Appeal — TEST-CLAIM-00079

Date: [Insert Submission Date]

To: Appeals and Grievances Department
Synthetic Humana
[Payer Address]

Re: Formal Appeal of Claim Denial
External Claim ID: TEST-CLAIM-00079
Internal Claim Reference: c652c10c-ba19-497e-8394-9ba765a5f0b4
Payer: Synthetic Humana
Service Date: April 23, 2026
Denial Date: May 21, 2026
Denied Amount: $2,665.79
Appeal Deadline: July 20, 2026

Dear Appeals and Grievances Department,

On behalf of our facility, we are submitting this formal appeal in response to the denial issued on May 21, 2026, for services rendered on April 23, 2026, under Claim ID TEST-CLAIM-00079. Synthetic Humana denied this claim under remark code CO-27, asserting that expenses were incurred after the member's coverage had terminated. We respectfully contest this determination and request that the claim be reprocessed and payment of the denied amount of $2,665.79 be issued.

I. STATEMENT OF DENIAL AND BASIS FOR APPEAL

The denial asserts that the member's coverage had terminated prior to the date of service, April 23, 2026, thereby rendering the billed services ineligible for reimbursement. The procedures at issue — billed under CPT codes 94599 and 29358, with a corresponding diagnosis of ICD-10 code E11.18 — were medically necessary and delivered in good faith on the stated service date.

Our facility has reason to believe that this denial is based on an inaccurate or erroneous termination date applied by Synthetic Humana. The documentary evidence we have gathered directly contradicts the payer's assertion that coverage had lapsed as of April 23, 2026. Specifically, member eligibility records, premium payment history, and policy documentation support the conclusion that the member maintained active coverage on the date services were rendered.

II. SUPPORTING EVIDENCE

In support of this appeal, the following documents are enclosed:

1. Member Eligibility Verification as of the Service Date (April 23, 2026): This record demonstrates the member's active enrollment status on the date in question and directly refutes the payer's stated basis for denial under CO-27.

2. Insurance Policy Document Showing Coverage Termination Date: The enclosed policy documentation establishes the actual effective termination date of the member's coverage. This document confirms that the termination date relied upon by Synthetic Humana in issuing the denial is factually incorrect.

3. Explanation of Benefits (EOB) / Denial Notice from Payer: The denial notice is enclosed for reference to confirm the denial reason and claim details as issued by Synthetic Humana.

4. Hospital Records Confirming Service Delivery Date: The enclosed medical and billing records confirm that the services billed under CPT codes 94599 and 29358 were rendered on April 23, 2026, as reported on the claim.

5. Proof of Active Coverage on Service Date (Premium Payment Records / Policy Declarations Page): The enclosed proof of premium payment and/or policy declarations page further corroborates that the member's coverage was in full force and effect on April 23, 2026.

III. APPLICABLE POLICY AND REGULATORY BASIS

Under Synthetic Humana's policies governing coverage termination and eligibility verification, a claim may only be denied under CO-27 when it is affirmatively established that the member's coverage had in fact terminated prior to the date of service. Where eligibility records, premium payment history, or policy declarations demonstrate active coverage on the service date, the stated basis for denial is factually unsupported and the denial must be overturned.

As the enclosed documentation demonstrates, the member held active coverage on April 23, 2026. The payer's reliance on an incorrect termination date does not constitute a valid or sufficient basis for denial under applicable eligibility and coverage termination guidelines. Our facility acted in reasonable reliance on the member's coverage status at the time services were provided, and the member is entitled to the benefits for which premiums were paid.

IV. REQUESTED REMEDY

We respectfully request that Synthetic Humana:

1. Overturn the CO-27 denial issued on May 21, 2026, for Claim ID TEST-CLAIM-00079;
2. Reprocess the claim in full based on the corrected eligibility determination reflecting the member's active coverage status on April 23, 2026; and
3. Issue payment of the denied amount of $2,665.79 in accordance with the applicable contract terms and benefits.

Should additional information or documentation be required to resolve this appeal, please contact our billing and appeals department at the information provided below. We request written confirmation of receipt of this appeal and a determination within the timeframe prescribed by applicable state and federal regulations.

Thank you for your prompt attention to this matter. We trust that upon review of the enclosed evidence, Synthetic Humana will agree that the denial was issued in error and that reimbursement is warranted.

Respectfully submitted,

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

Enclosures:
- Member Eligibility Verification as of April 23, 2026
- Insurance Policy Document Showing Coverage Termination Date
- Explanation of Benefits (EOB) / Denial Notice
- Hospital Records Confirming Service Delivery Date
- Proof of Active Coverage on Service Date (Premium Payment Records / Policy Declarations Page)