Chapter 4 — Billing, Claims, ERA, Payments, Coding, Reports

Sources: help center sections Billing, Insurance Claims, ERA, Payment Processing, Patient Accounting, Coding, Reports, Regulatory Health Data Submission.

4.1 Where billing lives

Billing hub: patient and insurance actions, reports, Search Billing Transactions (sortable, Select Columns, Export Spreadsheet).
Patient > Billing: balances, transactions, patient payments, misc charges and credits, statements, superbills, CMS-1500.
Patient > Billing Settings: insurance policies (primary through quaternary), cash rates, prior authorizations, additional claim info, saved cards, responsible party.
Appointment > Billing: per-date method, policy, rate, modifiers.
Settings > Practice Billing, Service Codes, Diagnosis Codes, Payers.

4.2 Charge and rate rules

A claim becomes ready when a clinician signs a billable note for an insurance-billed patient. Billing and To-Do counters increase.
Rate used: in-network → payer rate schedule; out-of-network or uninsured → patient custom rate if set, otherwise the practice default for that service code. Can be overridden per appointment.
Patient responsibility = copay + coinsurance + deductible + out-of-network share. Out-of-network: patient amount = service rate − insurance coverage.
Secondary insurance usually covers the primary's patient share; a secondary copay stays with the patient.

4.3 Patient money

Enter Patient Payment: saved card or + Add card, amount, allocate across dates → Charge Card and Save New Payment.
Edit a payment: method, date, amount, allocation, Write-Off checkbox (write-off removes the patient's responsibility).
Delete is not refund and can't be undone.
Refund flow: clear the allocations → save as unassigned credit → Billing > Enter Refund (amount, date, optional clinician, comments; optionally charge back to the card) → Save New Refund.
Misc Credit: amount + reason. Misc Charge exists alongside it.
Statements: preview, then auto-saved to Documents; shareable to the portal. Superbills and receipts come from the patient's Billing tab. A practice setting puts patient-paid amounts on CMS forms and superbills.
Appointment History shows every payment and claim action with user and time.

4.4 Claim lifecycle

Setup: Enable Billing Features + Enable Electronic Claims and ERA; Payer Billing Method = Electronic; clearinghouse enrollment per payer (Claims and ERA are separate). Status icons: green check = ready, yellow = action needed, gray ban = unsupported. Tax ID and NPI must match exactly; wait about 5 business days after enrolling.

Submit primary (electronic)

Entry points: To-Do, Billing, Patient > Billing or Payer > Billing → Submit Electronic Claims. Filters: Status, Payer, Clinician, Patient, Appointments. Default shows the last 90 days. One appointment group = one claim; batching follows payer rules; one bad line rejects the whole batch. Review Claim Details → choose the primary diagnosis only or up to 4 → Submit Claims. Red warnings block submission; yellow warnings only alert.

Paper (CMS-1500)

Method = Insurance – In/Out of Network – Paper. Print settings: preprinted red forms or printed background, margin offsets, test form. Up to 6 dates of service per patient per form; only the primary diagnosis is printed.

External

Method = … External; Mark External Items > Mark Submitted changes Pending External to Submitted External. Nothing is sent.

Statuses

| Status | Meaning | |---|---| | Submitted | Sent to the clearinghouse | | Sent | The clearinghouse forwarded it to the payer | | Resubmitted | Sent again | | Rejected – New | Rejection not yet reviewed (shows on To-Do) | | Rejected | Reviewed with Mark as Reviewed (doesn't fix anything) | | Paid | Payment entered and allocated |

Line insurance statuses: Pending Initial Submission, Pending Resubmit, Pending External, Submitted External, Pending Secondary, Secondary Submitted, Forward to Secondary, Future.

Rejections and resubmission

Rejections come from three layers: clearinghouse scrub (codes, taxonomy, enrollment, demographics), payer EDI check, and payer adjudication.
A rejection automatically sets the line to Pending Resubmit. Resubmission type: New Claim, Amended Claim (frequency code 7), or Void Claim. The Payer Claim Control Number is required for Amended and Void.

Secondary

Requires the primary's ERA to be posted. Billing > Submit Secondary Claims; uses the latest primary ERA by default; a secondary prior authorization belongs to the secondary policy.

4.5 Eligibility (RTE)

Enable in Practice Billing; the payer must show a green RTE check; the patient needs name and DOB.
Billing Settings > policy > Verify Eligibility: choose the provider (Type 1 clinician NPI or Type 2 location NPI) and coverage date → result in seconds (up to 2 minutes). Report filter: All Categories or Common Mental Health. Mark as Reviewed. 14¢ per check.

4.6 ERA posting

Billing > ERA: default shows unprocessed ERAs from the last 30 days. Unprocessed rows show Post Payment; processed rows show View Payment. Mark as Processed acknowledges without posting. Upload .835 or text files only; duplicates are discarded.
Post flow: resolve "No Match Found" (pick the patient or service, or mark it Not Recorded, which becomes a non-claim adjustment attributed to the practice) → review responsibility and allocations → Payment Amount must equal Total Allocated → Post Payment.
Validation (shown in red): responsibility below 0 or above the charge; allocations above insurance responsibility; negative allocations larger than amounts paid. Changed cells highlight yellow.
Interest and penalties go under Payment Adjustments.
Out-of-network claim paid to the practice: assignment switches to Practice Collects from Insurance, and displaced patient payments become unassigned credit.

4.7 Card processing

CardConnect / CardPointe (apply in Settings > Payment Processing). Credit, debit, HSA and FSA cards; US billing addresses only. Saved cards are tokenized.
Next-day deposit for payments made before 9:30 pm ET. Fees: 3.1% + 30¢; $35 per chargeback. Annual PCI questionnaire, or $29.95/mo if not completed.
Autopay rules are not documented — our autopay dropdown is a placeholder.

4.8 Codes

Service code: Service Type (decides the appointment and note template), code, add-on flag, description (appears on statements), standard rate, default duration, up to 4 default modifiers. The same CPT code can repeat with different descriptions. A code number can't be edited after creation.
Changing a note's service code: before the note exists, edit the appointment. After, same type: edit the note header and re-sign. Different type: delete and recreate the note (Clinical Admin).
Diagnoses: up to 4 per electronic claim; the first valid diagnosis is primary. A different diagnosis set or order splits claims. Custom codes and non-billable codes are allowed; search shows F codes first, then Z.
Modifiers: max 4, functional before informational. Default priority: clinician override → service code → location. Manually set modifiers replace the defaults for that date.
Prior authorization: code, services, start and expiry dates, uses allowed and remaining, once per service or per unit. Uses count down when a claim is first submitted or a CMS-1500 is generated.
Telehealth: per-payer Place of Service override plus an extra modifier when the appointment is flagged telehealth.

4.9 Reports

Billing Transactions; Prior Authorizations (filter by payer, expiry, status, uses remaining); Patient Credit Cards (expired, expiring, balance with card, no card); Write-Off; Insurance Adjustment; Note Count (author, type, location, date range, grouping); Revenue Report (criteria, date range, grouping, time increments, chart).
Insights dashboard (Practice Admin): date range, clinician, location. Shows scheduled count, missed and cancellation fees, average daily and weekly appointments, missed/cancel rate, churn and retention (settings: grace period, minimum follow-ups), appointments by type, in-person vs telehealth, per-clinician and per-location stats.

4.10 Regulatory

Health information exchange submission for NC (HealthConnex) and CT (Connie): signed notes queue encounter data; per-patient consent status (Consented, Opted Out, No Consent).

4.11 Open questions

Exact balance and aging math; statement and superbill screens; frequency codes for New and Void claims; Revenue Report formulas; autopay.