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. Cash visits are priced by your layered billing setup — organization defaults, service overrides, and per-patient exceptions. Insurance charges bill the payer’s contract rate, else a rate learned from that payer’s payments, else your CPT List Price (CPT prices & payer rates). A code with no price at all holds the visit’s claim until you price it — Hero never files a $0 line.
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 go to the clearinghouse. Ready claims leave by your practice’s claims route: Stedi sends them automatically every few minutes; Office Ally SFTP (and Availity SFTP) take them in a daily batch at a set time in your practice’s time zone; Optum-only practices send through Optum; or a biller submits them by hand or downloads a claim file (Manual 837P download) to upload elsewhere. The Claims Pipeline’s route line says which applies to you (see the claims pipeline). The clearinghouse answers with acknowledgements — a per-claim 277CA verdict, plus a file-level receipt (TA1 / 999) from clearinghouses that send one — confirming each claim actually arrived and was accepted for processing. Some connections never return a file-level receipt; Hero then relies on the 277CA and shows the missing receipt as Not returned rather than pending forever. A claim the clearinghouse bounces at this step shows as Rejected: it never reached the payer, so there is no decision to appeal — you fix the data and refile it (see the claims pipeline).
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 — an 835 you upload yourself posts the same way. Anything a person has to decide waits in Unposted Remittances with the reason and the next step.
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. There is no Billing button in the top toolbar. Admins open it from the Admin toolbar menu → Billing; anyone who can use Billing gets a Billing link and a Billing inbox count on the Home page, and Alt + 6 jumps to it from anywhere. Staff whose permissions include billing work start in Billing when they sign in. 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. Pick up where you left off. Billing opens on the Dashboard — or, for logins without Dashboard access (Front Desk, for example), on Patient AR → Day Sheet. Leave Billing for another workspace tab and come back (the tab, Alt + 6, or the Home link) and it reopens the page you were on, with its filters, for as long as that browser tab stays signed in. The very first time, the sidebar shows grey placeholders and the page reads Loading billing workspace… until your tools are known, so nothing jumps under the pointer.
3. 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. Date ranges are calendar periods — Today, This Week, This Month, Last Month, This Quarter, Last Quarter, This Year, or Custom Range — with the resolved dates shown under the select and on the result. The AR Aging Report places each account in one bucket (0–30 … over 120 days) by its oldest open balance and splits it into Patient AR, Pending with insurance, and Insurance AR, adding up to the same Total receivable as the Billing Monitor. The Revenue & Collections Summary shows charges, payments net of refunds, and the collection rate, with membership dues listed separately (for users who may see membership money). Reports grouped by payer show one row per payer, with its Payer IDs. The payer denial-rate report counts only claims the payer actually adjudicated and denied; claims the clearinghouse bounced before the payer saw them are broken out in their own Rejected Before Payer column, so routine transmission fixes never inflate your denial rate. Payers Hero knows to be clearinghouse test payers (the sandbox payers a demo or test practice uses) are left out of the payer reports — Denial Rates by Payer (rows, totals and exports), CPT Payment Analysis, and the by-payer view and spike alerts of Denial Trends & Spike Alerts — with the line “Clearinghouse test payers are not included: {names}.”; a practice without one sees no change. 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 — APCM, covered in APCM billing; RPM, when remote patient monitoring is on; Maternity, the global maternity-package worklist where proposed obstetric episodes are reviewed (Pending review, Pending facts, Confirmed, Dismissed), their facts and linked visits checked, and the global package confirmed into a claim; and Subscriptions, the membership workflow documented in Memberships. APCM, RPM, and Maternity appear only when enabled — Maternity needs obstetrics turned on under Additional Features, and confirming an episode additionally requires the claims-management permission.
   • Configuration — Payment Model, Collections & Fees, Service Menu, CPT List Prices, Negotiated Rates, Claim Submission, Billing Identity, Rules & Overrides, and Simulator. This is the setup material covered in Billing setup. If you switch tabs with unsaved Collections & Fees edits, an Unsaved changes dialog asks before discarding (Keep editing / Discard). Dialogs that hold unsaved edits work the same way: their Cancel or Close button, ×, Esc, or a click outside asks “Discard unsaved changes?” before throwing the edits away.
4. Open a patient’s billing from any name. Every patient name in Billing — Claims Pipeline rows and claim headers, Pre-visit, Patient AR (Aging, Invoices, Day Sheet), Subscriptions, Payments, APCM, IDR, and Maternity — opens the Patient billing dialog over the tab you are on, which keeps its filters (hover: Open patient billing). The dialog shows the patient’s name, MRN, DOB, age, and sex, an Open chart button for users who can open charts, and the tabs your permissions allow, in this order: Demographics · Prior Auth · Custom Billing Rules · Insurance · Invoices & Charges. With the standard role profiles, a Biller gets Demographics, Prior Auth, Insurance, and Invoices & Charges; a Billing Manager, Office Manager, or admin gets all five; Front Desk gets Demographics, Insurance, and Invoices & Charges. Billers fix a patient’s address and guarantor and their insurance here without chart access; clinical content stays closed.
5. Understand why tabs differ per person. Tab visibility follows the payment model first — Pure Cash practices don’t see Claims Pipeline, Negotiated Rates, or Rules & Overrides by default, and DPC practices also don’t see CPT List Prices — and is then filtered by each staff member’s billing permissions (assigned with role profiles). The rule is the same for staff and admins. A staff member with no matching permission sees No billing tools are available for this staff profile. When the model hides a tool you are allowed to use, the sidebar footer shows Show all tools (and, once on, Use model defaults); a Dashboard chip or link that points at such a hidden tool shows all tools for the rest of that visit and opens the tool.

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. A dashed amber No billing / Cash tile sits directly after Signed, counting signed visits that never enter the insurance pipeline (no claim) — it is informational, not an exception chip, so there is nothing to click and nothing to work. 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 or ERA manual review 2), and the newest alerts with timestamps. Open billing inbox jumps to the main Inbox’s Billing folder (see Inbox queues for how that folder groups and dates alerts), 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. A line above the cards adds up what the practice is owed: Total receivable = Patient AR + Pending with insurance + Insurance AR · Same total as Reports → AR Aging. Then three cards: Insurance AR — “Not filed yet, or back from the payer and needing billing review — excludes claims waiting on the payer”, split into Not filed yet and Needs billing review and aged 0–30 days through Over 120 days; Patient AR with its aging buckets and a Pending with insurance line (“Filed claims waiting on the payer; excluded from Patient AR”); 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 in plain words (for example ERA runs in window: 79 · Manual upload: 60 posted, 19 waiting to post, or Office Ally for clearinghouse files), and when the last one ran.
5. Expand the Revenue Overview for trends. The collapsible Revenue Overview has period buttons from 7 days to 12 months, summary cards such as Insurance Billed and Outstanding AR, a Claim Status Pipeline chart, and an AR Aging card with the same total and buckets as the AR Aging report. In Insurance and Hybrid practices it sits collapsed below the Monitor. In a DPC practice it is the Membership Overview (with Gross membership payments received · selected period (USD)), and in a Pure Cash practice the Collections Overview; there it comes first, expanded, with the Monitor below it, and the Monitor drops its claim stages when there is no claim activity.

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, claims a claim-file run had to leave out (see the claims pipeline), 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 has its own sidebar tab next to the Billing Monitor on the Dashboard. The header shows the date range plus Filters, CSV, and Refresh buttons. Dates and times — on the rows, in the drawer, and in the CSV — are in your practice’s time zone, providers show by full name, and your filters stay put when you switch tabs or reload, for the rest of the practice day.

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. The counts cover the date range and filters, whichever chip is on, and clicking a chip shows just those visits (it replaces any other chip filter). Hover a chip for its definition: Missing elig. — “No eligibility check on file for this visit’s primary policy.”; Stale elig. — “The last eligibility check will be more than 7 days old by the visit. Hero re-checks these automatically the day before the visit.”; COB missing — “Another plan is on file, or eligibility named another payer, and there is no COB result yet.” The automatic re-check skips self-pay visits. Filters narrows by Start date, End date, Payer search (Aetna, BCBS…), Provider, Visit type, Payer class, eligibility status (Any eligibility), Problem (Any problem state / No problem / Open / Resolved), New patient (New patient only / Established only), and Secondary insurance (Has secondary / Primary only). Reset filters clears the lot.
2. Run eligibility checks. Each row’s Recheck button queues a live eligibility verification with the payer for the patient’s primary policy, through whichever clearinghouse your practice has set up for eligibility (Office Ally or Stedi) — you’ll see Eligibility check queued. On rows without an active primary policy the button is greyed out — hover it for the reason (No active primary policy). Checks run in the background, so results don’t appear instantly; Refresh after a few minutes.
3. Read setup problems separately from patient problems. When checks can’t run because of your practice’s setup, the row keeps its real Missing or Stale badge with a small amber Not set up note, and one banner above the list explains it — for example “Eligibility checks aren’t set up · 3 upcoming visits couldn’t be checked. Office Ally isn’t connected for eligibility (or its sign-in expired), and no other clearinghouse took the check.”, or Office Ally needs to be signed in again. Admins get Open External Providers; everyone else reads “Ask your practice administrator to set this up in External Providers.” Problems with the patient’s own coverage still read Failed, in plain words rather than codes.
4. Run a COB check, and act on the answer. The row’s Run COB button (Run COB check ($1)) queues a paid coordination-of-benefits check against the visit’s primary policy — the same check, confirmation dialog, and cost as the one on the patient’s Insurance tab. It needs the COB permission (Requires the COB check permission) and an active primary policy, and it is disabled, with the reason on hover, when your practice can’t run COB checks (for example in Stedi test mode, or with COB turned off). The same reason appears as a note above the list only when a visit in the current list actually needs an other-coverage check (its COB cell reads Missing or Failed) — for example “Other-coverage checks can’t run in Stedi test mode — …”. The COB cell reads Not needed when nothing points to a second plan, and Missing (hover: Another plan is on file or Eligibility named another payer) when something does. While a check runs it reads Checking…; a check the payer refuses leaves Failed with the reason on the row. When a result finds other coverage the cell grows an amber Review order button that opens the same coverage-order dialog, so you can fix primary/secondary from the worklist without opening the chart. Once applied it reads Order applied.
5. Hold automatic charging when needed. For practices that charge saved cards before visits, the row’s auto-charge cell shows the next attempt (Next attempt in 3h), and Hold / Release stops or restarts automatic charging for that visit. Once the visit’s start time has passed the button is disabled — “This visit has started; automatic charging no longer applies.” The calendar’s right-click menu follows the same rule: Hold auto-charge… / Release auto-charge hold… and Waive pending deposit appear only before the visit starts, and Waive pending deposit also disappears once the patient has arrived (checked in, or joined a video visit, even early). A deposit the patient owes after arriving is handled on the patient’s billing instead — the refusal says “The patient has already arrived, so the deposit can’t be waived here. Use Invoices & Charges → Adjust / write off balance on the patient’s billing (needs sensitive billing access).”
6. Flag what needs a human. Flag (Flag billing problem) opens a dialog asking “What needs human resolution before this visit?” with Reason, Priority, and Notes fields; flagged visits later show Resolve. Both actions require billing AR permission (tooltip: Requires billing AR permission).
7. 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. The Coordination of benefits panel repeats the determination and coordination order, lists what the payer reported, and carries its own Run COB check and Review coverage order buttons; it says plainly when a result is in hand but the chart’s primary/secondary order has not been updated yet. The check log reads in plain words — Checked, Failed, Staff review, Checking…, and triggers such as Pre-visit recheck, Appointment, New policy, and COB check.

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. Every view has the same search box (Search patient, MRN or claim #), and names match in any order (“First Last” or “Last, First”). In Flight and Resolved search every claim on the server, not just the page you have loaded, and also match partial names, the payer’s claim number (ICN), the clearinghouse claim number, and the payer name. Switching views, searching, or changing a lane keeps the page in place: the list shows Loading work items… or Loading claims… the first time; after that the current rows stay, dimmed, with Updating… beside the title, and change once when the answer arrives. An open claim that is still in the list stays open. In Flight says when it shows only part of the list — “Showing 50 of 132 in-flight claims. Search to find the rest.” or “Showing 50 of 70 matching claims. Narrow the search to see the rest.” Patient names open the Patient billing dialog (§5.7).

A claim file the clearinghouse never answered is flagged at the top of the Claims Pipeline for staff who manage claims, on whichever view you open first: “Claim file B2 has had no clearinghouse response for 17 days (7 claims).” / “Confirm with the clearinghouse before sending these claims again.” with Review claim file, or, for several, “3 claim files have had no clearinghouse response — the oldest for 17 days (21 claims).” with Review claim files. It is red when a file is eligible for recovery or already a delivery incident, and amber when it is only delayed. If not every claim file could be checked from there, it adds “Not every claim file could be checked here — open In Flight for the full list.” The button opens In Flight at the Clearinghouse delivery lane.

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. A visit held because a code has no price reads No claim yet: 99050 has no price… with a Set a price for 99050 button (§5.4b). Cash-pay and self-pay charges, deposits, and patient fees never appear here.
2. Read how your claims are sent. Ready to Send opens with one line that says how this practice’s ready claims leave — the same sentence Claim Submission and External Providers show. For example: “Ready claims go to Office Ally SFTP in the daily batch. Next batch: today at 2:00 PM EDT.” (always in your practice’s time zone), “Ready claims go to Stedi automatically, about every 15 minutes.”, “Nothing is sent automatically. Select claims below and create a claim file to upload to your clearinghouse.”, or “Claims can’t be sent yet. …” with what is missing.
3. Send claims yourself. In Ready to Send, tick claims (or Select all) and pick the channel: Office Ally SFTP, Availity SFTP, Stedi, or Manual 837P download. The select starts on your route’s channel (or the first one that works), and a channel that can’t send yet says why — Not connected, Setup not finished, or Missing settings. The button follows the channel: Create Batch, Create Claim File (a downloadable 837P file for upload elsewhere), or Submit through Stedi. When nothing can send, the panel says “No way to send claims is set up yet.” and offers only Hold selected.
4. Hold claims. Hold selected opens Place submission hold. Held claims wait under Held (N), which follows the search box (No held claims match your search). The Held view also has an Insurer holds panel: Hold claims to an insurer holds everything going to one payer, and Lift hold ends it. Both dialogs leave the Follow-up date empty (“Leave empty for no reminder.”); the date you set is a date on your practice’s calendar, and for an insurer hold billers get an alert when it arrives.
5. 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. Each batch sums up its acknowledgements as one plain-language chip — Clearinghouse receipt ✓, Clearinghouse receipt ✗, or Clearinghouse receipt pending — instead of raw TA1/999 codes; the control numbers and raw acknowledgement text are still there for support calls, tucked into a collapsed Technical details disclosure inside the expanded batch. A batch the clearinghouse answered only with 277CA claim verdicts still counts as received (Clearinghouse receipt ✓; its tooltip adds 277CA: Received), and on the claim’s Submission box a file receipt that never came reads Not returned. Expanding a batch also shows the per-claim roster: every claim in the batch with a plain Accepted or Rejected verdict (no more ack-code legend to decode), the status message that came back, and a link that jumps straight to that claim’s Action Center item. A payer duplicate rejection reads Rejected with a Duplicate chip (“The payer already has a claim for this service. Check that claim before refiling.”). A claim moves through Draft, Ready, Submitted, Acknowledged, and In Process, then resolves to Paid, Denied, Partial, Pended, Appealed, Voided, Replaced, Removed at clearinghouse, or Closed (the Resolved view filters on each) — and a claim the clearinghouse bounced shows as Rejected, stays in this view tinted red, and carries a Correct & Refile button right on its row (the one exception is a rejected void — a claim you were cancelling has nothing to refile, so it reconciles from the batch view instead). A claim Hero couldn’t hand to the clearinghouse at all reads Submission failed. Rows also print the last submission error as readable text rather than hiding it behind an icon, and the status filter only offers statuses the view you’re on can actually contain. Claims with no activity for 25+ days raise an amber banner with a Review oldest stuck claims filter as soon as In Flight opens.
6. Watch for a claim file the clearinghouse never answered. The Clearinghouse delivery lane sits first in In Flight, above In Flight Claims. With nothing waiting it is a single line — Clearinghouse delivery · No uploaded claim file is waiting on a clearinghouse acknowledgement. with Refresh — and the Acknowledgement poller (separate from batch receipt) status under it. When files are waiting it shows a card for each uploaded batch that got no acknowledgement — batch number, a status such as Recovery eligible, Acknowledgement delayed, or Delivery incident, Uploaded — no acknowledgement, the clearinghouse, upload time, time elapsed, and claim count — with Release lost batch… to put its claims back to work.
7. Tell rejections from denials. Hero EMR treats these as different problems, because they need different responses. Submission failed means Hero couldn’t hand the claim over; fix what the error names and send it again. Rejected means the clearinghouse (or the transmission itself) bounced the claim before the payer ever processed it — no one adjudicated anything, so there is nothing to appeal; fix the underlying data and send a corrected claim with Correct & Refile. Denied means the payer processed the claim and decided not to pay — a real adjudication you work with Log Appeal, Resubmit as-is, or Write Off. Earlier versions of Hero EMR showed both as “Denied”; if you learned the pipeline then, the practical change is that a rejection is routine data-fixing on the way to the payer, not a lost decision.
8. 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 that leads with the first blocking problem by name — Patient ZIP code is invalid, say — with the issue count beneath it, so you know what to fix before you even open the claim (a claim with nothing blocking simply reads Ready). Each row’s reason line says what happened in plain words: on the Denied lane “Underpaid: Paid $121.60 of $190.38. $30.38 is unpaid and isn’t a contractual adjustment or the patient’s share.”, “Denied: Paid $0.00 of $190.38.” (plus what the patient owes, if anything), or “Line denied: Paid $150.00 of $190.38; a service line was denied.”, and once you log an appeal “Appealed: Paid $0.00 of $190.38. Appeal logged; waiting on the payer’s decision.” (a denied claim you write off leaves the lane); on the Rejected lane Rejected as a duplicate: … for payer duplicates; on the Pended lane the payer’s pend reason, else “The payer is holding this claim for review or more information.”; on the Fix lane the first blocking issue itself (for example Fix and submit: Patient ZIP code is invalid). A note you add shows under the reason as Note: …, and a claim appears once, not again as a separate charge row. Search by Search patient, MRN or claim #, sort by Smart sort / Newest update / Highest dollars, and narrow with My items, Include snoozed, or Group by lane. Selected claims take bulk Snooze selected / Flag; each item also offers Flag, Note, Assign me, Snooze, Mark ready (charges), and Mark uploaded (manual batches).
9. 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), an Issues & fixes panel (the same readiness checks behind the row badge, each issue with its own fix button), 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 Log Appeal, Resubmit as-is, and Write Off; partially paid (underpaid) claims offer Log Appeal and Write Off; rejected claims offer Correct & Refile and Resubmit as-is. Log Appeal opens the Log appeal dialog: “Hero records the appeal here; it doesn’t send it. File the appeal with {payer} in its portal or by mail or fax, then log it here.” — with the appeal deadline when known, a required Reason for appeal, and an optional Payer’s appeal reference. Mark reviewed files a claim away in Resolved (“It comes back automatically if the payer sends anything new.”); for a denied claim it needs a Reason of at least 5 characters — why it needs no appeal, refile, or write-off — and any unpaid balance stays in insurance A/R until you write it off. Selecting several claims gives a bulk Mark claims reviewed prompt that requires the note when a denied claim is among them. Resubmit as-is is the action formerly labelled “Correct & Resubmit” — the new name says what it always did: it re-sends the claim unchanged, so make your corrections first. And buttons that aren’t available are no longer silently greyed out — hover a disabled Edit Codes, Regenerate, PDF editor, or Mark Manually Submitted button and a tooltip says exactly why (for example “Locked: this claim already reached the payer — use Correct & Refile to change it.”).
10. Fix demographics without leaving the claim. Patient-address problems — the most common reason a claim blocks or bounces — are now fixed in place. On the claim’s Issues & fixes panel, and on the blocker list inside the Correct & Refile dialog, demographic issues carry an Edit demographics button that opens the patient’s demographics editor right there, already in edit mode — no jump to the chart, no lost context. Save the correction and the claim, its row badge, and its worklist item all refresh on their own. Insurance issues carry Edit insurance or Add replacement policy the same way. Billers and billing managers get these fixes without chart access: billing staff who manage claims but not the full patient record get a trimmed editor limited to address and guarantor fields (which is all their save can change), and staff with the claims permission can add, edit, and expire policies. Links that would leave Billing for the chart or a note are shown only to users who can open them. When the practice’s claims route can’t send at all, the panel says Claims can’t be sent yet with the setting to fix — Open Stedi settings, Open Office Ally SFTP settings, or Claim Submission settings for admins, and “Ask your practice administrator to finish this in External Providers.” for everyone else. Once the data is right, a demographic issue on a claim that hasn’t reached the payer also offers Rebuild claim, which rebuilds it from the corrected chart; a claim that has already reached the payer routes through Correct & Refile instead, so payer tracking is preserved.
11. Correct & Refile a claim the payer has. Correct & Refile builds the corrected claim and shows it beside the original (a Member row shows each side’s masked member ID and relationship) before anything is sent. A What will be sent line says which kind of claim it is, and the button follows: a replacement (“Sends a replacement (frequency 7) for {payer} claim {number}…”, Replace & Refile corrected claim); a new claim when the member ID or the policyholder/dependent relationship changed, because a replacement can’t change the member and the payer would deny it (File new claim); or a corrected claim when the payer never accepted the first one (Refile corrected claim). A member-ID change is sent only after the payer has answered the original without paying it: until then a Member ID changed — waiting on {payer} panel explains how to wait for the ERA or post the payer’s $0 EOB; if the payer paid the original, Member ID changed — {payer} paid the original claim tells you to ask the payer to void it and take the payment back, then contact Hero support. Moving a claim to a different payer is staged on hold (Stage new claim on hold), and an unpaid charge is re-priced for the new payer — for example “Charge changes from $271.22 to $86.78 (Aetna contract rate)”. When Hero can’t build the correction it says why in plain words, with Edit insurance where the fix is on the patient’s policy; Edit coverage dates opens the Patient billing dialog on Insurance and rebuilds the preview when you save.
12. Trust what the claim-file viewer tells you. The raw 837P viewer labels what you’re looking at: Transmitted file from batch N for bytes that actually went out, Stored file (not yet transmitted) for a built-but-unsent file, Upload outcome unknown — this file may have reached the clearinghouse when a hand-off was interrupted, or Live rebuild — not yet transmitted. If the chart changed after the file was built, an amber banner warns that the file is not the current claim content, with a View current rebuild button beside it — so “the file still shows the old address” confusion is over. When a preview can’t be generated, the viewer prints the reason instead of failing silently, and the CMS-1500 preview does the same: blank boxes come with an explanation (for example “Address boxes are blank: the patient chart has no complete address on file.”).

Post ERAs, manual payments & refunds

The Payments tab is headed Payment Posting, with Manual Entry, Post EOB, 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. The tab opens on Payment Posting; the Overpayments & credit balances panel is the last section on the page (shown to admins and staff who can collect payments), and a chip beside the Payment Posting title — Overpayments & credits · 18 open · 3 overdue, or none open — jumps straight down to it. The panel tracks “Payer overpayments and patient credits the practice may owe back” until they’re returned: confirming a case starts its clock — 60 days for a payer overpayment (the legal deadline for Medicare and Medicaid, a work target for commercial payers) and 30 days for a patient credit — or you dismiss it. It has its own search (Search patient, MRN or claim #) and, with nothing open, shrinks to one line: Overpayments & credit balances · None open.

1. Upload an ERA. Upload ERA 835 accepts .835, .edi, and .txt files and posts them the same way remittances from your clearinghouse post; anything that needs a person waits in Unposted Remittances. The result says what happened — for example “Posted 3 of 4 claims (3 payments, 5 adjustments). 1 needs review — see Unposted Remittances.”, “Nothing posted: 2 of 2 claims need review — see Unposted Remittances.”, or “Nothing new to post — all 4 claims on this file were already posted.” A file that was already posted is never posted twice, and a claim that matches nothing in Hero is left for review.
2. Post queued remittances by payer check. Unposted Remittances holds “Remittances Hero hasn’t posted yet, grouped by payer check. Each one says why it’s waiting and what to do next.” Each check group shows the claim count, the payer’s check date and when Hero received it, and Check total, Not posted, and Posted (plus Other — money on the check that isn’t on a listed claim — when there is any); Post all ready (N) posts every ready row at once. Expand a group for its per-claim rows (Claim, Billed, Paid, Patient Resp, Status), with a note saying why the check wasn’t posted automatically. Each row’s status pill names its situation — Ready to post, Payer take-back, Cancelled out, Match service lines, Claim already paid, Claim closed, Claim voided, Money posted since, Patient share too high, and others — with a sentence saying what happened, and the row shows only the buttons that resolve it: Post, Map lines, Rebuild claim lines from charges, Post to claim of record (type a reason; the payment is recorded on the visit and inert duplicate claims are closed), Record payer reversal (shows what will change before anything posts), Reviewed — no posting needed, or Post anyway (after you tick “I checked: the money recorded since the hold is not this payment.”). If a Post is held after all, the row turns amber — Not posted — {pill}. {reason} — and the matching dialog opens. With nothing waiting, the card reads “Nothing is waiting — every remittance Hero received has posted.”
3. Post a paper or portal EOB. When a payer sends a mailed or portal EOB instead of an 835, Post EOB opens Post Insurance EOB. Pick the claim with the same live search picker, then key what the EOB says: Payer paid, Allowed, Patient resp. (total), Deductible, Coinsurance, Copay, and Contractual write-off, plus a Write-off CARC (e.g. CO-45), a Denial CARC (e.g. CO-16) with the Denied amount, the Payer claim # (ICN), Check #, Payment date, EOB date, and a Note. For an EOB that splits amounts by service line, Enter EOB amounts by service line takes them line by line; a half-filled denial row is flagged when you leave it or press Post EOB. Submit with Post EOB. A CARC-coded denial entered here starts the appeal clock just as an 835 denial would. If an electronic remittance for the same payment is already waiting in Unposted Remittances, Post EOB refuses with a red banner that names it — “This claim already has an electronic remittance for this payment that hasn’t been posted yet (check {check #}, {amount}). Post it in Payments → Unposted Remittances instead of keying the paper EOB.” (or, for one on hold, “… Resolve it there instead of keying the paper EOB.”).
4. 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.
5. 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; at zero it still shows, with “No payer remittance or claim status has come back for a claim filed outside Hero.” Recent ERA Ingestion Runs shows “One row per 835 file, from your clearinghouse or an upload.” — received time, source (Office Ally, Stedi, Manual upload), status (Posted, Waiting to post, Needs review, Unmatched, Failed, and so on), and matched / posted / unmatched counts — your proof that remittances are actually flowing in.
6. Look up any check. Remittance History is the ledger of every payer check/EFT received, posted or not. Search by Check #, payer, or claim #, narrow with From / To dates and a status — Not fully posted, Posted, Partially posted, Needs review, or Unmatched, the same words the rows use —, and page through the results. Each row shows the Check date (the payer’s payment date, with a muted received date when Hero got it on a different day), check/EFT number, payer, method, check total, claim count, posted amount, and status — and expands into the per-claim EOBs behind that check, down to CPT-level adjudication. This is where you answer “did we ever get paid for this?”
7. Audit and refund. Recent Payment Activity lists the latest 200 payments with Date, Patient / Payer, Type (ERA-835, Insurance, Cash, Card, ACH), Check #, 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 three views — Aging, Day Sheet, and Invoices (the last one only for staff who may read patient invoices). Under the total, a second line splits the rest of what is owed: $A pending insurance · $B not filed yet · $C needs billing review · $D total receivable — the same figures as the Billing Monitor and the AR Aging report. Patient names open the Patient billing dialog.

1. Send a statement. Statement opens the Statement Preview — practice and patient addresses, line items with Charges / Insurance / You Owe columns, TOTAL AMOUNT DUE:, and a Due by date that follows the statement due days in Collections & Fees. Deliver it with Download PDF to print (records the statement and downloads the PDF — Hero never mails paper, so print and mail it yourself), Email payment link, or Email + download PDF. The message says which happened, for example “Statement recorded for {patient} — the PDF downloaded; print and mail it.” or “Statement emailed to {patient}.” A line whose share is held for a pending secondary claim ends “— waiting on {payer}”, is left out of TOTAL AMOUNT DUE:, and the preview adds “Pending other insurance: $10.00 (not due until the other insurance processes the visit)”. When nothing on the account is patient-billable, the statement actions are disabled with “No patient-billable balance — this balance is pending with insurance (including a secondary claim) or already settled, so a statement would be blank.”, and a bulk send skips that patient with the reason.
2. Send statements in bulk. In the Aging view, tick the checkbox on each row you want (up to 200 at a time), choose the method — Email, Download PDF to print, or Email + download PDF — and click Email statements (N), Download statements (N), or Email + download (N). Printing downloads one combined PDF. The result reports per patient — failures are named — 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 the history grouped by visit, newest visit first (Visit Sep 12, 2026 · Office visit). Inside a visit, events read in order — charge, claim, payer payment, payer adjustment, then a Patient share from {payer} line that spells out the coinsurance, copay, and deductible the payer assigned — then the patient’s payments. Statements and account-level events sit under Account activity. 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 missed-appointment policy, with a Waive Fee button that requires a waive reason (shown to admins and staff with the sensitive-billing permission); cancelling after you typed a reason asks before discarding it. The same fees can be waived from the fee’s invoice in Invoices & Charges with Waive fee. A fee is kept out of the money still on file for the visit (net of earlier refunds), so only the uncovered part appears as a new fee charge; and once a cancelled or no-show visit’s refund completes, its invoice reads Paid with an Appointment balance released line and the patient no longer shows that balance in Patient AR. 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 on an Aging row when the patient owes $100 or more and their oldest share is more than 90 days past due (hover: Owes $100 or more, more than 90 days past due) — the same rule as the Collections Warning status. It asks you to confirm sending the patient to collections, then moves the account into the collections workflow.
7. Prepare financial documents. Superbills, Good Faith Estimates, receipts, and statement PDFs live with the patient’s invoices — see Invoices & Charges.

Run membership & subscription billing

The Subscriptions tab (under Programs in the sidebar) — “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. Which visits a membership covers is set per service in the Service Menu (Membership coverage, §5.3), not on the plan.

1. Turn on subscriptions. The Subscription Settings card gates everything. With Enable subscriptions off, the rest is hidden behind “Turn on subscriptions to set payment, cancellation and access rules.” Turned on, it shows Allow patient self-cancel for portal self-service; Let patients undo a scheduled cancellation (until their paid period ends, a patient who cancelled can keep their membership from the portal); Members can finish portal setup with a balance due; the Grace period after failed payment; When cancelled, access ends — At end of billing period or Immediately; Access after a failed renewal; Messaging when membership access is restricted; the Booking exception; and Allow staff membership exceptions. The save bar reads No unsaved changes or Unsaved changes beside Discard and Save Settings. 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, an optional trial, and Plan group (optional): “Plans in the same group appear to patients as one plan with a Monthly/Annual choice. Leave blank to use the plan name without ‘Monthly’ or ‘Annual’.” Plan groups only pair the monthly and annual versions of one plan — there are no household or family plans. Plan cards (for example v1 · Group: adult · Order 1) support edit, publish/unpublish, and archive; published plans list first, and archived ones stay out of the way until you press Show archived plans (N). Editing a published plan’s price, billing interval, or trial creates a new version for new enrollments; existing members keep their signup price.
3. Enroll members. Under Enroll a patient, use Find patient (or paste a patient ID), pick a plan, and send the enrollment link: Text link, Email link, or Copy link. The result says where it went (“Enrollment link texted to •••-1234.”, a guardian’s contact for a minor) or why it couldn’t send — for example the patient opted out of texts, there’s no mobile number or email on the chart, or they already have a membership. A patient without a portal account is asked to sign in first, so send a portal invite if they can’t. The patient completes checkout in the patient portal (see Portal payments). To charge a card the patient already saved instead, use Enroll with saved card; a declined first payment shows in amber with the card’s reason — the membership isn’t active until it’s paid — and raises a Membership payment failed alert in the Billing inbox. Unpaid first payments are cancelled automatically after about 2 hours.
4. Find and manage 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 that finds “First Last” or “Last, First”. Above the table, Current (n) — the default — lists memberships that still run, past due, unpaid, and incomplete ones first, then active, trialing, and paused; Ended (n) holds memberships that have ended (an empty view reads “No ended memberships.”); All shows both. The search works inside the view you picked. Statuses read Active, Trial, Payment overdue, Unpaid, Paused, Setup incomplete, Setup expired, or Ended, and the Billing column names the latest invoice ($99.00 · Unpaid). 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, the Cancellation timing, a Reason (Patient requested, Payment issue, Plan fit, Staff review, Other), Notes, Email notification requested, and a Confirm access end date checkbox you must tick — cancelling doesn’t refund or prorate dues already paid, and refunds are issued in Stripe, not in Hero EMR. The dialog closes with its Close button, ×, Esc, or a click outside — asking “Discard unsaved changes?” if you typed Notes — and can’t be closed while the cancellation is running. Resume undoes a scheduled period-end cancellation; and Collect retries the open invoice immediately (enabled only while the latest invoice is open). Active and trialing members also have Change plan, End trial now (trials), and Pause payments / Resume payments (active members). A member who owes a payment — the same members the recovery queue lists — gets Payment link: Text link · Email link · Copy link under the row’s buttons, with the result line under it; paid members’ rows have no payment link.
5. Work the recovery queue. The Payment recovery queue highlights members with failed invoices, each with its status and the card’s decline reason (Setup incomplete · Your card was declined.) and Text link / Email link / Copy link to send the patient a payment link; rows flag Payment recovery needed, Cancels at period end, Plan no longer offered, and Snapshot needs staff review, alongside Stripe sync health. The queue doesn’t follow the roster’s view or search: it keeps every member who may owe a payment, including an ended membership that still owes. 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.