Care programs — claims & reports

Choose which care work can generate claims

Open Value-Based Care → Settings with care-program administration access and financial read/write access. Under Programs, Prepare CCM claims, Prepare PCM claims, Prepare BHI claims, and Prepare COCM claims prepare the corresponding claim families for review. Claim generation is a separate opt-in.

Under Claim policy, turn on Enable unified claim generation when ready, choose Generate on day and Submit on day, and set each family’s policy. Save with Save settings.

Add-on codes follow their base family’s policy. Read any Needs verification notice before enabling a family. Dates use the practice calendar; monthly services use the last day of the service month. Hero must enable scheduled background work for automatic runs — ask support. Electronic submission also follows the practice’s billing setup.

Resolve holds, approve work, and follow claims

1. Open Month-end & claims. Choose Service month and the program. This tab requires financial visibility and billing read access; managing clinical care alone is insufficient.
2. Generate and review candidates. With billing write access, use Generate now. Needs attention groups held items by what must be resolved; All items includes the rest.
3. Resolve the stated reason. Missing consent, conditions, diagnoses, insurance, or a reviewed plan must be addressed in the patient record. When offered, use Open enrollment & care plan. If CCM and PCM conflict, choose the appropriate program. If staff and physician time both qualify, select the billing role and actor rather than combining their totals. Clinical attestations require an eligible clinician.
4. Inspect and approve. Open an item for its supporting time, diagnoses, code lines, and Event history. Ready items without holds can use Approve & submit now; Submit ready now processes due approved work. Changed evidence may require a new approval.
5. Follow Outcomes. Review billed and paid amounts, claim outcomes, and reasons needing follow-up. Unallocated claim adjustments stay separate from program totals. For existing claims, use Open claim · Correct & Refile.

Where allowed, Skip item, Void item, and Reopen with audit trail require a reason. APCM and RPM rows are read-only here; use Open APCM, Open RPM, or Open native record to work those claims.

Review an optional care episode

A care-program administrator enables Settings → Programs → Capture online and phone episodes. Claim-family policies and generation remain separate settings. Only patient-initiated clinical work qualifies for this workflow; routine administrative requests do not become billable clinical work.

1. Open Episodes in the patient drawer. Review the episode, its time window, confirmed minutes, and any holds. An open episode can use Start episode timer.
2. Choose Review and close. Confirm Diagnosis codes, Purpose, and whether the request resulted in a visit. Complete the displayed review of a visit within 24 hours or the next available visit.
3. Use Close episode. Hero verifies the rendering clinician and applies billing holds. A held or closed review can be corrected through Correct episode review and Save corrected review; closing alone does not submit a claim.

Compare enrollment, time, and outcomes

In Reports, choose the service month and report. Clinical reports include Enrollment & growth, Minutes by staff & profile, Eligible, not enrolled, and HCC review. Financial access adds Revenue by program, Claim outcomes, and Work RVUs by provider.

Use Download CSV where offered. Eligibility reflects current checks, processed a page at a time; Download CSV page exports that page. Use Next patients for additional checks. HCC and RVU reports depend on the practice’s quality settings and reference data. Missing RVU values are omitted from sums and identified on the quality review screen.