Epic medical billing is the practice of running end-to-end revenue-cycle operations inside the Epic EHR. The work happens primarily through Resolute (Epic billing module). Resolute splits into Resolute Professional Billing (PB) for physician claims and Resolute Hospital Billing (HB) for facility claims.
The workflow runs in eight stages. The stages start with eligibility verification and run through coding, claim scrubbing, claim submission, payment posting, and denial follow-up. Work queues route every task to the correct staff member. The Charge Router applies payer-specific rules before any claim leaves Resolute.
Epic billing operations depend on certified Resolute analysts. Certified analysts maintain rule libraries, build claim edits, and adapt the system as payer policies shift. Provider organizations track seven core KPIs to gauge billing health.
This article covers Resolute architecture, the full eight-stage workflow, common challenges, KPI benchmarks, certifications, and the conditions under which outsourcing makes sense.
What is Epic Medical Billing?
Epic medical billing is the operation of revenue-cycle work inside the Epic EHR. The work runs primarily through Resolute, Epic’s billing module. Resolute handles eligibility, charge capture, coding, claim submission, payment posting, and denial management.
Resolute sits inside the same Chronicles database as the clinical record. Clinical actions feed charges directly into Resolute. Work queues then route tasks to billers, coders, and AR specialists. The shared-database design removes the clinical-to-billing data handoff that delays charges in separate billing systems.
Epic medical billing covers the following operations:
- Eligibility verification using the 270/271 transaction pair
- Charge capture from clinical modules (EpicCare Ambulatory, OpTime, Beaker, Radiant)
- Claim scrubbing through the Charge Router
- Claim submission as 837P or 837I files
- Payment posting from 835 ERA files
- Denial management inside work queues
- Patient billing and statements through MyChart and the Single Billing Office
What is Epic Resolute, and How Does it Handle Billing?
Resolute is Epic’s revenue-cycle module. Resolute sits inside the same Chronicles database as the clinical record. The shared database removes the clinical-to-billing data handoff that slows charges in separate-system setups.
Resolute splits into three components. The first is Resolute Professional Billing (PB) for physician claims. The second is Resolute Hospital Billing (HB) for facility claims. The third is the Single Billing Office (SBO), which unifies patient statements across PB and HB.
Resolute PB vs Resolute HB: What is the Actual Difference?
Resolute PB processes professional services claims using the CMS-1500 / 837P format. Resolute HB processes facility claims using the UB-04 / 837I format. The two modules use different account structures and serve different provider types.
The core differences between Resolute PB and Resolute HB:
| Attribute | Resolute Professional Billing | Resolute Hospital Billing |
|---|---|---|
| Claim format | CMS-1500 / 837P | UB-04 / 837I |
| Account structure | Guarantor account | Hospital Account Record (HAR) |
| Primary users | Physician groups, ASCs, ambulatory clinics | Hospitals, inpatient and outpatient facility departments |
| Billing trigger | Encounter close | Facility stay completion or service episode |
| Certification track | Resolute PB Certified Analyst | Resolute HB Certified Analyst |
What is the Single Billing Office (SBO)?
SBO is the unified patient-statement layer inside Resolute. Patients see professional and hospital balances on one statement. Payments post to one portal in MyChart, no matter whether the balance came from PB or HB.
How Does the Epic Medical Billing Workflow Work End-to-End?
The Epic workflow handles every touchpoint from the moment a patient schedules an appointment to the final dollar posted on a remittance. Eight distinct stages drive this process, each feeding directly into the next.
Step 1. Scheduling and Pre-Registration
Cadence manages appointment scheduling and captures the first layer of patient demographics. Staff enter insurance information, referral sources, and visit reasons here before the patient ever walks through the door. Getting this right sets the tone for everything that follows.
Prelude handles pre-registration, where demographic data gets scrubbed and confirmed against payer records. Address, date of birth, guarantor relationship, all of it needs to match what the payer has on file. Errors caught here cost minutes. Errors missed here cost weeks of rework post-claim.
Step 2. Eligibility Verification (270/271 Transaction Pair)
The 270 transaction is an electronic eligibility inquiry sent to the payer asking a direct question: Is this patient covered, and for what? Epic fires these automatically based on scheduled appointments, usually 24 to 72 hours out. The response comes back as a 271.
The 271 returns active coverage status, deductible balances, copay amounts, and service-level exclusions. Billing teams need to read these carefully, not just confirm that a policy exists. A patient can be active and still have zero benefits for a specific procedure code.
Step 3. Prior Authorization
Prior auth is where workflows either run smoothly or fall apart, depending on how well your team manages work queues. Epic flags encounters that require authorization based on payer-specific rules built into the system. Staff submits auth requests and tracks approvals directly within the workflow.
Authorization numbers must be linked to the encounter before charge capture closes. If that connection breaks, wrong auth number, expired dates, mismatched procedure, the claim goes out clean and comes back denied. No payer will back-date an authorization, so the time to fix it is always before submission.
Step 4. Encounter and Clinical Documentation (EpicCare)
EpicCare is where the clinical record gets built. Physicians document the visit, enter diagnoses, and complete orders. The quality of this documentation determines whether the coder has enough to assign accurate codes, or is left guessing and querying the provider repeatedly.
Vague notes produce vague codes. Vague codes produce underpayments or denials. The billing team cannot manufacture specificity that the clinical documentation does not support.
Step 5. Coding Review (CPT, ICD-10-CM, HCPCS, and Modifiers)
Coders review encounter documentation and validate or assign CPT, ICD-10-CM, and HCPCS codes. This stage is not rubber-stamping what the provider entered. It is an independent clinical review where specificity, sequencing, and medical necessity linkage are all confirmed.
Modifiers carry significant weight here. A 59 modifier defending a bundled service, a 25 on an E&M billed same-day as a procedure, and a 50 for bilateral; each one changes how the payer processes the claim. A wrong modifier means a denial or an audit flag. Correct modifier means payment.
Stage 6. Claim Scrubbing (Charge Router)
The Charge Router is Epic’s internal claim scrubber. Before any claim reaches the clearinghouse, it runs through a rules engine that checks for missing data, coding conflicts, payer-specific formatting requirements, and unbundling issues. Claims that fail these edits drop into a work queue for correction.
This stage is only as strong as the rules built into it. Out-of-the-box Epic rules catch common errors, but payer-specific edge cases require custom configuration. Practices that invest time building robust Charge Router rules catch denials internally, which is always faster and cheaper than chasing them post-submission.
Step 7. Claim Submission (837P / 837I)
Professional claims go out as 837P transactions; institutional claims go out as 837I. Epic sends these to a clearinghouse, Waystar, Change Healthcare, and Availity are the most common, which perform a second layer of validation before forwarding to the payer.
Clearinghouse rejection reports need daily monitoring. A rejected claim never reached the payer, which means the filing clock is still running. Practices that ignore clearinghouse rejections for days burn the timely filing windows they cannot recover. Every rejection needs same-day action.
Stage 8. 835 ERA Posting and Denial Routing
The 835 Electronic Remittance Advice carries the payer’s payment and adjudication details back into Epic. Auto-posting rules apply payments to the correct charge lines based on payer ID, procedure code, and contract rates. Clean ERAs post automatically; exceptions drop into a work queue.
Denials embedded in the 835 route to denial management queues based on CARC and RARC codes. Each denial code tells you exactly what went wrong and what the payer needs to process the payment. Working these queues by denial category, payer, and dollar value is where most of the recoverable revenue sits.
Where Do Charges Originate In Epic?
Charges originate from documented clinical actions. EpicCare Ambulatory captures office-visit charges. OpTime captures surgical charges. The beaker captures lab charges. Radiant captures imaging charges. ASAP captures emergency-department charges. Each module feeds data into Resolute through the Charge Router.
How Does Charge Capture Work in Epic?
Charge capture in Epic is documentation-driven. Charges fire automatically off coded orders, procedures, and clinical notes. Manual charges go through charge-session screens. The biggest risk is charge lag, which raises days in A/R.
Three patterns cause charge lag in Epic billing operations:
- Open encounters that block charge release
- Coding queries that pause the charge until resolved
- Manual-charge backlogs in service lines with limited automation
How Does Claim Scrubbing and the Charge Router Work?
The Charge Router is the rule-driven engine that validates every charge before submission. Rule libraries check payer-specific edits, NCCI edits, LCD and NCD coverage, modifier logic, and bundling rules. Failing charges land in work queues for biller review.
Rule libraries are built and maintained by certified Resolute analysts. Payer-policy changes trigger constant updates. A stale rule library raises denial rates and lowers the clean-claim rate within 30 days. Regular rule-library reviews are a baseline practice, not an optional task.
The Charge Router checks each claim against the following rule categories:
- NCCI procedure-to-procedure edits and medically unlikely edits (MUE)
- Local Coverage Determinations (LCD) and National Coverage Determinations (NCD)
- Payer-specific modifier rules
- Bundling and unbundling rules
- Place-of-service validation
- Diagnosis-to-procedure code linkage
How Does Epic Submit Claims to Clearinghouses?
Resolute generates 837P files for professional claims and 837I files for institutional claims. Files are transmitted to a clearinghouse, then on to the payer. Common clearinghouses include Waystar, Change Healthcare, Trizetto, and Availity.
Clearinghouses return acknowledgments as 999 and 277CA files. Epic routes the acknowledgments into acknowledgment work queues. Billers review rejections at the clearinghouse level before the claims reach payer adjudication. Catching errors at the clearinghouse level cuts denial-rework time downstream.
The four most common Epic clearinghouse partners and their typical configurations:
| Clearinghouse | Primary user base | Typical Epic connection |
|---|---|---|
| Waystar | Health systems, multi-specialty groups | Bidirectional 837/835/277 |
| Change Healthcare | Hospitals, ambulatory surgery centers | Bidirectional 837/835/277 |
| Trizetto | Mid-size groups, MSOs | Bidirectional 837/835/277 |
| Availity | Payer-direct workflows | Mixed direct plus clearinghouse routing |
How Does Payment Posting (835/ERA) Work in Epic?
Payment posting in Epic runs from 835 ERA files. ERAs auto-post into Resolute through posting rules. Posting rules match payments to charges, apply contractual adjustments, and post payer-allowed amounts.
Exceptions route to posting and variance work queues. Common exceptions include unmatched remits, partial payments, and contractual variance. Posters reconcile each exception, then update payer rules to prevent repeat issues.
Three exception types absorb the most posting-team time:
- Unmatched remits where the 835 reference does not tie to a Resolute claim
- Partial payments where the payer paid less than the allowed amount
- Contractual variance where the payer paid less than the expected fee-schedule rate
How Does Denial Management Work in Epic Work Queues?
Denials route to denial work queues based on denial reason code, payer, and dollar threshold. Each work queue is staffed by trained billers. High-dollar denials escalate to AR specialists. Denial trends are tracked in Reporting Workbench, Clarity, or SlicerDicer.
Work queues use prioritization logic. A $5,000 commercial denial outranks a $50 Medicare adjustment. Top denial reasons in Epic billing operations concentrate on eligibility errors, prior-auth gaps, and coding-level edits. Each reason has a fixed path.
The top denial categories in Epic billing operations and their fix paths:
| Denial reason | Typical root cause | Fix path |
|---|---|---|
| CO-16 (missing information) | Demographic or insurance data gap at registration | Rework demographic data; rebuild before refile |
| CO-29 (timely filing) | Claim aged past payer deadline | File appeal with documentation; tighten work-queue SLAs |
| CO-50 (not medically necessary) | LCD or NCD policy mismatch | Add supporting diagnosis; appeal with documentation |
| CO-97 (bundled service) | NCCI edit hit at claim build | Apply correct modifier; resubmit |
| CO-197 (prior auth not obtained) | Pre-certification gap | Retrospective auth request; fix front-end auth workflow |
What are the Most Common Epic Medical Billing Challenges?
Eight recurring challenges surface across Epic billing operations. Charge lag tops the list. Denial work-queue backlog comes next. Payer-edit drift, certified-analyst staffing, prior-auth gaps, reporting complexity, contractual underpayments, and Foundation System maintenance round out the set.
The eight challenges most Epic billing operations confront:
- Charge Lag: Encounters that stay open past 48 hours create cash flow gaps that compound fast. Every unresolved coding query sitting in a provider’s inbox is a charge that has not dropped yet.
- Denial Queue Backlog: When AR teams are short-staffed, denial queues age out and timely filing windows close permanently. Revenue that was recoverable on day one becomes a write-off by day ninety.
- Payer-Edit Drift: Payers update their editing criteria regularly, and EPIC rule libraries do not self-maintain. When your Charge Router runs on stale rules, clean-looking claims hit the payer and come back denied. Any EMR system that relies on static rule libraries will drift the moment payers update their editing criteria.
- Resolute Analyst Gaps: Resolute-certified analysts are hard to find and harder to keep. Without them, system configuration falls behind, work queues pile up, and no one has the access or knowledge to fix either.
- Prior-Auth Gaps: A single missed authorization at scheduling can unravel an entire claim months later. By the time the denial surfaces in AR, the window to obtain retro-auth has usually closed.
- Reporting Complexity: Each tool serves a different reporting layer, and most billing teams only know one of them well. That gap means leadership makes decisions on incomplete data pulled from the wrong source.
- Underpayments and Contractual Variance: Payers do not always reimburse at contracted rates, and most underpayments go undetected without a contract management tool running parallel to ERA posting. The loss is quiet, but it adds up.
- Foundation vs. Custom-Built Debt: Every custom build your team adds needs to be maintained through every upgrade cycle. Practices that over-customize early spend years paying for it every time Epic releases a new version.
Why Does Charge Lag Happen In Epic and How Do Teams Fix It?
Charge lag happens when documentation closure, coding, or charge release stalls. Open encounters block charge release. Coding queries pause charges until resolved. Manual charge entry creates queue buildup. Each cause has its own fixed path.
Three operational levers reduce charge lag inside Epic:
- Tighten encounter-closure SLAs to under 48 hours
- Automate charge-fire rules from coded orders wherever possible
- Track charge-lag dashboards weekly in Reporting Workbench
Why are Epic Denial Work Queues Hard to Staff?
Resolute-certified billers are scarce and expensive. Most provider organizations face two patterns. Over-trained internal staff often leave for higher pay elsewhere. Under-trained staff causes denials to compound. A managed-services partner with a Resolute-certified bench is the third option.
What KPIs Should Epic Medical Billing Teams Track?
Seven core KPIs define Epic billing health. Clean Claim Rate measures first-pass acceptance. First Pass Resolution Rate measures payer-level resolution. Days in A/R tracks revenue aging. Denial Rate, Net Collection Rate, Charge Lag, and Cost to Collect round out the set.
The seven core Epic medical billing KPIs with industry benchmarks:
| KPI | Definition | Industry benchmark | Epic report location |
|---|---|---|---|
| Clean Claim Rate | Percent of claims accepted on first submission | Above 95% | Reporting Workbench |
| First Pass Resolution Rate | Percent of claims paid on first payer pass | Above 90% | Reporting Workbench / SlicerDicer |
| Days in A/R | Average days revenue stays outstanding | Below 35 | Clarity / Caboodle |
| Denial Rate | Percent of claims denied on first pass | Below 5% | SlicerDicer denial dashboard |
| Net Collection Rate | Collections as a percent of net charges | Above 96% | Clarity |
| Charge Lag | Days from encounter to charge release | Below 3 days | Reporting Workbench |
| Cost to Collect | Billing-operations cost as percent of net patient revenue | Below 3% | Finance ledger plus Clarity |
What Certifications Do Epic Billers and Analysts Need?
Epic billing operations require role-specific certifications. Resolute Professional Billing Certification covers PB. Resolute Hospital Billing Certification covers HB. Claims and Remittance training covers the claim and ERA build. Standard coder credentials (CPC, CPB) supplement the Epic-specific certifications.
Certification training runs through Epic’s Verona, Wisconsin campus. Remote-equivalent programs run for some tracks. Each certification has a renewal cycle and Project Update Notes that analysts must follow. Hiring a certified analyst typically takes 6 to 12 months in tight markets.
Epic certifications that touch the billing workflow:
- Resolute Professional Billing Certified Analyst
- Resolute Hospital Billing Certified Analyst
- Resolute Claims and Remittance certification
- Reporting Workbench builder training
- SlicerDicer power-user training
When Should Practices Outsource Epic Medical Billing?
Four conditions trigger the outsourcing decision. Denial rate above 8 percent. Days in A/R above 45. Inability to retain Resolute-certified billers. Foundation System upgrade that requires a rule-library rebuild. Outsourcing addresses each one. For a closer look at how outsourcing works in practice and what the service covers, see Transcure’s EMR billing services.
The four Epic billing outsourcing trigger conditions:
| Trigger condition | Symptom | How outsourcing addresses it |
|---|---|---|
| Denial rate above 8% | Cash-flow drag, AR aging | Brings a Resolute-certified bench to clear work queues |
| Days in A/R above 45 | Working-capital pressure | Tightens follow-up SLAs and posting cycles |
| Resolute biller retention gap | Knowledge loss with each staff exit | Stabilizes operations with a managed-services bench |
| Foundation System rebuild | Rule library out of sync with payer policy | Brings rebuild experience and reduces internal load |
Practices looking for a specialized Epic billing company can see Transcure’s Epic medical billing services for future partnerships.
Is Epic’s billing module the same as Resolute?
Yes, Resolute is the brand name of Epic’s revenue-cycle module. Resolute splits into Professional Billing (PB), Hospital Billing (HB), and the Single Billing Office (SBO).
Can Epic submit claims directly to payers without a clearinghouse?
Epic supports direct payer connections for some payers. Most provider organizations route 837 files through a clearinghouse for edit checks, payer mapping, and acknowledgment handling.
How long does an Epic Resolute certification take?
Resolute certification training runs 4 to 6 weeks, plus a project phase. Total time to a fully certified analyst, including project work, typically takes 3 to 6 months.
What is the difference between Cogito, Clarity, Caboodle, and SlicerDicer?
Cogito is Epic’s reporting umbrella program. Clarity is the relational data warehouse. Caboodle is the next-generation columnar warehouse. SlicerDicer is a self-service analytics tool.
Does Epic handle prior authorization?
Epic supports prior-authorization workflows through the Referrals and Authorizations modules. Some payer connections automate the auth request. Most provider organizations still run prior auth as a partially manual workflow.
Can patients pay both hospital and professional balances in one transaction in Epic?
Yes, the Single Billing Office (SBO) unifies professional and hospital balances on one MyChart statement. Patients pay both in one transaction.
