Appeal — TEST-CLAIM-00071

Date: [Date of Submission]

Via: [Submission Method]

Synthetic Humana
Appeals and Grievances Department
[Payer Address]

Re: Formal Appeal of Claim Denial
Claim Number: TEST-CLAIM-00071
Payer: Synthetic Humana
Service Date: January 14, 2026
Procedure Codes: CPT 39392, CPT 24184
Diagnosis Codes: G43.47, E11.97
Billed Amount: $860.50
Denied Amount: $351.35
Allowed/Paid Amount: $509.15
Denial Date: March 14, 2026
Appeal Deadline: May 13, 2026

Dear Synthetic Humana Appeals and Grievances Department,

This letter constitutes a formal first-level appeal on behalf of [Hospital/Facility Name] regarding the denial of Claim TEST-CLAIM-00071, issued by Synthetic Humana on March 14, 2026. We respectfully request that Synthetic Humana reverse its denial and reprocess this claim for full payment of the denied amount of $351.35.

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I. DENIAL REASON

Synthetic Humana denied $351.35 of the total billed amount of $860.50 under adjustment reason code CO-45, citing that charges exceed the contracted or legislated fee arrangement. The payer allowed $509.15 against the billed total of $860.50 for services rendered on January 14, 2026, under procedure codes CPT 39392 and CPT 24184.

[Hospital/Facility Name] contests this denial on the grounds that the contracted rate was either misapplied or miscalculated by Synthetic Humana. Our review indicates that the billed charges for CPT 39392 and CPT 24184 are consistent with the terms of the executed provider service agreement in effect on the date of service, and that the allowable amounts applied by Synthetic Humana do not accurately reflect the negotiated fee schedule.

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II. BASIS FOR APPEAL

A. The Billed Charges Are Consistent with the Executed Provider Agreement

The enclosed executed provider service agreement and corresponding fee schedule, in effect as of January 14, 2026, establish the contracted allowable rates for CPT 39392 and CPT 24184. A careful review of these documents demonstrates that the billed charges either fall within or comply with the negotiated arrangement between [Hospital/Facility Name] and Synthetic Humana. The payer's application of a reduced allowable rate is not supported by the terms of the operative agreement.

B. The Payer's Contracted Rate Calculation Appears to Be in Error

The Explanation of Benefits (EOB) issued by Synthetic Humana reflects an allowable amount of $509.15—a reduction of $351.35 from the billed total of $860.50. Based on our review of the applicable contracted rate schedule, this reduction is inconsistent with the rates negotiated for CPT 39392 and/or CPT 24184 for the service date in question. The enclosed itemized charge breakdown, together with the hospital's chargemaster documentation for the relevant service date, substantiates that the amounts billed are appropriate and aligned with the provider agreement.

C. The Payer's Own Policy Supports Reconsideration

Pursuant to Synthetic Humana's contracted/legislated fee arrangement policy underlying the CO-45 payment adjustment, a CO-45 denial is subject to appeal where the provider can demonstrate, through the signed provider agreement and applicable fee schedule, that the billed charges comply with the negotiated arrangement or that the contracted rate was misapplied. [Hospital/Facility Name] submits that the enclosed documentation satisfies this standard and warrants full reprocessing and payment of the denied balance.

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III. SUPPORTING DOCUMENTATION

The following documents are enclosed in support of this appeal:

1. Executed provider service agreement between [Hospital/Facility Name] and Synthetic Humana
2. Fee schedule or contracted rate schedule in effect on January 14, 2026
3. Itemized charge breakdown by procedure code (CPT 39392, CPT 24184)
4. Hospital chargemaster or internal fee documentation for the date of service
5. Explanation of Benefits (EOB) issued by Synthetic Humana reflecting the contested allowable amounts
6. Any correspondence from Synthetic Humana clarifying the contracted fee arrangement terms, as applicable

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IV. REQUESTED REMEDY

[Hospital/Facility Name] respectfully requests that Synthetic Humana:

1. Overturn the CO-45 denial issued on March 14, 2026, with respect to Claim TEST-CLAIM-00071;
2. Reprocess the claim in accordance with the contracted rate schedule in effect on January 14, 2026, for CPT 39392 and CPT 24184; and
3. Issue payment of the full denied amount of $351.35, plus any applicable interest as required under state prompt-payment statutes or the terms of the provider agreement.

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V. CONCLUSION

[Hospital/Facility Name] is committed to resolving this matter cooperatively and in good faith. The denial of $351.35 under CO-45 is not supported by the executed fee arrangement governing this claim, and the enclosed documentation provides a clear basis for reversal. Should Synthetic Humana require any additional information or clarification in connection with this appeal, please direct all correspondence to:

[Hospital/Facility Name]
[Contact Name/Department]
[Address]
[Phone Number]
[Fax Number]
[Email Address]

Thank you for your prompt attention to this matter. We expect a written determination within the timeframe established under the provider agreement and applicable regulatory requirements.

Respectfully submitted,

[Authorized Signatory Name]
[Title]
[Hospital/Facility Name]
[Date]