Professional Work Samples 

Medicare Eligibility Verification (9-Step Checklist)

Software Used: Office Ally (Service Center) / MAC Portal Goal: To prevent administrative denials by verifying coverage before the appointment.

Step 1: Input Required Patient Details

• Action: I enter the patient’s Last Name, First Name, Date of Birth, and the Medicare ID# (MBI) into the eligibility inquiry screen.

• Why I do this: These four identifiers must match Medicare’s database exactly. If even one digit of the MBI or one letter of the name is wrong, the system will return a "Patient Not Found" error.

Step 2: Check Part B Status

• Action: I verify that Medicare Part B is listed as "Active" specifically for the scheduled Date of Service.

• Why I do this: Part A covers hospitals; Part B covers doctor visits. If Part B isn't active on the appointment date, the claim will be rejected immediately as non-covered.

Step 3: Check Remaining Deductible

• Action: I look for the "Part B Deductible Remaining" amount (usually $240.00 for the year).

• Why I do this: If the patient hasn't met their deductible, Medicare won't pay anything. I need to know this so we can collect the payment directly from the patient at the time of the visit.

Step 4: Check for HMO (Medicare Advantage)

• Action: I scan the response for any "Medicare Advantage," "HMO," or "PPO" plan codes.

• Why I do this: If a patient has an HMO (Part C), Medicare Part B is not the payer. We must bill the commercial plan (like Humana or UHC) instead. Billing Medicare Part B will result in an automatic denial.

Step 5: Check for MSP (Medicare Secondary Payer)

• Action: I check if there are any "MSP Codes" (like Working Aged or Auto Accident Liability) listed.

• Why I do this: These codes mean another insurance is responsible for paying first. If we bill Medicare as primary when they are secondary, they will deny the claim and tell us to bill the other carrier.

Step 6: Check for Hospice Episodes

• Action: I look for active "Hospice" dates in the episode section.

• Why I do this: If a patient is in Hospice, standard office visits are often denied unless they are unrelated to the terminal condition (requiring the GV/GW modifier).

Step 7: Check for Hospital / SNF Episodes

• Action: I check if the patient is currently admitted to a Hospital or Skilled Nursing Facility (SNF) under Part A.

• Why I do this: If a patient is technically an "inpatient" at a facility, we often cannot bill for separate outpatient office visits due to "consolidated billing" rules.

Step 8: Check Annual Wellness Visit (AWV) Eligibility

• Action: I check the date of the patient's last billed G0438 or G0439.

• Why I do this: Medicare only covers one Wellness Visit every 12 months. If I verify that they had one 6 months ago, I must alert the provider not to perform one today, or it will be denied for frequency limits.

Step 9: Document Everything

• Action: I save a screenshot of the eligibility response and log the details (Deductible, HMO status) into the patient’s chart or our verification tracker.

• Why I do this: This creates an audit trail. If Medicare later denies the claim saying the patient wasn't eligible, I have proof that we verified it on the date of service.

Posting this ERA in Office Ally

Software Used: Office Ally Service Center (Practice Mate) Module: Accounting > Payment Entry

Step 1: Batch Creation

• I navigated to Accounting > Payment Entry and created a new "Insurance Payment" batch.

• I entered the Payer Name (Medicare Part B), Check Number (EFT Trace #), and the Total Check Amount from the ERA header to ensure the batch would balance at the end.

Step 2: Posting & Status Management I located each claim by searching for the Patient Name. Once the claim was found, I applied the following logic based on the ERA response:

• Scenario A: Deductible (No Payment)

  • Paid Amount: I entered $0.00.

  • Adjustment: I entered the write-off amount (Contractual Adj).

  • Reference: I typed "DEDUCTIBLE" in the reference field to flag the reason for the balance.

  • Status:

    • If the ERA indicated the claim was forwarded to an IPA or Secondary: I changed the status to "Crossover."

    • If no forwarding occurred: I changed the status to "Patient Responsibility."

• Scenario B: Paid Amount (Coinsurance Remaining)

  • Paid Amount: I entered the specific amount paid by Medicare (e.g., $84.00).

  • Adjustment: I entered the CO-45 contractual write-off.

  • Reference: I typed "COINSURANCE" in the reference field.

  • Status:

    • If forwarded to Secondary/IPA: I changed the status to "Crossover."

    • If not forwarded: I changed the status to "Patient Responsibility."

• Scenario C: Full Denial (No Payment)

  • If the claim was denied (e.g., Duplicate or Medical Necessity), I entered $0.00 payment and $0.00 adjustment (unless a write-off was required).

  • I did not change the status to Patient Responsibility. Instead, I flagged the claim for Denial Management investigation.

Step 3: Final Balancing

• I verified that the "Unapplied Amount" reached $0.00, confirming that my total posted payments matched the ERA check total exactly, and then closed the batch.

Professional Appeal Letter 

Context: This sample demonstrates my ability to resolve complex administrative denials involving Managed Care Organizations (MCOs) and Independent Practice Associations (IPAs). 

• Scenario: A claim was originally submitted to the commercial payer (e.g., Health Net). They forwarded the claim to the capitated IPA (e.g., Hill Physicians), who then denied it for "Missing Prior Authorization." 

• Action: I identified that the authorization was obtained but failed to transfer with the claim data. I drafted an appeal to the IPA attaching the valid authorization. 

Date: February 2, 2025 

To: Valley Care IPA – Claims Appeals Department 

Re: Appeal for Denied Claim #882910-X 

Patient: John Smith (Member ID: HNET-998877) 

Date of Service: January 10, 2025 

To the Claims Adjudication Team: 

I am writing to appeal the denial of the above-referenced claim for CPT 99214 (Office Visit) and 20610 (Arthrocentesis), which was denied on January 25, 2025, with the reason code CO-197 (Precertification/authorization/notification absent). 

Claim History & Explanation: This claim was originally submitted to Health Net (Main Payer) on January 12, 2025. Health Net correctly identified that the patient is capitated to Valley Care IPA and automatically forwarded the claim to your office for processing. 

However, it appears the Prior Authorization (Auth #AUTH-2025-55), which was obtained from the patient’s Primary Care Physician prior to the visit, was not included in the data transfer between Health Net and the IPA. 

Correction & Evidence: The services rendered were fully authorized under your utilization guidelines. 

• Attached: A copy of the approved Referral/Authorization #AUTH-2025-55, dated January 5, 2025, specifically approving CPT 99214 and 20610 for this Date of Service. 

• Attached: The original denial letter from Valley Care IPA. 

Since a valid authorization was in place at the time of service, we request that you reprocess this claim and issue payment in accordance with the fee schedule. 

Sincerely, 

Zian Perater Medical Claims Specialist