Appeal — TEST-CLAIM-00036

Date: [Date of Submission]

To: Appeals and Grievances Department
Synthetic Medicaid-TX

Re: Formal Appeal of Claim Denial
External Claim ID: TEST-CLAIM-00036
Internal Claim Reference: 9e4ac96c-9c6a-45c4-8727-aeb6a860c946
Payer: Synthetic Medicaid-TX
Date of Service: May 1, 2026
Denial Date: May 27, 2026
Denied Amount: $3,417.51
Procedure Codes: CPT 11854, CPT 80010
Diagnosis Code: K21.05

Dear Appeals and Grievances Department,

This letter constitutes a formal appeal on behalf of the rendering provider and/or facility against the denial issued on May 27, 2026, for the above-referenced claim. We respectfully request that Synthetic Medicaid-TX overturn the denial and reprocess the claim for full payment of the denied amount of $3,417.51.

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I. DENIAL REASON

The claim was denied under reason code CO-242, indicating that services were not provided by network or primary care providers. Specifically, the denial pertains to services rendered on May 1, 2026, including CPT 11854 (skin lesion removal) and CPT 80010 (blood chemistry panel) in connection with diagnosis K21.05 (gastroesophageal reflux disease with esophageal ulcer).

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II. BASIS FOR APPEAL

We respectfully contest this denial on the following grounds:

1. The rendering provider held active in-network enrollment status with Synthetic Medicaid-TX on the date of service, May 1, 2026. The denial under CO-242 therefore does not accurately reflect the provider's network participation at the time services were rendered.

2. In the alternative, if any component of the services was provided by a specialist outside the primary care network, a valid referral order from the primary care provider and/or a prior authorization for out-of-network specialist care was issued prior to the date of service. Such authorization would satisfy the payer's network provider requirement or out-of-network services restriction and eliminate the basis for denial.

3. The services billed — skin lesion removal (CPT 11854) and a blood chemistry panel (CPT 80010) — were medically necessary and clinically appropriate in the context of the patient's diagnosis of GERD with esophageal ulcer (K21.05). The enclosed letter of medical necessity provides detailed clinical justification for the specialist procedures performed.

4. Synthetic Medicaid-TX's own provider directory and fee schedule in effect on May 1, 2026, as well as the enclosed network status verification documentation, confirm the provider's enrollment and credentialing status at the relevant time, directly refuting the factual basis upon which CO-242 was applied.

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III. SUPPORTING DOCUMENTATION

The following documents are enclosed in support of this appeal:

- Network status verification letter from payer confirming active in-network enrollment on the date of service
- Provider credentialing and enrollment documentation
- Referral order from the primary care provider
- Prior authorization approval for specialist care, if applicable
- Letter of medical necessity justifying specialist procedures
- Payer's provider directory or fee schedule in effect on May 1, 2026

Collectively, these documents establish that the rendering provider satisfied Synthetic Medicaid-TX's network participation requirements on the date of service, or that a properly authorized out-of-network referral was in place, and that the services rendered were medically necessary.

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IV. POLICY BASIS

The applicable payer policy at issue is the network provider requirement and out-of-network services restriction underlying CO-242. As set forth above and in the enclosed documentation, the conditions of that policy were met on May 1, 2026. When a provider's active credentialing and enrollment status is confirmed, or when a valid prior authorization or referral order exists for out-of-network specialist care, the network-status basis for a CO-242 denial is directly refuted, and payment should not be withheld.

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V. REQUESTED REMEDY

We respectfully request that Synthetic Medicaid-TX:

1. Overturn the denial issued under CO-242 for claim TEST-CLAIM-00036;
2. Reprocess the claim in full; and
3. Issue payment of the denied amount of $3,417.51 in accordance with the applicable contracted or Medicaid rate.

Please note that the appeal deadline for this claim is June 26, 2026. We ask that this appeal be reviewed and adjudicated in a timely manner consistent with Synthetic Medicaid-TX's appeals processing requirements.

Should additional information be required to complete the review of this appeal, please do not hesitate to contact our office. We welcome the opportunity to provide any further documentation or clarification necessary to resolve this matter.

Respectfully submitted,

[Authorized Representative Name]
[Title]
[Facility / Provider Name]
[Address]
[Phone Number]
[Fax Number]
[Email Address]