Appeal — TEST-CLAIM-00087

Date: [Date of Submission]

Synthetic Aetna
Appeals and Grievances Department
[Payer Address]

Re:    Formal Appeal of Claim Denial
       Claim Number:       TEST-CLAIM-00087
       Payer:              Synthetic Aetna
       Date of Service:    July 29, 2025
       Procedure Code(s):  CPT 88282
       Diagnosis Code(s):  I10.20, I10.88
       Denied Amount:      $850.03
       Denial Date:        October 20, 2025
       Appeal Deadline:    April 18, 2026

Dear Synthetic Aetna Appeals and Grievances Department,

On behalf of our facility, we are writing to formally appeal the denial issued on October 20, 2025, for the above-referenced claim (TEST-CLAIM-00087). Synthetic Aetna denied this claim under remark code CO-31, citing that the patient cannot be identified as an insured member. We respectfully contest this determination and request that the claim be reprocessed and paid in full for the denied amount of $850.03.

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I. BASIS FOR THE DENIAL

Synthetic Aetna issued a CO-31 denial, asserting that the patient could not be identified as a covered insured under the plan at the time the services were rendered on July 29, 2025. The services in question consisted of cytopathology (CPT 88282), provided in accordance with the patient's documented clinical need.

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II. GROUNDS FOR APPEAL

The CO-31 denial is factually unsupported and should be overturned. Our facility verified the patient's eligibility and identity prior to and in connection with the provision of services on July 29, 2025. The documentation enclosed with this appeal collectively and conclusively establishes that the patient was an active, covered member of Synthetic Aetna on the date of service. Specifically:

• The patient presented a valid Synthetic Aetna insurance card at the time of service, and our facility retained a copy of both the front and back of that card.

• Our facility obtained a payer-generated eligibility verification report dated on or near the service date of July 29, 2025, confirming active coverage under the Synthetic Aetna plan.

• An enrollment confirmation letter issued by Synthetic Aetna further substantiates that the patient held active coverage on the date services were rendered.

• Hospital medical records, including the patient's full name, date of birth, and medical record number, corroborate the patient's identity as consistent with the information reflected in Synthetic Aetna's own records.

• A patient demographic verification form, signed by the patient, confirms that the identifying information submitted on the claim accurately reflects the member's enrollment data.

Taken together, these documents directly rebut the stated basis for the CO-31 denial. Pursuant to Synthetic Aetna's member eligibility verification requirements, active coverage on the date of service is the operative standard for establishing eligibility. The enclosed documentation satisfies that standard in full.

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III. SUPPORTING DOCUMENTATION ENCLOSED

The following documents are enclosed in support of this appeal:

1. Copy of patient insurance card (front and back)
2. Patient demographic verification form signed by the patient
3. Hospital medical record reflecting patient name, date of birth, and medical record number
4. Payer eligibility verification report dated on or near July 29, 2025
5. Enrollment confirmation letter from Synthetic Aetna showing active coverage on the service date
6. Explanation of Benefits (EOB) or prior claim approval demonstrating patient eligibility on or near the service date

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IV. REQUESTED REMEDY

Based on the foregoing, we respectfully request that Synthetic Aetna:

1. Overturn the CO-31 denial issued on October 20, 2025, for claim TEST-CLAIM-00087;
2. Reprocess the claim in full for the services rendered on July 29, 2025 (CPT 88282); and
3. Issue payment of the denied amount of $850.03 in accordance with the applicable plan terms and contractual obligations.

We are confident that a thorough review of the enclosed documentation will confirm that this patient was an active and identifiable insured member of Synthetic Aetna on the date of service, and that the denial should be reversed accordingly.

Should additional information be required to resolve this appeal, please do not hesitate to contact our Appeals and Billing team at the contact information listed below. We appreciate your prompt attention to this matter and look forward to a favorable resolution.

Respectfully submitted,

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

Enclosures: As listed in Section III above