Appeal — TEST-CLAIM-00031

Date: [DATE OF SUBMISSION]

To: Appeals and Grievances Department
Synthetic Medicaid-TX

Re: Formal Appeal of Claim Denial
External Claim ID: TEST-CLAIM-00031
Internal Claim ID: 51d568c3-60eb-4111-acb5-93c48ba13173
Service Date: 2026-05-12
Denial Date: 2026-06-14
Denied Amount: $2,000.92
Procedure Codes: CPT 90728, CPT 80539
Diagnosis Codes: ICD-10 R07.55, ICD-10 F32.34

Dear Appeals and Grievances Review Committee,

Our facility formally contests the denial issued on 2026-06-14 for claim TEST-CLAIM-00031, covering services rendered on 2026-05-12 and totaling $2,050.48 in billed charges, of which $2,000.92 was denied. The denial was issued under reason code CO-16, indicating that the claim or service lacked information or contained a submission or billing error. We respectfully submit that this denial should be overturned and the claim reprocessed for payment, as the documentation enclosed with this appeal directly addresses and resolves the identified deficiency.

I. BASIS FOR DENIAL AND GROUNDS FOR APPEAL

CO-16 denials are administrative in nature and are not, in and of themselves, a determination that the services rendered were medically unnecessary or non-covered. Rather, they reflect a deficiency in the completeness or accuracy of the claim as submitted. Synthetic Medicaid-TX's own claim submission and billing accuracy requirements (the CO-16 missing or erroneous information rule) contemplate that such denials may be resolved by supplying the missing information or correcting the identified error. Our appeal does exactly that.

Our billing team has conducted a thorough review of the original submission and has identified and corrected any incomplete or erroneous information associated with the procedure codes (CPT 90728 and CPT 80539) and diagnosis codes (ICD-10 R07.55 and ICD-10 F32.34) reported for the 2026-05-12 date of service. The corrected claim submission, together with complete supporting clinical documentation, is enclosed herewith.

II. SUPPORTING DOCUMENTATION

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

1. Corrected Claim Submission — A corrected claim with amended CPT and ICD coding that addresses the specific submission or billing error identified under CO-16.

2. Clinical Documentation Supporting Medical Necessity — Clinical notes and supporting documentation establishing the medical necessity of the services billed under CPT 90728 and CPT 80539 for the 2026-05-12 date of service.

3. Itemized Superbill / Charge Ticket — The itemized charge ticket from the 2026-05-12 date of service, corroborating the procedures performed and the associated diagnoses.

4. Diagnostic and Clinical Notes Justifying Reported Diagnoses — Clinical findings and diagnostic results supporting the assignment of ICD-10 diagnosis codes R07.55 and F32.34.

5. Claim Submission Logs / EDI Transmission Records — Electronic data interchange (EDI) transmission records documenting the original claim submission, providing transparency into what was originally submitted and facilitating comparison with the corrected submission.

Taken together, these documents provide a complete and accurate record of the services rendered, the clinical basis for the codes reported, and the corrective action taken in response to the CO-16 denial.

III. REQUESTED REMEDY

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

1. Accept and review this appeal and all enclosed supporting documentation;
2. Overturn the CO-16 denial issued on 2026-06-14 for claim TEST-CLAIM-00031; and
3. Reprocess the corrected claim and issue payment of the denied amount of $2,000.92 in accordance with the applicable fee schedule and contractual terms.

This appeal is being submitted in advance of the appeal deadline of 2026-07-14. Should your office require any additional information or documentation to complete its review, please contact our Provider Relations and Appeals team at the address or contact information listed below.

We appreciate your prompt attention to this matter and look forward to a favorable resolution.

Respectfully submitted,

[Authorized Signatory Name and Title]
[Facility Name]
[Facility Address]
[Phone Number]
[Fax Number]
[Email Address]

Enclosures:
- Corrected claim submission with amended CPT/ICD coding
- Clinical documentation supporting medical necessity for CPT 90728 and CPT 80539
- Itemized superbill/charge ticket from 2026-05-12
- Diagnostic test results and clinical notes supporting ICD-10 codes R07.55 and F32.34
- Claim submission logs/EDI transmission records