Guides

Revenue Cycle Management

We partner with ClaimMD, Waystar, and Candid Health to handle the full revenue cycle management process. This guide covers the prerequisites, creating insurance claims, submitting them to the clearinghouse, and working remittances. For reporting, follow the guide on billing analytics.

Prerequisites

In order to submit insurance claims, there are a couple of items you need to set up first.

Part 1: Create billing providers (EMR)

The billing provider is the provider or business entity submitting the claim and represents the person or entity being reimbursed. The billing provider should be the entity contracted with the payer.

Follow the instructions here to set up your billing providers.

Part 2: Create service facilities (EMR)

Next, set up your service facilities.

The service facility is location a medical service was rendered, such as the provider office of hospital. For telehealth, the service facility can be the provider’ location when the service was delivered (e.g. home) or the location where the in-person would have taken place. The service facility address listed must match what you provided to the payer during the credentialing process.

Follow the instructions here to set up your service facilities.

Part 3: Create referring providers (EMR)

Then, set up your referring providers.

The referring provider is the provider who directed the patient for care to the provider rendering the services being reported.

Follow the instructions here to set up your referring providers.

Part 4: Set patient demographic details (EMR or Patient Portal)

We pull the patient’s name, gender, MRN, date of birth, and address for the insurance claim from the patient’s profile. This information is automatically added to the patient profile during the registration process.

Follow the instructions here to ensure that all the pertinent demographic details are set on the patient’s profile.

Part 5: Create patient insurance policies (EMR or Patient Portal)

Add insurance policies for each patient.

Follow the instructions here to set up each patient’s insurance policies.

Part 6: Set up RCM integration (EMR or Patient Portal)

Lastly, you need to set up an RCM integration with ClaimMD, Waystar, or Candid Health.

Follow the instructions here to set up the RCM integration.

Part 7: Turn on the required permissions (EMR)

Under Settings > Organization > Access Controls, the specialization working claims needs:

  • Can view insurance claims: Shows the "Billing" section of the menu, including the Claims and Remittances pages
  • Can add or edit insurance claims: Allows editing a claim, marking it ready to submit, and posting remittance payments
  • Can submit insurance claims: Shows the "Submit Claims" and "Generate Itemized Statement" buttons on the Claims page

Follow the instructions here to set access controls.

Part 8: Set up Claims Scrubber rules (EMR, optional)

The Claims Scrubber runs a set of rules on every claim before it leaves Avon. Required-information checks always run. On top of those, custom rules can be written for the problems payers reject claims for, such as a telehealth visit missing modifier 95. A rule can block submission until the claim is fixed, or just warn the biller.

Follow the instructions here to write scrubber rules.

Create insurance claims

Step 1: Create an insurance claim (EMR)

To create a insurance claim:

  • Go to the EMR (e.g. emr.avonhealth.com)
  • Click on the hamburger menu on the top left corner > Patients
  • Click on the “View Chart” button of the appropriate patient
  • There are two ways to create a new claim
    1. Click on “Add” button on the top right corner and select “Insurance Claim” in the dropdown
    2. Pick the “Bills” shortcut in the patient panel on the left side of the screen, click on “Add a new bill” button on the top right corner, and select “Insurance Claim” in the dropdown
  • Fill out the requisite information
    • Name: Name of the claim
    • Patient: Verify that the patient name, gender, MRN, date of birth, and address are accurate.
    • Appointment: Appointment this claim is associated. If there is no appointment this claim is associated, leave this dropdown blank.
    • Visit Note: Visit note this claim is associated with. If there is no visit note this claim is associated with, leave this dropdown blank.
    • Primary insurance: Patient’s primary insurance policy. This field is auto-populated with whichever policy the patient has set as their primary insurance policy. If you want to change the patient’s primary insurance policy to a different policy for this bill, simply choose another policy from the dropdown.
    • Secondary insurance: Patient’s secondary insurance policy. This field is auto-populated with whichever policy the patient has set as their secondary insurance policy. If you want to change the patient’s secondary insurance policy to a different policy for this bill, simply choose another policy from the dropdown.
    • Rendering provider: Provider that provided the medical services. This field is auto-populated with either:
      • The provider who wrote the note that is generating this bill, if this bill was generated from a note
      • The provider who clicked “Create a new bill,” if this bill was NOT generated from a note If you want to change the rendering provider, simply choose another provider from the dropdown.
    • Referring provider: Provider who directed the patient for care to the provider rendering the services being reported.
    • Service facility: Location a medical service was rendered, such as the provider office of hospital. This field is auto-populated with the default service facility set in Prerequisites Part 2 of this document. If you want to change the service facility, simply choose another service facility from the dropdown.
    • Billing provider: Provider or business entity submitting the claim and representing the person or entity being reimbursed. This field is auto-populated with the default billing provider set in Prerequisites Part 1 of this document. If you want to change the billing provider, simply choose another billing provider from the dropdown.
    • Prior Authorization: Number indicating that the services provided on the claim have been authorized by the payer. If there is no prior authorization number, leave this box blank.
    • Permissions: Permissions that:
      • Patient has authorized release of medical information for billing purposes
      • Patient has authorized payments to be made to the billing provider
      • You have accepted patient's authorization for payments to be made to the billing provider
    • Diagnoses: Relevant diagnoses for this claim. If this bill has been generated from a note, the ICD codes from the note are automatically added as diagnoses. For each diagnosis, specify whether it is active, onset date, and end date (if not active anymore).
    • Billing Items: Relevant billing items for this claim. If this bill has been generated from a note, the CPT codes from the note are automatically added as billing items. For each billing item, specify the date of service, any modifiers, quantity of the procedure performed, fee per procedure, and associated diagnoses. Each billing item must have at least one associated diagnosis.
  • All information set is autosaved so click “Finish and Go Back” if you are done with the claim for now

Step 2: Request review (EMR)

You can request review of the insurance claim before submitting it. Follow the instructions here to request review.

Step 3: Add comments (EMR)

You can add comments to the insurance claim before submitting it. Follow the instructions here to add comments.

Step 4: View, edit, and delete insurance claims (EMR)

To view, edit, or delete insurance claims:

  • Go to the EMR (e.g. emr.avonhealth.com)
  • Click on the hamburger menu on the top left corner > Patients
  • Click on the “View Chart” button of the appropriate patient
  • Either:
    • Scroll through the patient’s chart to find the desired insurance claim OR
    • Click the “Bills” shortcut on the patient panel and scroll to find the desired insurance claim
  • If a claim has a “Missing Information” or “Rejected” status, open it to see what needs to be fixed before resubmitting. Follow the instructions in Submit insurance claims to fix and resubmit a claim.
  • Click on the insurance claim card to go into viewing mode
  • Toggle the top dropdown to go into editing mode
  • Scroll to the bottom right-hand corner of the card to find the “Delete” button (NOTE: the “Delete” button is only visible when you are in editing mode)

Submit insurance claims

Once an insurance claim has been created, it goes through three stages: a biller marks it ready, the Claims Scrubber checks it, and it is submitted from the Claims page. Claims go to whichever clearinghouse the organization is connected to.

Step 1: Mark the claim ready to submit (EMR)

To mark a claim ready:

  • Go to the EMR (e.g. emr.avonhealth.com)
  • Click on the hamburger menu on the top left corner > Patients
  • Click on the "View Chart" button of the appropriate patient
  • Click the "Bills" shortcut on the top bar and open the insurance claim
  • Optionally, link the claim to any patient invoices for the same visit under "Invoices". One claim can be linked to several invoices.
  • Click "Mark Ready to Submit". The button reads "Checking claim..." while the scrubber runs.

One of three things happens:

  • The claim is clean: Its status changes to "Ready to Submit" and the page returns to the Bills list
  • Something is missing or a blocking rule fired: A red panel reads "This claim isn't ready to submit yet" and lists each issue. Missing required fields are shown as links that scroll to the right section of the claim. Fix the issues and click "Mark Ready to Submit" again.
  • Only warnings fired: An amber panel lists the warnings. Click "Go back and review" to fix them, or "Submit Anyway" to mark the claim ready regardless.

The required-information checks are: patient first name, last name, date of birth, and address; billing provider; service facility; primary insurance policy; at least one diagnosis; and at least one billing item.

"Mark Ready to Submit" only appears while the claim is in "Draft". It does not send the claim anywhere. Submission happens from the Claims page in Step 3 of this section.

Step 2: Review claims on the Claims page (EMR)

The Claims page lists every insurance claim in the organization.

  • Go to the EMR (e.g. emr.avonhealth.com)
  • Click on the hamburger menu on the top left corner > Billing > Claims
  • Use the search box to find a claim by claim name, patient name, or MRN
  • Use the filters to narrow the list by Primary Insurance Policy, Patient, Rendering Provider, Tag, or Status
  • Each row shows the claim name, patient, date of service, tags, billing items (CPT codes), status, and any responses from the clearinghouse
  • Click "View" on a row to open the claim

A claim's status can be changed directly from the list by clicking its status badge and choosing another status. This is useful for marking a claim "Paid" or "Denied" once the payer responds. Changing the status here does not submit the claim or post any payments.

Step 3: Submit claims (EMR)

Claims are submitted in bulk from the Claims page:

  • Filter the list to Status: "Ready to Submit"
  • Tick the checkbox on each claim to submit, or tick the checkbox in the header to select every claim on the current page. A banner shows how many claims are selected, with a "Clear Selection" button.
  • Click "Submit Claims" in the top right corner

Before anything is sent, Avon re-checks every selected claim for required information and runs the Claims Scrubber on it. Claims that pass go to the clearinghouse. Claims that do not are held back, and a summary appears:

  • Held back: Claims with missing information or a blocking rule finding. These are not submitted and their status changes to "Missing Information". Each entry lists the findings and has a "View claim" link that opens the claim in a new tab.
  • Needs your confirmation: Claims that only have warnings. Click "Submit anyway" to send them, or "Close" to go back and review them first. "Submit anyway" is only offered when no claim in the batch is held back.

After submitting, the selection narrows to the claims that still need attention so they can be worked through.

Claims are sent to whichever clearinghouse the organization is connected to. Submission does not remove the claim from the list; its status changes to "Submitted".

Step 4: Generate an itemized statement (EMR, optional)

To produce a printable statement for one or more claims, select them on the Claims page and click "Generate Itemized Statement". A PDF with the organization's letterhead opens in a new tab.

Step 5: Track claim status (EMR)

Each claim has one of the following statuses:

  • Draft: Being built. The only status that shows "Mark Ready to Submit".
  • Ready to Submit: Passed the required-information check and the scrubber. Waiting to be submitted from the Claims page.
  • Submitted: Sent to the clearinghouse.
  • Missing Information: Held back by the scrubber, or flagged in Avon because the payer needs more information.
  • Rejected: The clearinghouse or payer rejected the claim before adjudication, usually for a formatting or data problem. Check the "Responses" column on the Claims page for the reason.
  • Denied: The payer adjudicated the claim and declined to pay. Set this in Avon when the denial arrives. Denial codes from remittances are reported under Analytics > Claim Denials.
  • Paid: The payer paid the claim. This is set automatically when a payment from a remittance is posted. Follow the instructions here to post payments.

Status responses from the clearinghouse appear in the "Responses" column. If the organization uses Waystar, click "Check" on a claim to fetch the latest acknowledgement, then refresh the page to see the result. Waystar acknowledgements are only picked up on the day Waystar produces them.

Step 6: Fix and resubmit a claim (EMR)

To resubmit a claim that was held back, rejected, or needs a correction:

  • Open the claim from the Claims page or the patient's chart
  • Toggle the top dropdown to "Edit Mode" and fix the claim
  • Set the status back to "Draft" using the status dropdown, then click "Mark Ready to Submit" so the scrubber runs again
  • Select the claim on the Claims page and click "Submit Claims"

A claim that has already received a response from the clearinghouse cannot be deleted.

Remittances

A remittance is the payer's response to an insurance claim: what was allowed, what was paid, what was adjusted, and what is the patient's responsibility. Remittances arrive in Avon from the clearinghouse as electronic remittance advice (ERA / 835) files, or can be entered directly. Posting the payments on a remittance marks the claim paid and updates the patient's ledger.

Step 1: Open the Remittances page (EMR)

  • Go to the EMR (e.g. emr.avonhealth.com)
  • Click on the hamburger menu on the top left corner > Billing > Remittances

The page lists one row per claim on each remittance, newest first. Each row shows the Payer, Patient, Charge, Paid, Pt. Resp. (patient responsibility), Received date, and Status. Click any column header to sort by it. Use the search box to find rows by payer name or patient name, and the Status filter to narrow the list. The list shows 20 rows per page.

Step 2: Receive remittances from the clearinghouse (EMR)

How remittances arrive depends on the clearinghouse:

  • Waystar or Stedi: Remittances are imported automatically on a schedule. New ERAs appear on the Remittances page with the status "Pending". No action is needed.
  • ClaimMD: Click "Download" in the top right corner of the Remittances page to import any new ERAs from ClaimMD. This imports the remittances into Avon; it does not save a file to the computer.

Each imported remittance is matched to the insurance claim it references, and each line on the remittance is matched to the billing item on that claim by procedure and fee. If a claim cannot be matched automatically, open the remittance and link it yourself in Step 3. A remittance is never imported twice; the check or trace number identifies it.

Step 3: Add or edit a remittance in Avon (EMR)

To enter a paper remittance, or to correct an imported one:

  • On the Remittances page, click "Add Remittance" to create a blank one, or click "View" on an existing row and then the pencil icon to open it for editing
  • Toggle the top dropdown to "Edit Mode" if it is not already
  • Fill out the "Remittance Details":
    • Name: A name for the remittance (e.g. "Aetna Remittance Claim — 2026-09-01")
    • Payer: The insurance company that paid. Choose from the list or type a new name.
    • Check Number: The check or EFT trace number
    • Paid Amount: The total amount of the check
    • Payment Date: The date on the check
    • Billing Provider: The provider or entity that was paid. Its name, NPI, tax ID, and address appear once selected.
  • Under "Claims", click "Add Claim" for each insurance claim covered by the remittance
    • Insurance Claim: Search by patient name, MRN, or claim date and select the claim. The claim's billing items are pulled in as charges, with their Date of Service, Procedure, Modifiers, Quantity, and Charge. These come from the claim and cannot be edited here.
    • Paid: Enter the amount paid for each charge
    • Adjustments: Click "Add Adjustment" on a charge to record a claim adjustment. Choose the Group (CO for contractual obligation, PR for patient responsibility, OA for other adjustment), the Code, and the amount, then click "Done". The available codes are CO 4, 16, 45, 146, 253; PR 1 (deductible), 2 (coinsurance), 3 (copay); and OA 18, 23.
    • Associated Invoices: Optionally link the patient invoices for this visit to the claim. One claim can have several invoices.
  • All information set is autosaved so click "Finish and Go Back" when the remittance is complete

To remove a claim from the remittance, click the trash icon on it. To delete the whole remittance, click "Delete Remittance" and confirm. This cannot be undone.

Step 4: Review a remittance (EMR)

Click "View" on any row of the Remittances page to open the "Remittance Details" modal. It shows the payer, a link to the insurance claim, the check number, total charge, total paid, patient responsibility, any linked invoices, and a table of each charge with its allowed amount, paid amount, and adjustments. The "Status History" at the bottom records when the remittance was created, when payments were posted, and who did it.

Step 5: Post payments (EMR)

Posting writes the payments from the remittance onto the claim's billing items. Post one claim at a time or a whole remittance at once:

  • One claim: On the Remittances page, click "View" on the row and then "Post Payment"
  • Whole remittance: Open the remittance in Edit Mode and click "Post Payments in Bulk". Claims that have already been posted are skipped.

When a payment is posted:

  • Each charge's paid amount and adjustments are recorded against the matching billing item on the insurance claim
  • The remittance row's status changes to "Payment Posted"
  • The insurance claim's status changes to "Paid"
  • The payment appears on the patient's Ledger and in the claim's "Claim History"

Before posting, make sure every claim on the remittance is linked to an insurance claim and every charge shows a Date of Service and Procedure. A charge that shows "—" was not matched to a billing item, and posting will not run until it is. If a charge does not match because its fee differs from the claim, edit the claim's billing item so the fees agree.

To reverse a posted payment, open the row's "View" modal and click "Delete Posted Payment". The status changes to "Posted Payment Deleted". The insurance claim stays "Paid", so change its status on the Claims page if needed.

Step 6: Move patient responsibility to the patient's balance (EMR)

When the payer assigns part of the allowed amount to the patient (a PR adjustment such as PR-1 deductible or PR-2 coinsurance), that amount stays on the insurance side of the ledger until the patient is billed for it. To move it:

  • Go to the patient's chart, click the "Bills" shortcut, and create an invoice. Follow the instructions here to create an invoice.
  • On the invoice, click "Add Charge" and choose "Deductible" or "Coinsurance", then enter the amount from the remittance
  • Link the invoice to the insurance claim, either from the "Invoices" section of the claim or from "Associated Invoices" on the remittance
  • Send or charge the invoice as usual

Once linked, the Ledger moves the deductible or coinsurance amount from the Insurance balance to the Patient balance, and the invoice's payment counts toward the claim. Copays work differently: they are collected up front on an invoice and are already netted out of the insurance charge, so they do not need to be transferred. Follow the instructions here to collect a copay.

Step 7: Mark a remittance settled (EMR)

Once a remittance has been fully worked, including any patient invoices, click "View" on the row and then "Mark Remittance Settled". This changes the status to "Settled" so it drops out of the working list. It does not post or change any payments.

Step 8: Read the patient's Ledger (EMR)

To see how a claim, its remittance, and its invoices net out:

  • Go to the EMR (e.g. emr.avonhealth.com)
  • Click on the hamburger menu on the top left corner > Patients
  • Click on the "View Chart" button of the appropriate patient
  • Click the "Bills" shortcut on the top bar and switch the view from "Card View" to "Ledger"

The Ledger shows four summary cards, each split between Insurance and Patient: "Total Charges", "Total Paid", "Adjustments", and "Balance". Below them, each bill is a row with Total Charge, Total Paid, Adjustments, Refunds, and Balance. Click the eye icon in the "History" column of an insurance claim to open "Claim History", which shows the remittance, check number, patient responsibility, linked invoices, and every payment posted against each billing item.

Contractual adjustments (CO and OA groups) reduce the balance. Patient responsibility adjustments (PR group) do not; they stay in the balance until an invoice covers them as described in Step 6.

Remittance statuses

  • Pending: Received or created, no payment posted yet
  • Payment Posted: Payments have been written to the claim's billing items and the claim is marked "Paid"
  • Posted Payment Deleted: A posted payment was reversed
  • Settled: Closed out in Avon. No further action expected.

A row's status can also be changed directly from the Remittances page by clicking its status badge. This only updates the label; it does not post or reverse payments.

CoPay

To add a CoPay do the following:

  • Go to the patient chart.
  • Click Details to open their patient profile.
  • Set their default copay in the profile (click Edit to change it). Note: You only need to do this once if the patient is coming in for the same service.
  • Go back to their chart, click Bills, and create an invoice.
  • Click “Add Charge” and choose “Copay” — the default amount should appear. Use this amount or update it if it's for a different service.
  • Complete the rest of the form and process the transaction.
  • Once you return, you can view the patient’s total charges, bills, etc., to make adjustments on follow-up visits based on what you’re reimbursed for.

Analytics

Reports covering claims submitted, clean claim rate, claim denials, underpayment and variance, payments posted, aging, and revenue forecast are available under hamburger menu > Analytics, alongside the appointments, form response, and course reports. Follow the instructions here to use the reports.

Previous
Superbills
Next
Billing analytics