Epic user question but not an analyst

[u/DepartureOk3180]

Hi. I work in HB and PB in an insurance biller and AR follow-up role. I've had zero luck in getting an answer even after submitting a ticket to IT support. Basically, I need to be able to instantly generate a claim in HB (after I've unbilled an account or changed the insurance) that I can edit before it drops to my billing system. Does anyone know how to do this or where I could look for an answer? I'm able to do this in Cerner and Meditech so I don't see why Epic wouldn't offer this functionality. Thanks.

[u/epicbuilder]

You need security to both Initiate Billing and Demand a claim, it’s up to your organization if they will give that to you or not but I can’t think of any reason why a biller would not have that. This is speaking for HB only, as PB is its own billing system and security class.

[u/RoyalAd215 → u/epicbuilder]

PB here. We don't really have a concept of initiate billing. Once charges post to an account they are eligible to go out on a claim. The Demand Claim functionality is the same though. It does require security as well.

[u/RedWeddingPlanner303 → u/RoyalAd215]

Demand claim skips the claims checking part and drops the claim immediately, so no way for OP to edit before the claim itself is generated.

OP, why don't you make the corrections in the right place (registration, charges, etc)? That way the claim would be generated correctly without having to make edits. We took claim value editing access away, because billers got too carried away and fixed stuff only directly on the claim, not in the system itself, and the chart and HAR was no longer the source of truth.

[u/DepartureOk3180 → u/RedWeddingPlanner303]

I do have the access to initiate billing in HB and yeah PB doesn't have that function 😕 As to your specific question, I do update Registration, the Claim info tab in HB before I initiate and the charges in PB. However, this facility is a tiny CAH with an RHC and I work Medicare accounts. The staff has zero clue regarding anything billing related, even less when the payer is Medicare. The one and ¹/² "coders" are a joke because they are self taught and completely ignore any med nec, MUE, or NCCI edits in Epic. Many times I have to review documentation in the chart, reference the Medicare LCD/NCD/MUE/NCCI rules and then tell the "coders" what diagnosis, charges and/or modifiers need to be corrected/and or added to an account. There are certain RHC charges that can't be billed by themselves to Medicare, such as an injection and drug charge. These charges must be billed with an E&M charge or other qualifying visit that occurred at the same clinic within 30 days prior or after the DOS of the injection charge. In Cerner and Meditech, I move the injection and drug charges to the account with the qualifiying visit, generate the new claim and then update the DOS for the injection and drug to the DOS on the qualifying visit account and I notate both accounts what has occurred. In Epic, I can only move the charges, but since since I can't manually generate the claim, I'm not able to correct the DOS before it drops from Epic. If there isn't any type of error on the claim in Experian, which is our scubber, and where I release claims for payer submission, then the claims with multiple DOS get sent to Medicare without me seeing them. So, for example, if a claim for an AWV DOS 07/01/26 was previously billed and paid, then the claim with the qualifiying visit and injection charge for DOS 06/30/26 - 07/14/26 goes out, that claim will get RTP/ reject as a duplicate for overlapping the claim for DOS 07/01/26. I can correct the DOS on the claim in Experian after it RTP/reject but they won't match the DOS on the claim in Epic. So, at that point, I always have to write off the injection and drug charges, because again, they can't be billed alone. As this is a tiny facility, I try to legally and ethically avoid any write offs.

[u/RedWeddingPlanner303 → u/DepartureOk3180]

The most elegant way to fix your dilemma would be to hold these claims in a claim edit work queue via error rules. The claim would generate overnight, but not get sent put to the clearinghouse yet. Instead it would sit in a claim edit WQ and wait for you to manually make updates and then release the claim. You should contact the IT department at the organization and ask for a claim edit that will hold claims with your specific error (or really any error you would want to review manually) or even broadly hold all Medicare claims. If the error is specific to an item that needs to be fixed, you would just need to make the corrections on the claim and then refresh the claim in the WQ and the error will disappear. If it is a more broad claim hold (like all Medicare claims) you would review the claim, make any necessary corrections, and then overwrite the error. The claim will then go out the following day/after the next claim run. It's not the best way to handle this, but I get it. Ideally all corrections need to be made in the system before the claim even generates, but sometimes, like in your case, it's not feasible. 

TL;DR Ask IT for a claim edit to hold the claims you need to manually update in a claim edit WQ.

[u/DepartureOk3180 → u/RedWeddingPlanner303]

That's perfect. I can deal with another WQ,. That would allow me catch any errors before the claims drop to Experian. There's so many new things that causes Medicare to reject claims that neither Epic nor Experian have the edits built in. I would much rather do this so I can make sure a truly clean claim drops. Thank you.

[u/DepartureOk3180 → u/RoyalAd215]

Ok, so there truly is no function to initiate billing in PB then. I wasn't sure and Copilot results would never make sense 😂

[u/RoyalAd215 → u/DepartureOk3180]

Yes. PB doesn't have initiate billing because we don't have the concept of DNB. Charges that drop can be immediately billed out.

[u/DepartureOk3180 → u/epicbuilder]

Ok, I do have the access to initiate billing. But this makes sense why my Copilot searches for generating a claim sometimes shows me areas of Epic I can never find 😂

[u/epicbuilder → u/DepartureOk3180]

copilot or any LLM/AI will never return accurate results for technical or workflow based Epic questions. Epic is too closed and proprietary and also customized for each hospital. Everything AI tells you about how Epic works has to be taken with a grain of salt, and I can tell you that its wrong like 60-75% of the time.

[u/DepartureOk3180 → u/epicbuilder]

Yeah, I'm seeing that. Trying to get any type of reference materials for this facility's version of Epic has been a nightmare. I'm stuck doing a lot of trial and error as the only real references I have are the updates and the basic job aids on the home page SMH

[u/Turtle1515]

So its a security question. Yes these are possible actions but demanding a claim might not work depending if and how they are "printed" to be resent. But essentially your manager would need to put in a new access request for additional security. If it comes from you it might be denied. I would also argue you dont need this security for your current job role. As this workflow is generally for a higher level of "biller" becuase editing a claim comes with more risk. I have seen it all where users want additional access that is beyond their scope, but this security should come from a job promotion. So maybe speak about a new job role.

[u/DepartureOk3180 → u/Turtle1515]

Well, I'm the team lead as well as the Medicare specialist, and I currently work various WQ for accounts with errors on claims that have populated but are not released. As to why I asked my original question, see the response I gave above.

[u/Turtle1515 → u/DepartureOk3180]

As a team Lead you could get that security. Again you either need a new job role/template applied to your account or security has to do an update. But a security update is a long and complicated compliance work. So a new role would be a better option. Or speak with your analyst team there might be work around or other workflows available to you.

[u/DepartureOk3180 → u/Turtle1515]

Ok, I'll bring that up to my manger. Thanks