Appeal — TEST-CLAIM-00033

[Hospital Letterhead]

Date: [Date of Preparation]

Appeals and Grievances Department
Synthetic Cigna
[Payer Address]

RE:     Formal Appeal of Claim Denial – CO-29 Timely Filing
        Claim Number:       TEST-CLAIM-00033
        Payer:              Synthetic Cigna
        Date of Service:    November 28, 2025
        Denial Date:        February 26, 2026
        Procedure Code:     CPT 21221
        Diagnosis Code:     ICD-10 S82.62
        Denied Amount:      $1,406.18
        Appeal Deadline:    June 26, 2026

Dear Cigna Appeals and Grievances Department,

This letter constitutes a formal, first-level appeal on behalf of [Hospital Name] regarding the denial of claim TEST-CLAIM-00033. Synthetic Cigna issued a denial on February 26, 2026, citing adjustment reason code CO-29: "The time limit for filing this claim has expired." The hospital respectfully contests this determination and requests that the claim be reprocessed and paid in the denied amount of $1,406.18.

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I. BASIS FOR APPEAL

The CO-29 denial presupposes that the claim for services rendered on November 28, 2025 was not submitted within Synthetic Cigna's applicable timely filing window. The hospital's internal billing records directly contradict this finding. Submission documentation — including system-generated timestamps and payer receipt acknowledgment — establishes that the claim was presented to Synthetic Cigna within the required filing period. Accordingly, the denial is factually unsupported and should be overturned.

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II. SUPPORTING EVIDENCE

In support of this appeal, the hospital submits the following documentation, enclosed herewith:

1. Claim Submission Records with Timestamp — Hospital billing system records reflecting the date and time the claim was originally transmitted, demonstrating submission within the timely filing window.

2. Hospital Billing System Logs — Internal system logs confirming the initial claim submission date relative to the November 28, 2025 date of service.

3. Payer Correspondence Documenting Claim Receipt and Processing Dates — Any acknowledgment, electronic remittance, or correspondence from Synthetic Cigna confirming receipt of the claim, which directly establishes the payer's awareness of the submission within the required period.

4. Evidence of Any Claim Reopening Requests or Appeals Filed Within the Timely Period — Documentation of any interim communications that further demonstrate the hospital's diligence in pursuing resolution of this claim.

5. Documentation of Extenuating Circumstances (if applicable) — Should Synthetic Cigna's review identify any gap in the submission timeline, the hospital is also prepared to present documentation of any system-related or external factors that would qualify as good-cause exceptions under applicable filing policies.

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III. POLICY AND REGULATORY BASIS

Synthetic Cigna's own timely filing policy provides that a CO-29 denial may be overturned when the provider presents credible evidence of original, timely submission. The hospital's submission records and payer receipt documentation constitute precisely such evidence. Where payer records confirm receipt within the filing window, a CO-29 denial directly contradicts the payer's own claim processing data and cannot be sustained.

Furthermore, it bears noting that the denial was issued on February 26, 2026 — approximately 90 days following the November 28, 2025 date of service. This interval is consistent with a claim submitted in a timely manner and thereafter subject to normal payer processing cycles, rather than one presented after a deadline had elapsed.

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IV. REQUESTED REMEDY

The hospital respectfully requests that Synthetic Cigna:

1. Overturn the CO-29 denial on claim TEST-CLAIM-00033 in its entirety;
2. Reprocess the claim in accordance with the member's applicable benefits and the hospital's contracted or applicable fee schedule; and
3. Issue payment of the denied amount of $1,406.18 without further delay.

Should additional information be required to complete this review, please contact the hospital's Patient Financial Services or Provider Relations department at the address or telephone number reflected on the enclosed claim documentation.

The hospital reserves all rights to pursue further appeal levels, external review, or any other available remedy should this first-level appeal not result in a favorable determination prior to the appeal deadline of June 26, 2026.

Thank you for your prompt attention to this matter.

Respectfully submitted,

[Authorized Signature]
[Name and Title]
[Hospital Name]
[Address]
[Phone / Fax]
[Date]