Insurance follow-up

Check claim code pairs and units before sending

In Billing → Configuration → Claim Submission, an administrator or staff member with billing-settings permission can configure Check code pairs and units (NCCI and MUE). These checks compare claim coding with Medicare’s practitioner code-pair edits and unit limits. They start off and do not recheck claims already sent to the payer.

Start with warnings while your team reviews the results. On the claim, open Issues & fixes and review the affected codes and units. Correct the coding when appropriate; use an override only with the required reason and the appropriate billing permission. A finding is not an instruction to add a modifier without supporting documentation.

Claims staff can use Edit Codes for a supported modifier correction or Record override with a reason. Unit and code-removal corrections may require the clinician to amend the visit’s charges and then rebuild the unsent claim.

The same Claim Submission page has Send the referring provider on claims, off by default. Administrators or staff with billing-settings permission can turn it on to include the visit’s referring provider name and NPI in CMS-1500 box 17.

Next to it, List the provider as the ordering provider for their own tests (also off by default) covers a test the provider ordered and performed themselves, for example an in-office ultrasound: a radiology or lab line is sent with the rendering clinician as the ordering provider. It is used only when the claim has no referring provider to send, and the claim’s readiness check warns when that clinician’s name or NPI is missing. With it on, Billing Hero can also refile a test denied for a missing ordering provider.

The same page holds the Appeal kit card and Post-op visits (99024).

Bill tertiary insurance after the secondary payer responds

Tertiary claims start off. An administrator or staff member with billing-settings permission opens Billing → Claim Submission → Secondary and tertiary claims and turns on Bill a third insurance (tertiary) after the secondary pays.

1. Check the patient’s coverage order. Record the third active policy as coverage order 3 on Patient Information → Insurance. Review the first and second policies too.
2. Choose the sending policy. Before sending secondary and tertiary claims offers Hero default (with the current default shown), Send automatically, or Hold for review. Held claims wait in Claims Pipeline → Held.
3. Review or prepare the claim. After the secondary payer has processed the visit, Hero can prepare a tertiary claim carrying both earlier payers’ payments. Staff with claims-management access can also use Prepare tertiary claim on the secondary claim when available. Read any reason it cannot be prepared before changing coverage.

Hero skips automatic tertiary preparation when the secondary payer says it already forwarded the claim, and does not send tertiary claims to traditional Medicare. Manual preparation after a reported forwarding opens Prepare a tertiary claim anyway?; verify that another submission is needed before choosing Prepare anyway. An eligible pending tertiary claim holds the patient’s share while the next payer answers, just as a pending secondary does. With tertiary billing off, the share left after secondary processing is billed to the patient.

Apply an undoable self-pay price after an eligible denial

Billing → Configuration → Denial Self-Pay lets a practice set a lower patient price for selected codes after the final insurer denies them as the patient’s responsibility. Administrators and staff with billing-settings permission manage the rules; applying or undoing an adjustment requires billing-adjustment permission.

1. Add a price rule. Use Add rule, enter the CPT / HCPCS code, optional modifier, and Self-pay price per unit, then Save rule.
2. Turn it on, then choose manual or automatic. Use self-pay prices for denied claims starts off. Turning it on lets authorized staff apply a rule to an eligible denied line from the claim. Underneath, Apply automatically when an eligible claim is denied also applies the rules to new remittances as they post; it starts off when you first turn the feature on, so a practice can work denials by hand only. Automatic application never reprocesses old denials. A practice that used automatic application before this option existed keeps it on.
3. Review an existing denial. On an eligible claim line, choose Apply self-pay price, review the patient price and adjustment against the unpaid balance, then Apply price. Recent applications shows the outcome. If the patient already paid, review the payment separately; the price adjustment does not issue a refund.
4. Undo when needed. Choose Undo on the application or claim line, enter a reason, and confirm with Undo adjustment. This restores the balance affected by the adjustment; it does not move cash.

Connect Stedi, track enrollments, and download received ERAs

Connect the practice’s own Stedi account

An administrator opens Admin → External Providers → Stedi. When Hero has enabled account self-setup, the Your Stedi account card offers Set up Stedi account. Create an account or sign in on Stedi’s website, review HeroEMR’s requested access, and approve. You return to Hero, where the card shows Connected. If the card is absent, ask Hero support to enable self-setup.

Connecting this account does not change the practice’s current claims or eligibility route and does not itself approve payer enrollments. Reconnect renews the connection. Disconnect removes the connection from Hero; to remove access completely, also uninstall HeroEMR from Apps in the Stedi account.

Work the enrollment tracker

In Practice Setup, use Open enrollment tracker on the Stedi tasks step. Administrators and staff with billing-settings permission can open the workspace. The Enrollments tab groups work into Practice action, Needs review, Waiting on Stedi / payer, and Live. Select an enrollment to read the payer, provider, transaction, and What to do next, then complete the requested information or task.

Search, the status groups, and their counts cover every enrollment in the practice, not just the page you are on; results are paged. Counts use each enrollment’s latest saved status, and the page you are viewing refreshes from Stedi. Show all enrollments clears the search and filters — the enrollment you had open may then be on another page. If a status is Not verified, Hero could not verify it with Stedi and pauses task submission for that enrollment. Refresh and resolve the reported issue. Submitting a task is not payer approval.

Download transition remittances

Open Received ERAs in the same workspace. Filter by Received from and Received through, or choose All dates. Each report shows its payer/payment details and matched, unmatched, and posted claim counts. Download PDF additionally requires claims-management permission. Reports can remain available even when the original claims were filed outside Hero.

Choose the default payer for scanned Medicare cards

In Admin → External Providers → Stedi, set Default Medicare payer to the practice’s Medicare Part B payer. Scanned Original Medicare cards then start with that payer in staff and patient-portal insurance forms, and staff payer searches list it first. Review the match before saving; staff can change it. Medicare Advantage cards still need their own plan’s payer. The Medicare claims card beside it, and what to do with claims addressed to another state’s contractor, are in Medicare claims.

Check the claims payer separately from eligibility

A policy’s eligibility payer can differ from the payer that receives its professional claims. Hero explains the destination when it applies a supported payer mapping. For supported out-of-area commercial Blue plans receiving care in Colorado, claims route to the local Blue plan while eligibility stays with the member’s home plan. This is not a blanket rule for every Blue plan or every state.

A delegated behavioral-health network can also require a different claims payer. Hero turns that routing on for an eligible practice after reviewing its network arrangement — ask support. Keep the patient’s actual coverage on file and review the claim’s destination instead of changing the insurance card just to redirect a claim.

Payers that send no electronic remittance, and enrollments Stedi started on its own: Catch payers with no electronic remittance.

Follow up on authorizations across the practice

Billing → Operations → Prior Auths brings the practice’s authorizations into one worklist. Administrators, practice owners, and staff with prior-authorization access can work it; billing-dashboard access also allows viewing. It complements the patient’s Prior Auth tab.

1. Choose the work to do. Use Needed, Pending, Follow-up due, Denied, Expiring, Expired, Partial approval, or All actionable. Search by patient, MRN, or authorization number, and filter by payer or provider. An authorization can belong to several buckets, so their counts need not add up to the overall count.
2. Review the request and decision. Rows show the effective dates, requested/approved/used units, and next follow-up. A Partial approval badge identifies fewer units approved than requested — the same wording as the patient’s Prior Auth tab.
3. Update the record. Edit auth opens the patient’s authorization record when your permissions allow it. Set follow-up opens Set follow-up date; choose a date and Save follow-up, or leave it blank to clear the date.
4. Send it to Human Review when a person needs to work it. Send to Human Review creates a Human Review item for an authorization that is not already there. An authorization that already has an open item shows an In Human Review · {who has it} chip in its status cell instead; select the chip to open that item and follow up there rather than sending it again.

Authorizations marked Entered in error are left out of every bucket, count and search, and an authorization that a newer one replaced drops out of Expiring and Expired without an alert (see Prior auth letters & corrections).

At the top of the queue, Read authorization letters with AI (off by default) adds Scan authorization letter to each patient’s Prior Auth tab and Add authorization from this fax to filed prior-authorization faxes: Hero reads the payer’s letter and fills in the authorization for your staff to check before saving. Administrators and staff with the billing-settings permission can turn it on.

In Claims Pipeline → Action Center, denial rows now include the denial code and explanation, plus Appeal by or Timely filing dates when known. Use that context to prioritize the next action.

Send billing problems to Human Review and choose who works them

Billing → Operations → Human Review (formerly Hero Billing) is the practice’s queue of billing problems that need a person: the ones you send, the ones your Send automatically rules send, and the ones Billing Hero, the AI billing assistant, can’t fix. Items go to a person at your practice: by default the practice’s main physician, or the reviewer you choose. Hero can also have the Hero billing team work some of your items; Hero arranges that, not the practice. Old links to the Hero Billing tab open Human Review.

The tab opens on the queue: Human Review · Billing problems that need a person. At the top right sit Send a patient to Human Review and a gear, Human Review settings, which opens the settings in their own window: who reviews, the Send … automatically rules, the Hero billing team block and Standing instructions. Closing that window with unsaved changes asks first.

Anyone with billing-dashboard, claims-management, or prior-authorization access can see the queue. Working items takes claims-management permission (prior-authorization permission is enough for authorization items); someone who can see the tab but not work items reads “Your role can’t open Human Review items.” Changing the Human Review settings takes billing-settings permission, which administrators and practice owners have; everyone else sees A practice administrator can change these settings. Items whose chart, claim, visit or authorization was deleted drop out of the list and its counts.

Choose your reviewer

In Human Review settings, under Who reviews, the window says where new items go. Usually it reads Human Review items go to the reviewer below.: new items go to the person in Reviewer, and anyone who manages claims can still take or reassign an item. If Hero has set your practice up so the Hero billing team works your items, it reads Hero sends your practice’s Human Review items to the Hero billing team. The person below answers their questions., and the list is labeled Practice contact: that person answers the team’s questions and gets the items it hands back. Only Hero changes where items go; there is no switch for it in the settings.

The Reviewer (or Practice contact) list starts on the automatic choice, shown with the name it picked — for example Main physician (automatic) — currently Dr. Dean Smith. The automatic choice is the physician who owns the practice; otherwise the only physician; otherwise the physician who was added first. Only people who can work billing items count: administrators and owners of the practice, and staff with claims-management permission and access to the Billing inbox. A physician counts only if they administer or own the practice, because other physicians can’t open the Billing inbox. If no physician qualifies, items go to the practice owner, then the earliest administrator, and the card explains why (Automatic — currently {name}). If nobody qualifies, new items wait under Needs someone. To use someone else, pick their name from the list. If the person you picked is deactivated or loses billing access, new items go back to the automatic choice and the card shows a warning.

Send items automatically

Send denials automatically, Send rejections automatically, and Send prior authorizations automatically stay off until you turn them on. A rule that is on says where its items go, for example Goes to Dr. Dean Smith: your reviewer, or the Hero billing team if Hero has set your practice up that way. With prior authorizations on, set Renewal window (days) and Pending follow-up (days). Switches and lists save as soon as you change them; Save settings appears only when a typed field has unsaved edits.

Send an item to Human Review

1. Start from the problem. Use Send to Human Review on a Claims Pipeline → Action Center row, on a Prior Auths row, or on a Billing inbox alert that names a patient. On the Human Review tab, Send a patient to Human Review starts with a patient search. To send several claims at once, select Action Center rows and choose Send to Human Review in the selection bar (Send {N} claims to Human Review): each claim becomes its own item.
2. Check where it goes. Goes to starts on your practice’s default, marked (default). You can pick another person who can work the item. Only Hero can send an item to the Hero billing team.
3. Add the details and send. Choose the Issue type (for a patient send), and add an optional Title, Instructions, Priority, and Due date. Then choose Send to Human Review.

Nothing is sent twice. A claim or authorization that already has an open item shows an In Human Review · {who has it} chip instead of the button; select the chip to open the item. If a send collides with an open item, the dialog says Already in Human Review and offers Open item. A bulk send skips claims that are already there and counts them. A patient send lists the patient’s open items first: reply on one of those unless this is a separate issue.

Work the queue

The queue has five views: Mine, Needs someone, All open, Waiting (waiting on a payer, or on your answer to the Hero billing team), and Done. Each row shows the patient, the status, and who has the item: a person’s name, Hero billing team · {biller}, or Needs someone. A chip marks items that were Sent automatically or came From Billing Hero. Open an item to see its instructions, Billing Hero’s proposed changes, and the Activity history. Make the actual fix in the normal billing screens, with your own permissions. The item’s Open claim {number} and Patient billing (or Prior authorization) buttons take you there.

A resolved item shows Resolved · {how it ended} and, when the records show what changed, a one-line summary Hero works out from the eligibility checks and claim history at the time it was resolved — for example Fixed: member ID changed; coverage now active or Claim resubmitted. The summary names what changed, never the values. Hero uses these outcomes to see which problems Billing Hero could fix on its own next time. Reopening an item clears its summary.

Which actions appear depends on who holds the item and on your permissions. While the Hero billing team holds an item, your practice can reply, take it back, or withdraw it, and the team does the rest. When the team hands an item back, it returns to your reviewer as an open item with the team’s note. Resolving or withdrawing an item rejects any Billing Hero changes still waiting on it; the dialog warns you first.

Billing inbox alerts

The person who holds an item gets an alert in the Inbox’s Billing view, grouped under Human Review. A physician who owns or administers the practice has the Billing view too, so the main physician (the automatic reviewer) sees these alerts. Alerts are raised when an item is assigned to someone, needs someone (unassigned), comes back from the Hero billing team, or when the team needs an answer from your practice contact. One also appears when a Billing Hero change on the team’s item needs your practice to decide it. Open in Human Review opens the item. Assign teammate on the alert reassigns the item itself (Save assignment). These alerts have no Done or Resolve: they clear on their own when the item closes or moves, or when you answer the team’s question.

Billing Hero’s hand-offs and proposed changes

When Billing Hero (Billing → Operations → Billing Hero) can’t fix a problem, it sends the problem, with what it found, to Human Review. The item goes to your reviewer, or to the Hero billing team if Hero has set your practice up that way; Billing Hero never picks. If the claim or patient already has an open item, Billing Hero adds its findings to that item instead of opening a second one. When it fixes a problem with changes it is allowed to make on its own and the problem already has an open item, it adds a note listing them, with a member ID or group number shown only by its last four characters (for example “Billing Hero made these changes on its own: Correct the insurance (member ID changed from one ending 0001 to one ending 1234); Send the claim again.”), so nobody redoes or undoes them. Handing a problem to Human Review never waits for approval. The Billing Hero settings window says where hand-offs go (When Billing Hero needs a person, it sends the problem to Human Review ({name}).) and links to Open Human Review. The Billing Hero tab’s Hand-offs to a person list (press Show) is a read-only record, with In Human Review or Closed in Human Review and Open in Human Review on each one. Items Billing Hero filed close by themselves once their problem is gone, unless a person is working them (see Billing Hero).

Changes Billing Hero proposes appear on the item under Billing Hero’s proposed changes. This happens while Billing Hero is set to A person approves each change (recommended to start), for actions set to Propose, and whenever a person is already working the item. Each change offers Approve, Edit then approve (for changes that can be edited), and Reject. Approving re-checks the change against today’s records first. Deciding a change takes claims-management permission; filing a claim to another insurance company is always a proposal and also needs the reroute permission. The same changes appear in the Billing Hero tab’s Waiting for approval list; the first decision wins, and the other place shows that it was already decided.

When the Hero billing team works your items

Hero decides when its billing team works a practice’s items. Hero can move a particular item to the team, or send your practice’s Billing Hero hand-offs to the team instead of your reviewer. Ask Hero support if you would like this; there is no switch for it in the settings. Hero’s billers see the patient details of the items they hold, under your practice’s agreement with Hero. The team works its items in its own workspace, Human Review — Hero billing team, and each item shows the name of the biller working it.

While the team has access to your practice, Human Review settings show a Hero billing team block: Hero’s billers work the items Hero sends them., Your team with the billers’ names, and how items are handed out (Items sent to the Hero billing team go to {biller}. when one biller takes your new items, or Items sent to the Hero billing team are shared by the team.). It also lists what the team may do, as Hero has set it for your practice: correct and resubmit claims (including coding and line corrections), post insurance payments, write off balances (up to a largest write-off, if one is set), send patient statements (emailed, or copies for the practice to print and deliver; Hero does not mail the paper), update a patient’s billing address, guarantor and insurance, and see your billing dashboard. These apply only to items the team holds. Standing instructions is guidance the team follows for every item from your practice; use Save settings after typing it.

The same permissions decide which Billing Hero changes the team may approve on its items:

• Correcting insurance, filling in a patient’s address, or checking eligibility again needs Update a patient's billing address, guarantor and insurance.
• Sending a claim again, rebuilding a held claim, or releasing Billing Hero’s own holds needs Correct and resubmit claims. An insurance correction that also corrects unsent claims needs both switches.
• Contacting the patient or the provider is always your practice’s decision.

When the team can’t approve a change, your practice contact gets a Billing inbox alert to decide it, and anyone at the practice who manages claims can always approve or reject the change on the item.

Your practice can always bring an item back with Take back. If Hero ends the team’s access to your practice, the team’s open items move to your reviewer, and new items go there too.

Billing Hero: let Hero work insurance problems for you

Billing → Operations → Billing Hero is Hero’s AI billing assistant. It looks into failed insurance checks, claims rejected or held before sending, and some denials; it fixes what it can, or proposes the fix for a person to approve, and hands the rest to Human Review with what it found. It is off until your practice turns it on.

Turn it on

1. Open the settings. Click the gear, or Set up Billing Hero on the tab while it is off.
2. Choose How Billing Hero works. Off (Billing Hero does nothing.), A person approves each change (recommended to start) (“Billing Hero looks into each problem and proposes a fix. Nothing changes until a person approves it.”), or Automatic (“Actions you set to Automatic happen on their own. Actions set to Propose still wait for a person.”).
3. Choose What sends a problem to Billing Hero. Each switch is off when you first turn Billing Hero on (table below).
4. Choose What Billing Hero may do. Each action is Off, Propose or Automatic (look-ups and Hand to a person are simply Off or On). While a person approves each change, every change waits for approval, even actions set to Automatic; handing a problem to Human Review never waits.
5. Click Save Billing Hero settings. Closing the window with unsaved changes asks first.

The settings window also says where hand-offs go: “When Billing Hero needs a person, it sends the problem to Human Review ({name}).” with Open Human Review. Who reviews is set in the Human Review settings.

Approve or reject a proposed change

Waiting for approval (“Approving re-checks them against today’s records first.”) has Waiting and Decided views. Each card names the change, the patient, the claim and payer, when it was proposed, Billing Hero’s reasoning and the exact values it would set; an insurance correction says The payer confirmed these details or The payer has not confirmed these details. Choose Approve, Edit then approve (change the details; the patient, policy and claim stay the same), or Reject with a Why?. The same cards appear on the item in Human Review; the first decision wins. History lists each problem with what the payer said, the result (Fixed or proposed a fix, Handed to a person, Nothing to do…) and Show steps.

What Billing Hero does with common problems

Billing Hero reads each denial code with its official meaning. Its own Human Review items close by themselves once the problem is gone, for example when a held claim reached the payer, a rejected claim went out again and the payer acknowledged or accepted it (whoever fixed it), a later check confirmed active coverage, or the corrected claims were accepted: “Closed automatically: … Nothing else is left on this item.” Items a person is working stay open.

When Billing Hero contacts the patient

Contact the patient starts at Propose, so a person approves (and can edit) each message first. Billing Hero asks only for something the patient can give, such as a clear photo of their insurance card, and never tells a patient their coverage was not found. The patient gets a secure portal message from the visit’s provider (Action needed: please send {items}) with how to reply or update their card, plus a text and an email pointing to it, and reminders after 1 and 3 days, sent only during the day in your practice’s time zone, until they reply or upload. A patient without a portal account gets one text or email. Their opt-outs apply, and each patient has one open request at a time. When they reply, upload, or don’t answer, the Human Review item gets a note saying so. Set Contact the patient to Off to stop it.

Appeal a denied claim with the appeal kit

The appeal kit puts everything an appeal needs in one place: why the insurance company didn’t pay, the best next step, the insurance company’s own appeal steps with their sources, a suggested letter you can edit, and one PDF packet with the evidence. When you are ready, you send it from Hero by fax, by mail, or through the insurance company’s portal, or you record what you sent yourself. Hero sends nothing until someone on your team confirms the send.

Prepare the appeal

The kit opens on the claim with its patient, claim number, the insurance company’s claim number, the visit and what wasn’t paid, plus an Appeal by chip (Appeal by {date} · N days left, amber at 30 days or fewer and red at 7 or fewer) and a reference such as Ref HA-7K3M9Q that insurance companies quote back. Everything you type saves as you go. The steps:

1. What happened — why the insurance company didn’t pay, in plain words: each denial code with its official wording, the billed, paid and not-paid amounts, and the services.
2. Best next step — what usually gets this kind of denial paid, such as Send a corrected claim, Ask for a reconsideration, File a written appeal, Send the requested records, Update the coverage on file or Fix provider enrollment. Other options and Use this instead pick another path; Open Correct & Refile takes you to a corrected claim instead.
3. Where to send it — the insurance company’s own appeal steps, each with its source: Open portal, the provider phone, the Time limit, the appeal form, and the ways to send (online, mail, fax). If it’s the wrong plan, use Not the right plan? and Find it in the directory. When Hero can’t confirm a step on the insurance company’s own website it says so: check the back of the patient’s card or the EOB before you send.
4. Your argument — a suggested letter built from the denial, with numbered sources. Edit any paragraph; parts that still need your words are highlighted in yellow in [brackets]. Copy all and Copy for portal copy it; Reset to suggested starts over.
5. Evidence packet — choose what goes in and in what order: the appeal letter (always first, on your letterhead with a signature line for the provider), a claim summary, the insurance payment notice (EOB), signed visit notes, insurance card photos, and files you add (drop an EOB or letter as PDF, JPEG or PNG up to 25 MB, and say What is it?). Items Hero can’t include are listed under Not available with the reason. Build & preview makes the PDF; look at every page, then Download, Print, or Send this packet.
6. Send — a column on wide screens, a step on narrow ones (below).
7. Response & outcome — what the insurance company said back, and what happens next (below).

Send it

Tracking shows each send’s progress (a fax from sending to delivered; a letter from the printer to delivered). A fax Hero couldn’t confirm asks you to check your fax service’s sent list and choose It went through or It didn’t go through. A delivered fax, a mailed letter or a logged submission marks the appeal Submitted and the claim appealed. Hero won’t log a submission after the appeal window has closed: contact the insurance company about a late appeal first.

Response & outcome

• Answers find the appeal. An incoming fax that quotes the appeal reference, or a payment report for the claim, appears under Needs your review as a possible answer: Confirm it or choose Not this appeal.
• Record a response yourself: attach the letter (Read it for me fills in the fields from it, and says how clearly it could read it; check them), then What did they decide?, how and when it arrived, the amount approved, a respond-by date, their reference and notes, and Record response.
• Outcomes are Won, Partly won or Lost. Recording one adds a note to the claim and never changes money: payments still post only from the ERA or EOB. After a loss, Start level 2 appeal starts the next level; Hero tracks up to level 3, and after that the decision letter says how to ask for an external review.
• Alerts. The Billing inbox reminds you when a follow-up is due, and tells you when an appeal fax didn’t go through or a letter came back.

The Appeals list

Billing → Operations → Appeals (shown while the kit is on, to people who manage claims) lists every appeal under Open, Submitted and Closed, with Needs review and Follow-up due chips and a search by patient, claim number or reference. Each row shows the insurance company, the claim, the appeal-by date, the status with the latest send, and the last update. Statuses are Draft, Ready, Submitted, Insurance asked for more, Won, Partly won, Lost and Closed. New appeal for a claim billed outside Hero starts an appeal from an EOB for a claim Hero didn’t file: enter the patient, the claim, the denial codes and the services, then Create appeal. It never changes Hero’s claims.

Settings

In Billing → Configuration → Claim Submission, the Appeal kit card holds the main switch and Hero mails appeals for you, which starts off: “When it’s on, the appeal kit’s Send panel can print and mail a packet for you. Each letter is confirmed, with its price, before it goes out.” Postage and printing go on your Hero invoice. Usual service sets the default mail service; you can pick another for each letter. Turning mail off later still delivers letters already on their way.

Expected denials and 99024 post-op visits

Some denials are expected and need no appeal: a 99024 post-op visit inside a surgery’s global period, or a line the payer pays only as part of another service it already paid. Two settings keep them from piling up in the Denied / underpaid lane: one stops the claim being sent at all, the other lets Billing Hero close the denial when it comes back.

Record 99024 post-op visits without a claim

In Billing → Configuration → Claim Submission, the Post-op visits (99024) card explains: “99024 records a follow-up visit during a surgery’s global period. The surgery’s payment already covers it, so insurance companies deny a claim for it.”

1. Choose When a visit's only service is 99024. Send a claim (default) or Record the visit only, no claim.
2. Choose For. Original Medicare only (the default) or Every insurance.

The card saves as you change it; it needs the billing-settings permission. With Record the visit only, signing a visit whose only service is 99024 makes no claim, and Hero removes its 99024 charge so no one is billed for it; the clinician sees “This practice records 99024 post-op visits without sending a claim; the surgery’s global payment covers them. Ask your billing team if this visit needs a claim.” A visit with any other billable service, money already posted on its charges, or a claim that may have reached a payer is billed as before.

Let Billing Hero close expected denials

In Billing Hero settings, set Close a denial the payer was expected to make to Propose or Automatic (it starts Off), and turn on Denied claim (coverage or patient identity) under What sends a problem to Billing Hero. Billing Hero then closes a denial instead of sending it to Human Review when the payer denied a line as included in another service it paid (CO-97, CO-234 or CO-236, or Medicare’s CO-B15 on a 99024) and that was expected:

• a 99024 post-operative visit inside a surgery’s global period;
• a code-pair edit that never pays the line separately;
• a line billed for the same problem as a paid line.

Closing resolves the denial on the claim with a note saying why it was expected. A CO-97 denial needs no write-off; a CO-234, CO-236 or 99024 CO-B15 amount is written off. The claim is marked reviewed when the payer owes nothing else on it. Billing Hero never files a new claim, never adds a modifier, and never bills the patient: if closing would change what the patient owes, nothing is changed. A write-off above $250, an E/M line, a line with a patient share or a payment, a claim with another open denial, or any case that isn’t clear goes to a person in Human Review instead.

Decide what happens when an insurance check fails

Billing → Configuration → Eligibility decides what Hero does when an insurance check says the patient’s coverage can’t be confirmed: stop new bookings, cancel upcoming visits, tell the patient or your team, ask the clinician at signing, hold the claim, or hand the problem to Billing Hero. “Everything is off until you turn it on.” The top of the card counts N open insurance problems · N claims on hold.

Staff with the billing-settings permission, administrators and the practice owner can change it. Pure Cash and DPC practices find the tab with Show all tools. Press Save changes (or Discard) when you are done; leaving with unsaved changes asks first.

Which failed checks count

Tick the failures that should trigger your choices: Coverage not active, Member not found, and Name or date of birth does not match (all three to start). Only problems with the patient’s own coverage count. A setup problem on your side, a temporary error, or an insurer that won’t answer for a date that far ahead never blocks a booking, holds a claim, or alerts anyone.

At booking, signing and sending

• Booking. Insurance check failed shows what the insurer said, for example Member not found, with “Fix the insurance and re-check, or book anyway with a reason.” With permission, type the Reason for booking anyway (Reason for saving anyway when moving or editing a visit) and press Book anyway; the reason is saved with the visit. Without it the dialog reads “Ask a biller or the office manager to book this visit.” Treatment series rows show insurance check failed instead of booking.
• Signing. Insurance check failed says “Your note is signed either way. This only decides what happens to the claim.” Choose Sign and hold the claim (the claim is held even when choice 6 is off), or, with permission, Sign and send anyway with a Reason to send anyway. It asks only at the first signing of a visit that makes a claim; addenda are never asked.
• Held claims. The claim waits in Claims Pipeline → Held with the reason Coverage verification. Its Release dialog shows Held because the insurance check failed, what the insurer said, Re-check eligibility (“If the insurance now checks out, the hold comes off on its own.”) and, with permission, Reason to release anyway and Release anyway. The hold never replaces another hold.

Open insurance problems

The tab lists “Patients whose last insurance check failed. Fixing the insurance and checking again closes the problem on its own.” with the patient, insurance, date of service, What the payer said and the claims on hold. Re-check runs the check again (claims-management permission). Mark resolved closes the problem and releases the claims it was holding, with an optional note; use it when the insurance is fixed or no longer matters. It needs the permission to go past a failed check (below). A problem also closes, and its holds come off, when a new check comes back active or the member ID, name, date of birth or payer on the policy changes.

Send Original Medicare claims to the right contractor

Medicare bills by where you saw the patient, not where the patient lives. A patient’s Original Medicare card names no region, so a policy often points at the Part B contractor of the patient’s home state. Hero helps you send each claim to the contractor your practice bills.

Your practice’s Medicare payer

In Admin → External Providers → Stedi, set Default Medicare payer to your practice’s Medicare Part B payer. Then:

• scanned Original Medicare cards start with that payer, in staff and patient-portal insurance forms;
• payer searches for Original Medicare list it first, marked Your practice's Medicare payer;
• picking a different Original Medicare payer warns “Your practice bills Original Medicare through {payer}…” with Use {payer} instead (see Original Medicare payers and Medicare IDs).

Medicare Advantage, supplement and railroad plans keep their own payer.

Fix claims addressed to another state’s contractor

An Original Medicare claim addressed to a contractor your practice isn’t enrolled with is held instead of sent. When Hero can tell which contractor the claim belongs with, the hold note says so, for example “Not sent: this claim is addressed to {contractor}, but Medicare bills by where you saw the patient, and you saw this patient in {state}, where claims go to {payer}. Use the button below to switch this patient’s Medicare and send the claim.”

1. Find the claim in Claims Pipeline → Held. The held row shows Switch Medicare payer (claims-management permission).
2. Check the suggestion. Switch Medicare payer says which contractor the patient’s Medicare is set to and suggests one, with the reason: “Your Medicare claims go to {payer}.”, “Your practice’s Medicare payer is {payer}.”, or “You saw this patient in {state}, where claims go to {payer}.” Press Switch to {payer}, or Choose a different Medicare payer to pick from Your practice is enrolled with or All Medicare Part B payers (“Choose the payer for the state where you saw the patient.”).
3. Check the other claims it moves. The switch updates every unsent claim on the same Medicare policy (“This also updates 2 unsent claims on the same Medicare policy…”), and warns when one of them was a visit in another state.
4. Read the result. For example “Switched this patient’s Medicare to {payer}. 1 held claim released to send.” Claims still held for another reason keep their hold note. The policy’s eligibility result is kept, and the claim’s history on the patient’s invoice shows that its Medicare payer was switched.

To let Hero do this for you, turn on Send Original Medicare claims to our Medicare contractor in the Medicare claims card, next to Default Medicare payer in Admin → External Providers → Stedi. It is off by default and needs the billing-settings permission: “When a patient’s Medicare names another state’s contractor, Hero switches the claim to yours and sends it. Hero only does this when it is clear which one is yours and nothing has gone to Medicare yet; otherwise the claim is held for you to review.”

Other Medicare rules Hero follows

• Part B decides coverage. For Original Medicare, an eligibility answer with only Part A active shows as inactive coverage.
• No replacement claims. Traditional Medicare takes no replacement (frequency 7) claims, so a correction is a reopening or a new claim; see Correct & Refile.
• Split claims. When Medicare answers some lines on a separate notice, the claim reads Waiting for Medicare’s second notice and isn’t counted as underpaid in the meantime.
• Medicare IDs. An Original Medicare policy needs an 11-character Medicare ID.
• 99024 post-op visits. You can record them without a Medicare claim; see Expected denials and 99024 post-op visits.

Catch payers with no electronic remittance, and read Stedi-started enrollments

A payer sends electronic payment notices (ERAs) only after the practice enrolls for them. Until then its payments arrive as paper EOBs that someone has to key in. Hero can watch for that gap, and the enrollment tracker now shows enrollments Stedi started on its own.

Turn on the ERA enrollment watch

1. Open the switch. In Billing → Configuration → Claim Submission, below the claim settings, find Watch for missing ERA enrollments. Administrators and staff who may change billing settings can turn it on; others see “Someone who manages billing settings can change this.” It is off by default.
2. Turn it on. “Once a day, Hero looks at the payers you sent claims to in the last 120 days. When one has never sent you an electronic payment notice (ERA) and no ERA enrollment is on file, the Billing inbox names the payer so someone can start its ERA enrollment before paper EOBs pile up. The alert closes itself when the first ERA arrives, or you can close it. Hero never enrolls for you.” Hero confirms ERA enrollment watch is on · Hero checks every morning.
3. Work the alert. A Billing inbox item titled ERA enrollment needed: {payer} says which route needs the enrollment and where to start it, for example “Stedi needs an ERA enrollment for Blue Shield of California (payer ID BS001) before its payment notices arrive electronically. Start it in Admin → External Providers → Stedi (payer enrollments); until then post paper EOBs with Post EOB.” For Office Ally it points at Office Ally’s payer enrollment, and for Claim.MD at Admin → External Providers → Claim.MD.
4. Let it close. The alert closes by itself, with a note, when that payer’s first ERA arrives or an ERA enrollment is on file. If you close it yourself it stays closed. Turning the watch off stops new alerts; alerts already in the inbox stay until someone closes them.

Enrollments Stedi started on its own

When Hero checks eligibility with a payer that requires enrollment first, Stedi can create an enrollment by itself, often with a task for the practice. The enrollment tracker (§5.21) now brings these in: opening the tracker, and its Refresh, ask Stedi for them.

• Where it came from. Such a row and its details say Started automatically by Stedi after an eligibility check, Started automatically by Stedi, or Started in Stedi outside Hero.
• Not used by Hero. An enrollment for an NPI Hero doesn’t send to that payer is marked Not used by Hero and never counts as Practice action, with the reason, for example “Hero checks this payer’s eligibility under your practice’s group NPI, not this provider’s NPI, so Hero does not use this enrollment. Nothing is needed from your practice.” Its tasks are listed as Steps Stedi lists (not needed). A Not used by Hero filter appears next to the other groups when there is at least one.
• When Hero can’t tell. “Hero could not confirm which NPI it sends to this payer; review the practice’s billing identity.”

Other enrollment changes

• PTAN on ERA enrollments. Medicare contractors need the PTAN on ERA enrollments as well as claims enrollments, so the enrollment form in Admin → External Providers → Stedi now shows PTAN for both. Eligibility enrollments still don’t take one.
• The environment stays Production. Once a practice has live Stedi provider records, the Stedi settings’ environment is locked: “Stays Production: this practice has live Stedi provider records.” Switching such a practice to Test would stop its ERAs from arriving, so Hero refuses it.

Fix a claim whose member ID and group number are the same

The member ID identifies the patient and the group number identifies the plan, so the two are never the same. When one value ends up in both fields of a policy (often the card’s group number typed into Member ID as well), Stedi refuses the claim. Hero catches this before the claim is sent, and Billing Hero can correct the policy from the payer’s own eligibility answer. Hero ignores spaces, dashes and capital letters when it compares the two fields, so ABC-123 456 and abc123456 count as the same.

What you see

• A warning on the claim. The claim’s Issues & fixes shows Member ID and group number are the same: “This insurance policy has the same value as its member ID and its group number. The member ID identifies the patient and the group number identifies the plan, so one of them is wrong, and Stedi rejects the claim. Correct it from the insurance card or the payer’s eligibility answer.” Every practice sees this warning, whatever its claims route.
• A hold, when your practice sends claims only through Stedi. The claim isn’t sent. It waits in Claims Pipeline → Ready to Send → Held, marked Held · Awaiting review, with the note “Held before sending: this claim’s insurance policy has the same value as its member ID and its group number, which the clearinghouse rejects (the subscriber ID, NM1-09, and the group or policy number, SBR-03, must differ). Correct the member ID or the group number from the insurance card or the payer’s eligibility answer.” A claim that is already on another hold keeps that hold instead.
• No hold, when your practice also has another claims channel. Hero doesn’t hand the claim to Stedi; it goes by your other channel, as any claim Stedi can’t take does.
• A claim Stedi already refused reads Submission failed on the Action Center’s Rejected lane, with Stedi’s own words: “33: The Subscriber Primary Identifier (NM1-09) and Subscriber Group/Policy Number (SBR-03) should not be the same. Correct and resubmit.” (see the claims pipeline). A payer can also turn a claim back because the member ID is invalid or too long; Billing Hero handles that the same way.

Clear the hold

• Through Billing Hero. When the policy is corrected through Billing Hero (below), the hold comes off on its own, on every unsent claim on that policy, and the claim then goes out with your practice’s normal sending. Only this hold is released; any other hold stays.
• Releasing it yourself. Release in Held takes the hold off, but while the policy still has the same value in both fields Hero holds the claim again the next time it would be sent (and, with Billing Hero on, sends it the problem again).
• Correcting the policy yourself. Once a policy has a claim, Edit policy won’t change its member ID or group number and asks for a new policy instead. If your practice doesn’t use Billing Hero, contact Hero support to correct the policy and its held claim.

What Billing Hero does

Billing Hero works these claims when it is on and the matching switch under What sends a problem to Billing Hero is on: A claim was held before sending for the hold, and A claim was rejected before the payer processed it for a claim Stedi or the payer turned back over the member ID or group number. It also needs Ask the payer about corrected details on and Correct the insurance set to Propose or Automatic.

1. It asks the payer about the policy as it is. It checks eligibility for the claim’s date of service with the policy exactly as it is now. When the payer confirms coverage, its answer includes the member ID and the group number the payer has for this member. The check is listed in the policy’s eligibility history and doesn’t change the policy.
2. It corrects the policy to the payer’s numbers. With Correct the insurance it sets the member ID and the group number from the payer’s answer, or clears the group number when the payer returned none. The policy and its unsent claims are corrected together, and eligibility is checked again.
3. It sends the same claim again. With Send a claim again the claim goes out again as a fresh send. The payer never had it, so this is not a corrected claim and not a Correct & Refile.

The payer’s own answer confirms the new details. So with How Billing Hero works set to Automatic and these actions set to Automatic, all of this happens without anyone. Otherwise each change waits in Waiting for approval and on the problem’s Human Review item. The card reads Correct the insurance with The payer confirmed these details, the Member ID and Group number it would set ((cleared) when it removes the group number), and “Corrects the policy and its unsent claims together (none reached the payer).” Approving the correction takes a held claim off this hold. A claim Stedi or the payer turned back still has to be sent again: approve Billing Hero’s Send the claim again change if it proposed one, or send the claim yourself.

What Billing Hero never does here

• It never makes up a number. It sets only a group number the payer returned or a card on file shows (or clears it), and a policy change the payer didn’t confirm always waits for a person.
• It corrects a policy only while no claim on it has reached the payer. When one has, or when the payer doesn’t confirm coverage or returns nothing different, it hands the problem to Human Review with what it found.
• It doesn’t take this hold off with Release its own holds: Hero placed it, not Billing Hero. Correcting the policy is what releases it.
• It uses these steps only on a claim whose policy has the same value in both fields, or whose rejection names the member ID or group number. Other rejections are worked as before.

On the Human Review item

• What it changed on its own. When Billing Hero makes a change by itself and the problem already has an open Human Review item, the item gets a note naming each change, with a member ID or group number shown only by its last four characters, for example “Billing Hero made these changes on its own: Correct the insurance (member ID changed from one ending 0001 to one ending 1234; group number cleared (was ending 0001)); Send the claim again.”
• Closing by itself. An item Billing Hero filed about the claim closes once the claim went out again and the payer acknowledged or accepted it, whoever fixed it: “Closed automatically: claim {number} went out again and reached the payer (now acknowledged). Nothing else is left on this item.” It then reads Resolved · Claim resubmitted (an item about a held claim reads Resolved · Released the hold). An item a person is working only gets a note and stays open.