Appeal — TEST-CLAIM-00018

Date: [Date of Letter]

Synthetic Humana
Appeals and Grievances Department
[Payer Address]

Re: Formal Appeal of Claim Denial
Claim Number: TEST-CLAIM-00018
Service Date: February 21, 2026
Denial Date: April 27, 2026
Denial Reason: CO-27 – Expenses Incurred After Coverage Terminated
Denied Amount: $1,181.76

Dear Appeals and Grievances Review Team,

On behalf of [Hospital/Facility Name], we are submitting this formal appeal contesting the denial issued on April 27, 2026, for Claim Number TEST-CLAIM-00018, submitted to Synthetic Humana. The claim was denied under reason code CO-27, asserting that expenses were incurred after the member's coverage had terminated. We respectfully submit that this denial is factually incorrect and request that Synthetic Humana overturn the denial and reprocess the claim for full payment of the denied amount of $1,181.76.

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I. BACKGROUND AND BASIS FOR DENIAL

The claim at issue covers services rendered on February 21, 2026, for procedures billed under CPT codes 52237, 70946, and 67905, in connection with diagnoses coded under ICD-10 J45.65 and R07.94. The total billed amount for this claim is $1,673.91, of which $1,181.76 was denied. Synthetic Humana applied denial code CO-27, indicating that the member's coverage had terminated prior to the date on which services were rendered.

We respectfully and firmly dispute this characterization.

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II. GROUNDS FOR APPEAL

It is the hospital's position that the member carried active, valid coverage with Synthetic Humana on the date of service, February 21, 2026. The application of CO-27 to this claim is therefore factually unsupported. The following arguments form the basis of this appeal:

1. Active Coverage on the Date of Service

The member's insurance coverage was in full force and effect on February 21, 2026. The enclosed coverage verification documentation and/or explanation of benefits (EOB) demonstrates that the member was actively enrolled in their Synthetic Humana plan on the date services were rendered. The termination date referenced or implied by the payer in issuing this denial does not precede the service date of record.

2. Hospital Records Confirm Service Date

The enclosed hospital service records confirm, with specificity, that all procedures identified under CPT codes 52237, 70946, and 67905 were performed on February 21, 2026. There is no discrepancy between the service date documented in the medical record and the service date reported on the claim. The date of service was accurately reported at the time of claim submission.

3. Payer Policy on Eligibility Determination

Under Synthetic Humana's applicable policy governing eligibility and coverage termination date determination, coverage is to be assessed based on the member's enrollment status as of the actual date of service. Where contemporaneous coverage verification records and hospital documentation confirm active enrollment on the service date, a CO-27 denial is not warranted. The denial as issued is directly inconsistent with the eligibility facts presented herein.

4. Timely and Accurate Claim Submission

This claim was submitted in accordance with applicable filing requirements. To the extent that any question exists regarding the timeliness or accuracy of claim submission, the enclosed proof of timely claim submission and correspondence with Synthetic Humana confirming the member's coverage status as of the service date further support the validity of this claim.

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III. SUPPORTING DOCUMENTATION ENCLOSED

In support of this appeal, the following documents are enclosed for the reviewer's consideration:

- Member's insurance coverage verification or Explanation of Benefits (EOB) confirming active enrollment on February 21, 2026
- Policy document or coverage summary reflecting coverage effective and termination dates
- Hospital service records documenting that all billed procedures were rendered on February 21, 2026
- Correspondence with Synthetic Humana confirming the member's coverage status as of the service date
- Proof of timely claim submission, as applicable
- The enclosed letter of medical necessity, as applicable to the services rendered

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IV. REQUESTED REMEDY

Based on the foregoing, we respectfully request that Synthetic Humana:

1. Overturn the denial issued under CO-27 for Claim Number TEST-CLAIM-00018;
2. Reprocess the claim in full, recognizing the member's active coverage status as of February 21, 2026; and
3. Issue payment of the denied amount of $1,181.76 in accordance with the applicable contractual reimbursement terms.

Please note that the appeal deadline for this matter is June 26, 2026. We respectfully request that this appeal be reviewed and a determination issued in a timely manner in advance of that date.

Should the reviewing team require any additional information or clarification, please contact [Hospital Contact Name and Title] at [Phone Number] or [Email Address].

Thank you for your prompt attention to this matter. We look forward to an expeditious and favorable resolution.

Respectfully submitted,

[Authorized Signatory Name]
[Title]
[Hospital/Facility Name]
[Address]
[Phone]
[Email]
[Date]