses, e.g. CO-16: “Claim is missing information or has invalid information.”; codes it can’t decode still appear with their raw code rather than being dropped), Codes (editable diagnoses and per-line CPT/modifier edits with save-and-resubmit), Financials, Submission, and a Manual Submission Package with Show Raw 837P / Copy raw 837P / Download raw 837P. Denied claims offer File Appeal, Correct & Resubmit, and Write Off; a Regenerate action rebuilds the claim from the patient’s current insurance after a coverage correction.

Post ERAs, manual payments & refunds

The Payments tab is headed Payment Posting, with Manual Entry, Upload ERA 835, and Refresh buttons across the top. It’s where insurance remittances and hand-keyed payments get applied to claims — and where refunds are issued.

1. Upload an ERA. Upload ERA 835 accepts .835, .edi, and .txt files, then parses and auto-matches the remittances. The result message reports what happened — for example “3/5 claims posted (4 payments, 2 adjustments).” — with unmatched claims left staged for review rather than blocking the post.
2. Post queued remittances by payer check. Electronically received remittances wait in Unposted Remittances (N), grouped by payer check — the 835 trace number. Each check group shows the check total, the unposted amount, and the posted/other variance, so a check whose money doesn’t add up stands out before you post; expand a group for its per-claim rows (Claim, Billed, Paid, Patient Resp, Status). Rows marked Ready to post take Post; reversals and takebacks instead carry an amber Needs review (reversal/takeback) badge with the reason, and their Post button stays disabled until you resolve the claim state.
3. Enter a manual payment. Manual Entry opens the Manual Payment Entry form: Claim # (required), Payment Type (Insurance Payment, Patient - Cash, Patient - Card, Patient - ACH), Payer, Check #, Amount (required), Payment Date, and Note — then Post Payment. The Claim # field is a live search picker — type a couple of characters of the patient, claim number, or payer and pick the claim from the results; no more pasting exact identifiers.
4. Reconcile the edges. Two collapsible panels keep the odd cases honest. External / filed outside EMR (N) lists remittance and status references that match no claim in Hero EMR — typically claims filed directly at the clearinghouse portal (Office Ally references like C###P##) — with source, payer, service date, and amounts, so money arriving for them is tracked instead of vanishing. Recent ERA Ingestion Runs shows one row per 835 file processed by the pollers or a manual upload — received time, source, status, and matched / posted / unmatched counts — your proof that remittances are actually flowing in.
5. Audit and refund. Recent Payment Activity lists the latest 200 payments with Date, Patient / Payer, Type (ERA-835, Insurance, Cash, Card, ACH), Billing Entity, Amount (with any Refunded sub-line), Claims, and Status (Posted / Pending). Refundable payments show a Refund action that opens the Issue Refund modal — remaining refundable balance, Refund amount, and Refund reason, confirmed with Refund Payment. Card refunds flow back through Stripe automatically.

Manage patient balances, statements & collections

The Patient AR tab opens the AR Workspace, which summarizes total outstanding (for example $1,601.51 across 10 patients) with Filters and Refresh buttons and a Search by patient name or MRN… box; practices with multiple billing entities also get a Billing entity switcher. Billing-inbox alerts about a specific patient deep-link straight here with that patient already filtered, so you land on the account in question rather than the whole roster. A toggle flips between two views:

1. Send a statement. Statement opens the Statement Preview — practice and patient addresses, line items with Charges / Insurance / You Owe columns, and TOTAL AMOUNT DUE: at the bottom. Deliver it with Print or Email.
2. Send statements in bulk. In the Aging view, tick the checkbox on each row you want and click Send Statements (N) to email them all at once. The result reports per patient — for example Sent 12, failed 2 with the failing names — and the failed patients stay selected so you can fix the issue (say, a missing billing email) and retry without double-sending anyone who already got theirs.
3. Open the billing timeline. The Timeline row action opens the Billing Timeline drawer: the patient’s outstanding balance and available credit up top, then every billing event in one chronological view — charges from their visits, claims, payments, refunds, and statements. It’s the fastest way to answer “what happened with this patient’s money?” without hopping between tabs.
4. Offer a payment plan (beta). Plan — badged Beta in the UI — opens Create Payment Plan with a frequency choice and an installment preview before you commit.
5. Review fees and payment activity. On the Day Sheet, Fees opens the Fee Review modal listing no-show and late-cancellation fees generated by your visit policies, with a permission-gated Waive Fee button that requires a waive reason. Activity opens the Payment Activity modal — the receipts and credits hub: receipt numbers, amounts, refunded amounts, payment methods, a Statement history (delivery method and status per statement), and Issue Refund, Hold Credit, Apply Held Credit, and Release Held Credit actions (all require the sensitive-billing permission). Available credits auto-apply to future balances; held credits stay off the balance until you apply or release them.
6. Escalate to collections. Collections appears once a patient carries $100 or more in the 90+ Days bucket. It asks you to confirm sending the patient to collections, then moves the account into the collections workflow.

Run membership & subscription billing

The Subscriptions tab — “Manage recurring membership plans and patient billing.” — is the home of recurring revenue, and the primary billing workflow for DPC practices. All money movement runs through your connected Stripe account, so complete Stripe Connect onboarding first.

1. Turn on subscriptions. The Subscription Settings card gates everything: an Enable subscriptions toggle, Allow patient self-cancel for portal self-service, and a cancellation-timing choice of At end of billing period or Immediately. If Stripe Connect isn’t active you’ll see: “Stripe Connect is not active. Plans cannot be published until Stripe is configured in Admin > External Providers > Stripe.”
2. Build your plans. Under Membership Plans, New Plan opens the plan form — Plan name, Amount, Currency, an Every billing-interval selector, and an optional trial. Plan cards support edit, publish/unpublish, and archive. Editing a published plan’s price, cadence, or trial shows a versioning warning: existing members keep the price they accepted, and the new version applies only to new enrollments.
3. Enroll members. The Member Roster (“Monitor active subscriptions and resolve billing issues.”) lists Member, Plan, Status, Renews, Billing, and Actions, with a Search by name or plan box plus status and plan filters. To enroll, enter a Patient ID, choose a plan, and copy the Enrollment link — the patient completes checkout in the patient portal (see Portal payments).
4. Manage each member. Per-member actions: Details expands an Invoice timeline with per-invoice status and hosted Stripe invoice links; Cancel opens the Cancel membership modal with a proration/access preview, a reason selector (Patient requested, Payment issue, Plan fit, Staff review, Other), and a typed confirmation; Resume undoes a scheduled period-end cancellation; Collect retries the open invoice immediately (enabled only while the latest invoice is open); and Payment link copies a hosted payment link for the patient.
5. Work the recovery queue. The Payment recovery queue highlights members with failed invoices; rows flag Payment recovery needed, Cancels at period end, Plan no longer offered, and Snapshot needs staff review, alongside Stripe sync health. Staff with the access-override permission can use Record override to grant temporary access while billing is being fixed — care continues, the invoice gets chased.

Bill the APCM program

APCM (Advanced Primary Care Management) is an opt-in module: the tab is absent until an admin enables it under Additional Features, and it shows only for users with billing dashboard or AR permission. Once on, it manages the full monthly cycle — enrollment, consent, care plans, and G-code billing — across four sub-tabs:

1. Watch the dashboard. The Dashboard sub-tab shows tier counts — Enrolled, G0556, G0557, G0558 — plus Monthly Revenue, an Alerts card, and an Upcoming Generation card with a month picker and Preview Generation / Generate Now buttons.
2. Enroll patients. Enrollments has three views: Enrolled (N), Pending review (N), and Eligible (N). From Eligible, select patients and click Enroll selected (N); from Pending review, bulk Approve (N) or Reject (N). Each enrolled row shows Tier, Chronic conditions, Last appt, Coordinating provider, Status, and Consent badges, with a Manage link to the enrollment detail. An auto-enrollment settings card can scan for eligible patients automatically or on demand (Scan now); the Eligible table shows Est. tier and Est. / mo revenue.
3. Capture consent. Patient consent is a formal e-signed agreement. The Consent badge on each enrollment reflects pending vs. obtained consent (with method and date), and the signed consent PDF files to the patient’s media tab.
4. Generate and track billing. Generate Now (or Preview Generation first) creates the month’s APCM billing events. The Billing History sub-tab lists them by month with Patient, Code, Amount, Status, and Generated columns and a Refresh button. Generated events flow into the normal claims pipeline as G-code charges.
5. Keep care plans current. The Care Plans sub-tab manages each enrollment’s plan — Goals with + Add goal, Interventions with + Add intervention, and Save Care Plan — and surfaces a Missing Care Plans list, since care-plan documentation supports the billed codes.