Appeal — TEST-CLAIM-00007

Date: [Date of Letter]

Synthetic Cigna
Appeals and Grievances Department
[Payer Address]

Re:     Formal Appeal of Claim Denial
        External Claim ID:    TEST-CLAIM-00007
        Internal Claim ID:    6477968b-7453-4a2c-84ac-794546c4ad89
        Payer:                Synthetic Cigna
        Date of Service:      January 2, 2026
        Denial Date:          February 25, 2026
        Denial Reason Code:   CO-27
        Billed Amount:        $1,528.82
        Denied Amount:        $1,177.47
        Procedure Codes:      CPT 69929, CPT 51441
        Diagnosis Code:       ICD-10 M17.58
        Appeal Deadline:      June 25, 2026

Dear Synthetic Cigna Appeals and Grievances Department,

This letter constitutes a formal first-level appeal on behalf of [Hospital/Facility Name] (hereinafter "the Facility") regarding the denial of the above-referenced claim. Synthetic Cigna issued a CO-27 denial on February 25, 2026, asserting that the expenses were incurred after the patient's coverage had terminated. The Facility respectfully disputes this determination and requests that the claim be overturned, reprocessed, and paid in full for the denied amount of $1,177.47.

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I. STATEMENT OF THE DENIAL

Synthetic Cigna denied Claim No. TEST-CLAIM-00007 under CARC CO-27 — "Expenses incurred after coverage terminated" — on the basis that the patient's Cigna coverage was no longer active as of the January 2, 2026 date of service. The Facility asserts that this determination is incorrect: the patient maintained active Cigna coverage on the date services were rendered, and the denial reflects an administrative error in the payer's termination date record.

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II. BASIS FOR APPEAL

A. The Patient's Coverage Was Active on the Date of Service

The Facility conducted an eligibility verification prior to rendering services on January 2, 2026, and the patient's Cigna coverage was confirmed as active at that time. The enclosed patient eligibility verification report, drawn from the Facility's records system, documents this real-time confirmation. The claim was submitted in good faith consistent with that verified eligibility status.

B. Administrative Termination-Date Errors Are Common at Calendar-Year Transitions

January 2, 2026 falls immediately at the start of a new calendar year — a period well recognized as prone to administrative processing errors in coverage termination and renewal records. Employer group enrollment changes, policy renewals, and system updates that take effect on January 1 frequently result in erroneous termination entries for members whose coverage in fact renewed without interruption. It is the Facility's position that such an administrative error occurred in this instance, resulting in an incorrect termination date being reflected in Synthetic Cigna's eligibility system.

C. Supporting Documentation Directly Contradicts the Payer's Termination Date Determination

The Facility submits the following enclosures in support of this appeal, each of which directly contradicts the CO-27 denial:

  1. Patient Eligibility Verification Report — A contemporaneous eligibility verification report from the Facility's records system confirming active Cigna coverage as of the January 2, 2026 service date.

  2. Proof of Active Insurance Coverage — Documentation (such as the patient's insurance card, a payer-issued explanation of benefits, or policy document) demonstrating that coverage was in force on or immediately before January 2, 2026.

  3. Hospital Billing Records — The Facility's billing records confirming that services identified under CPT codes 69929 and 51441 were rendered on January 2, 2026.

  4. Communication Regarding Coverage Status — Any available correspondence from the patient, the employer, or Synthetic Cigna itself confirming the patient's enrollment and coverage effective dates surrounding the service date.

Taken together, these documents establish that the patient was an eligible, covered member of Synthetic Cigna on the date of service, and that the CO-27 denial is not supported by the facts of record.

D. Payer Policy on Eligibility and Coverage Termination Date Determination

Under Synthetic Cigna's applicable policy governing eligibility and coverage termination date determination, a CO-27 denial is appropriate only where coverage can be affirmatively established as having lapsed prior to the date of service. Where the documented record — including the Facility's real-time eligibility verification and the patient's coverage documentation — shows active enrollment, the denial should be rescinded. The Facility asserts that Synthetic Cigna's internal termination date record is in error, and respectfully requests that Synthetic Cigna review its own enrollment and group records to confirm the correct termination date applicable to this member.

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III. REMEDY REQUESTED

The Facility respectfully requests that Synthetic Cigna:

  1. Overturn the CO-27 denial for Claim No. TEST-CLAIM-00007;
  2. Reprocess the claim in accordance with the patient's active coverage terms as of January 2, 2026; and
  3. Issue payment of the denied amount of $1,177.47 in accordance with the applicable plan benefit and contractual obligations.

Should Synthetic Cigna require any additional documentation to resolve this appeal, please contact the Facility's Patient Financial Services department at [Contact Name, Phone Number, and/or Email Address] at your earliest convenience. The Facility is committed to resolving this matter promptly and cooperatively.

The appeal deadline for this claim is June 25, 2026. The Facility requests that a written determination be issued within the timeframe required under applicable state and federal regulations and Synthetic Cigna's internal appeals procedures.

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Respectfully submitted,

[Authorized Signature]
[Printed Name and Title]
[Hospital/Facility Name]
[Address]
[Phone Number]
[Date]

Enclosures:
  - Patient Eligibility Verification Report
  - Proof of Active Insurance Coverage (insurance card, EOB, and/or policy document)
  - Hospital Billing Records (Date of Service: January 2, 2026)
  - Coverage Status Communication (patient/employer/payer correspondence, as available)