Appeal — TEST-CLAIM-00063

Date: [Appeal Preparation Date]

Synthetic BCBS-TX
Appeals and Grievances Department
[Payer Address]

RE: Formal Appeal of Claim Denial — Timely Filing
Claim Number: TEST-CLAIM-00063
Payer: Synthetic BCBS-TX
Service Date: February 18, 2026
Denial Date: March 28, 2026
Denied Amount: $2,319.62
Procedure Codes: 88269, 12799, 16629
Appeal Deadline: June 26, 2026

Dear Appeals and Grievances Department,

This letter constitutes a formal first-level appeal on behalf of our facility regarding the denial of Claim No. TEST-CLAIM-00063, submitted to Synthetic BCBS-TX for services rendered on February 18, 2026. The claim was denied on March 28, 2026, under CARC CO-29, with the stated reason that "the time limit for filing this claim has expired." We respectfully contest this denial in its entirety and request immediate reprocessing and payment of the denied amount of $2,319.62.

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I. BASIS FOR DENIAL AND GROUNDS FOR APPEAL

The CO-29 denial asserts that the subject claim was submitted outside the payer's applicable timely filing window. We dispute this determination. The services at issue were rendered on February 18, 2026, and the denial was issued on March 28, 2026 — a period of only 39 days following the date of service. This timeline strongly suggests that the claim was submitted well within the standard timely filing limit applicable under the Synthetic BCBS-TX member contract and provider agreement, which our records indicate is 90 days from the date of service.

Our billing system records confirm that the claim was transmitted to Synthetic BCBS-TX prior to the expiration of the applicable filing deadline. The denial, therefore, appears to have been issued in error, and the CO-29 code was applied incorrectly to this claim.

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II. SUPPORTING DOCUMENTATION

In support of this appeal, please refer to the following enclosed documentation:

1. Claim Submission Receipt / Proof of Timely Filing — This document establishes the date on which the claim was electronically transmitted to Synthetic BCBS-TX and confirms submission occurred within the applicable filing window.

2. Hospital Billing System Records — Internal billing system logs showing the claim transmission date and confirming that the claim was submitted prior to any applicable filing deadline.

3. Payer Correspondence Confirming Receipt Date — Any acknowledgment, clearinghouse confirmation, or payer-generated receipt that documents Synthetic BCBS-TX's receipt of the claim.

4. Medical Record Documentation — Clinical records confirming that the services billed under CPT codes 88269 (cytology), 12799 (wound repair), and 16629 (burn treatment) were rendered on February 18, 2026, establishing the controlling date from which the timely filing period is calculated.

Together, these documents demonstrate that the claim was filed within the required timeframe and that the CO-29 denial is inconsistent with the actual submission history.

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III. POLICY AND CONTRACTUAL BASIS

Under the timely filing provisions applicable to Synthetic BCBS-TX claims, providers are afforded a defined window — understood to be 90 days from the date of service — within which to submit claims for reimbursement. A CO-29 denial is only appropriate when a claim is demonstrably filed after that window has closed. Given that the denial was issued a mere 39 days after the February 18, 2026 date of service, there is no factual basis to conclude that the claim was filed late. The application of CO-29 to this claim is therefore improper under the payer's own timely filing policy.

Furthermore, where a provider can produce documented proof of timely submission — such as a clearinghouse receipt, billing system transmission log, or payer acknowledgment — most payer contracts and applicable state regulations require that the CO-29 denial be overturned. The enclosed documentation provides precisely this proof.

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IV. REQUESTED REMEDY

Based on the foregoing, we respectfully request that Synthetic BCBS-TX:

1. Overturn the CO-29 timely filing denial issued on March 28, 2026, with respect to Claim No. TEST-CLAIM-00063;
2. Reprocess the claim in full in accordance with the member's applicable benefit plan and the provider's contracted rate; and
3. Issue payment of the denied amount of $2,319.62 promptly upon reprocessing.

Should additional information be required to complete the review of this appeal, please contact our billing department at the address or telephone number listed below. We respectfully request that this appeal be adjudicated prior to the appeal deadline of June 26, 2026.

Thank you for your prompt attention to this matter. We remain committed to resolving this dispute through the appropriate administrative process and appreciate your timely review.

Respectfully submitted,

[Authorized Facility Representative Name]
[Title]
[Facility Name]
[Facility Address]
[Phone Number]
[Fax Number]
[Date]

Enclosures:
- Claim submission receipt or proof of timely filing
- Hospital billing system records showing claim transmission date
- Payer correspondence confirming receipt date (if available)
- Medical record documentation confirming service date of February 18, 2026