Appeal — TEST-CLAIM-00077

Date: [Date of Submission]

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

Re:     Formal Appeal of Claim Denial
        Claim Number:       TEST-CLAIM-00077
        Internal Claim ID: aff753e9-8c65-48d3-8895-65cb2a38b607
        Payer:             Synthetic BCBS-TX
        Date of Service:   January 14, 2026
        Denial Date:       March 24, 2026
        Denied Amount:     $7,809.93
        Denial Code:       CO-27
        Appeal Deadline:   June 22, 2026

Dear Appeals and Grievances Department:

On behalf of our facility, we are submitting this formal first-level appeal contesting the denial of Claim TEST-CLAIM-00077 issued by Synthetic BCBS-TX on March 24, 2026. The claim was denied under adjustment reason code CO-27 — "Expenses incurred after coverage terminated" — for services rendered on January 14, 2026, involving procedure codes CPT 93904, 64747, and 47947 in connection with diagnosis ICD-10 S82.02 (fracture of the tibia). The denied portion of the claim totals $7,809.93 of the $11,135.09 billed.

We respectfully assert that this denial is factually incorrect and requests that Synthetic BCBS-TX reverse the denial and reprocess the claim for full payment of the denied amount.

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I. BASIS FOR APPEAL

The CO-27 denial code presupposes that the member's coverage had terminated prior to or on the date services were rendered. Our records and the enclosed supporting documentation directly contradict this assertion. The evidence establishes that the member held active coverage with Synthetic BCBS-TX on January 14, 2026 — the date on which all disputed services were delivered. Because coverage was in force on the date of service, the payer's application of the post-termination exclusion is factually unsupported, and the denial should be overturned.

Specifically, our appeal is grounded in the following:

1. Active Coverage on the Date of Service: The enclosed member eligibility verification report, obtained as of January 14, 2026, confirms that the member's policy was active on the date services were provided. This documentation directly refutes the premise of the CO-27 denial.

2. Policy Documentation Confirms Coverage Was in Force: The enclosed insurance card and/or policy documentation corroborate the member's active enrollment status as of January 14, 2026, further establishing that no coverage termination had occurred prior to the delivery of services.

3. Payer's Stated Termination Date Is Inconsistent With the Evidence: A review of the Explanation of Benefits and/or coverage termination notice issued by Synthetic BCBS-TX — also enclosed — reveals that the effective termination date cited by the payer does not precede January 14, 2026. The payer's own correspondence supports the conclusion that the member remained covered when these services were rendered.

4. Hospital Records Confirm Service Delivery on January 14, 2026: The enclosed hospital records documenting the admission, services rendered, and procedure dates confirm that all billed services were provided on January 14, 2026, within the coverage period. There is no ambiguity regarding the date of service.

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II. APPLICABLE PAYER POLICY

The CO-27 denial is governed by Synthetic BCBS-TX's policies regarding member eligibility and coverage termination date determination. Under those policies, the post-termination exclusion applies only when services are rendered after the effective date of coverage termination. Where contemporaneous eligibility documentation establishes that a member's policy was active on the date of service, the denial of a claim on CO-27 grounds is inconsistent with the payer's own coverage determination standards. The enclosed eligibility verification report and supporting policy documentation satisfy the evidentiary standard necessary to rebut a CO-27 denial under this framework.

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III. ENCLOSED DOCUMENTATION

In support of this appeal, please find the following documents enclosed:

  1. Member eligibility verification report (as of service date January 14, 2026)
  2. Insurance card and/or policy documentation showing active coverage on January 14, 2026
  3. Explanation of Benefits (EOB) and/or coverage termination notice reflecting the payer's stated termination effective date
  4. Hospital records confirming service delivery date and admission/authorization timeline
  5. Correspondence from payer showing coverage status and termination date

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IV. REQUESTED REMEDY

Based on the foregoing, we respectfully request that Synthetic BCBS-TX:

  (1) Overturn the CO-27 denial of Claim TEST-CLAIM-00077 in its entirety;
  (2) Reprocess the claim in accordance with the member's active coverage terms as of January 14, 2026; and
  (3) Issue payment of the denied amount of $7,809.93 consistent with the applicable contractual and plan benefit provisions.

If additional documentation or clarification is required to resolve this matter, please contact our appeals department at the information provided below. We request written acknowledgment of receipt of this appeal and a determination within the timeframe required under applicable state and federal regulations.

Thank you for your prompt attention to this matter.

Respectfully submitted,

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

Enclosures: As listed in Section III above