Appeal — TEST-CLAIM-00051

Date: [Date of Submission]

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

Re: Formal Appeal of Claim Denial
External Claim ID: TEST-CLAIM-00051
Internal Claim Reference: c76703ec-8931-4ed9-8ed2-fa5fe2902cff
Payer: Synthetic Medicaid-TX
Date of Service: 2026-03-30
Procedure Code(s): CPT 53065
Diagnosis Code(s): N39.80, R07.69
Denial Date: 2026-06-04
Denied Amount: $658.02
Appeal Deadline: 2026-07-04

Dear Appeals and Grievances Department:

On behalf of the treating facility, we are submitting this formal appeal contesting the denial of claim TEST-CLAIM-00051, issued on 2026-06-04 by Synthetic Medicaid-TX. The claim was denied under CARC CO-16 (Claim/service lacks information or has submission/billing error(s)), resulting in a denied amount of $658.02 of the total billed amount of $1,137.98. We respectfully request that this denial be overturned and that the claim be reprocessed for full payment of the denied amount.

I. BASIS FOR DENIAL AND GROUNDS FOR APPEAL

The CO-16 denial indicates a correctable submission or billing deficiency — specifically, missing or incomplete information — rather than a determination of non-coverage or lack of medical necessity. As such, this denial is administrative in nature and is fully addressable through the provision of complete documentation and corrected billing information. The denial does not reflect a finding that the service rendered (CPT 53065, performed on 2026-03-30) was medically inappropriate or non-covered under the applicable Medicaid benefit.

Upon review of the denied claim, we have identified the following correctable deficiencies that we believe gave rise to the CO-16 denial:

1. Incomplete operative or procedural documentation submitted with the original claim for CPT 53065.
2. Insufficient linkage between the submitted diagnosis codes and the billed urological procedure, including the presence of ICD-10 code R07.69 (chest pain, unspecified), which is unrelated to a urological procedure and may have triggered a billing edit or claim-level rejection.
3. Potential gaps in the itemized billing detail supporting the individual service components of the claim.

These are correctable submission deficiencies, not substantive coverage issues, and Synthetic Medicaid-TX's claim submission and billing completeness requirements (as applicable to CO-16 coding/billing errors) provide a clear pathway for resolution upon resubmission with complete and corrected documentation.

II. SUPPORTING DOCUMENTATION

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

1. Corrected/Amended Claim Submission — A corrected claim with complete billing information, including accurate diagnosis-to-procedure code linkage, is enclosed. The submission has been reviewed to ensure compliance with Synthetic Medicaid-TX billing requirements.

2. Operative Report / Procedure Note for CPT 53065 — The enclosed operative report provides a full account of the procedure performed on 2026-03-30, confirming the nature, clinical indication, and technical execution of the service billed under CPT 53065.

3. Letter of Medical Necessity — The enclosed letter of medical necessity documents the clinical basis for the procedure, establishing the treating provider's rationale and supporting the primary diagnosis of N39.80 (other specified urinary incontinence) as the appropriate and relevant diagnosis code for this service.

4. Itemized Superbill / Detailed Charge Sheet — The enclosed itemized charge sheet details all service components billed on the claim date, providing transparency as to the composition of the billed amount.

5. ICD-10 Code Justification / Clinical Notes — Enclosed clinical notes clarify the diagnosis code linkage and support the relevance of N39.80 to the billed urological procedure. We acknowledge that ICD-10 code R07.69 (chest pain, unspecified) was submitted alongside the urological procedure code and may have contributed to a billing edit or claim rejection. The corrected submission addresses this issue by ensuring that diagnosis-to-procedure code linkage accurately reflects the clinical encounter.

III. REQUESTED REMEDY

For the foregoing reasons, we respectfully request that Synthetic Medicaid-TX:

1. Accept this appeal and the enclosed corrected documentation;
2. Reprocess claim TEST-CLAIM-00051 in full in accordance with the applicable Medicaid fee schedule and billing guidelines for CPT 53065; and
3. Issue payment of the denied amount of $658.02 to the facility of record.

The service was rendered, medically indicated, and the denial is the result of a correctable billing deficiency, not a substantive coverage determination. We are confident that the enclosed documentation satisfies the payer's billing completeness requirements and resolves all identified deficiencies.

We respectfully request that this appeal be reviewed and adjudicated prior to the appeal deadline of 2026-07-04. Should additional information be required, please contact our billing and appeals department at the information listed below.

Thank you for your prompt attention to this matter.

Sincerely,

[Authorized Signature]
[Name, Title]
[Facility Name]
[Address]
[Phone Number]
[Fax Number]
[Date]

Enclosures:
- Corrected/Amended Claim Submission
- Operative Report / Procedure Note (CPT 53065)
- Letter of Medical Necessity
- Itemized Superbill / Detailed Charge Sheet
- ICD-10 Code Justification / Supporting Clinical Notes