How Billing Works
This page explains insurance billing in everyday terms for front desk, billers, and managers. Use it to train staff and to answer questions like “How do we create a claim?” or “What happens after we get a payment file from the insurance company?” Self Pay visits do not use this insurance claim path—they collect payment at the visit instead.
Billing Summary
Income Analysis
Payment Speed
(1 paid of 6 Claims)
10 Days
FASTEST
10 Days
SLOWEST
10 Days
AVERAGE
Payer Mix
- Medicare35%
- Private Insurance30%
- Medicaid25%
- Self Pay10%
Revenue Trends
Performance Indicators
What Billing Is For
Billing is where your practice creates insurance claims, sends them to the insurance company through a clearinghouse, reviews payment files (ERA or paper EOB), posts payments, works denials, and follows patient balances after insurance. Open Billing from the main menu when Billing is turned on for the practice and your role can view Billing.
Step-by-Step: From Visit to Payment
1) Book an Insurance appointment (not Self Pay). 2) Complete Check-In—the system usually creates a draft claim. 3) Open the claim and enter diagnosis codes (ICD-10) and procedure codes (CPT), plus insurance member ID and place of service. 4) Save until the claim is Ready. 5) Submit the electronic claim (EDI 837). 6) Watch status as the clearinghouse and payer acknowledge the claim. 7) Receive the payment file (ERA 835) or enter an EOB. 8) Verify the remittance so money posts. 9) If needed, bill secondary insurance, collect patient balance, or work a denial.
Insurance Visits vs Self Pay
Insurance visits can create claims in Billing. Self Pay means the patient pays for that visit without sending an insurance claim. An active membership/subscription can also skip claim creation. Choosing Self Pay on an appointment is not the same as opening the Billing module.
How to Create a Claim
Most claims start automatically at Check-In for Insurance visits. Then open the claim from Live Claims Feed (or the appointment Billing area). Add at least one ICD-10 diagnosis and one CPT procedure, set providers and place of service, confirm member ID, and save. When those pieces are present, status becomes Ready. Submitting sends the claim electronically—it does not create a brand-new blank claim by itself.
CPT and ICD Codes (Plain Language)
ICD-10 codes describe why the patient was seen (diagnosis). CPT codes describe what was done (services or procedures) and drive the charge. You need both before a claim is Ready and before submit. Manage your practice’s code list and fees under Fee Schedule. Product / Procedure is a summary report of CPT usage—not where you build a claim.
Claim Statuses You Will See
Draft = incomplete. Ready = has diagnosis and procedure and can be submitted. Submitted = sent to the clearinghouse. Accepted / Accepted By Clearinghouse / Payer Acknowledged = moving through electronic acknowledgements. ERA Received = a payment file is on the claim but may still need verify. Paid In Full = settled. Balance Due = money still owed (patient or remaining). Bill Secondary Insurance = ready to send to the next payer. ERA Denied = payer denied on remittance. Rejected = rejected in acknowledgement—you can usually edit and resubmit. You can freely edit mainly Draft, Ready, and Rejected claims.
EDI, HCFA (CMS-1500), and ERA
EDI 837 is the electronic claim you submit. HCFA / CMS-1500 is the printable paper-style claim form (also used in denial appeal packages). ERA 835 is the electronic remittance (payment advice) from the payer; paper EOB is entered under Remittance Reports. Match payments to the claim number, then verify so balances update correctly.
Which Billing Screen to Use
How Billing Works (this page) = big picture. Billing Summary = dashboards. Live Claims Feed = daily claim work and submit. Patient Statements = patient balances after insurance. Transactions = claim money detail and export. Remittance Reports = ERA/EOB verify. Denials = denied claims and appeals. Unmatched ERAs = payment lines that did not match a claim. Product / Procedure = CPT totals. Fee Schedule = CPT/ICD fees. Billing Log = history of electronic claim activity and patient payment logs.
Checklist Before You Submit
Usually required: at least one CPT and one ICD; clinic or provider NPI and Tax ID; primary insurance and member ID; patient gender; place of service on charges; clearinghouse settings (account key, sender, receiver—ClaimMD or SecureConnect). Referring provider NPI if a referring provider is listed. Missing items keep the claim Draft or block submit with rule messages.
Common Problems
No claim after check-in: visit was Self Pay, subscription-covered, or check-in was not finished. Stuck in Draft: missing CPT, ICD, member ID, NPI, Tax ID, or place of service. Cannot submit: clearinghouse settings incomplete. Payment file unmatched: claim number on the ERA does not match, or primary/secondary level is wrong. Amounts look wrong: remittance is still Unverified—verify it. Billing Not Available: Billing is turned off for the practice.