Appeal — TEST-CLAIM-00045

Date: [Insert Date of Letter]

Via: [Insert Submission Method]

Synthetic Humana
Appeals and Grievances Department
[Payer Address]

Re: Formal Appeal of Claim Denial — CO-29 Timely Filing
Claim Number: TEST-CLAIM-00045
Service Date: January 29, 2026
Denial Date: April 22, 2026
Denied Amount: $1,857.17
Procedure Codes: CPT 75338, 91973, 67939
Diagnosis Code: ICD-10 J45.34

Dear Synthetic Humana Appeals and Grievances Department,

[Hospital Name] (hereinafter "the Facility") submits this formal, written appeal on behalf of the patient identified under Claim Number TEST-CLAIM-00045, contesting the denial issued by Synthetic Humana on April 22, 2026. The claim was denied under CARC CO-29, citing expiration of the timely filing limit. For the reasons set forth below, supported by the enclosed documentation, the Facility respectfully requests that Synthetic Humana overturn this denial and reprocess the claim for payment of the denied amount of $1,857.17.

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I. BASIS FOR DENIAL AND GROUNDS FOR APPEAL

Synthetic Humana denied Claim TEST-CLAIM-00045 under adjustment reason code CO-29, asserting that the time limit for filing the claim had expired. The Facility contests this determination. As demonstrated by the enclosed contemporaneous submission records, the claim was filed within the applicable timely filing window following the date of service on January 29, 2026. The denial, issued on April 22, 2026 — approximately 83 days post-service — does not reflect an accurate assessment of the Facility's filing timeline.

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II. SUPPORTING EVIDENCE

The Facility submits the following documentation in support of this appeal:

1. Claim Submission Evidence: The enclosed clearinghouse confirmation report, electronic transmission log, and/or postal receipt establishes the date on which the claim was originally submitted to Synthetic Humana. This contemporaneous record demonstrates that the claim was tendered within the contractually required filing window.

2. Internal Billing and Claims Records: The enclosed records from the Facility's billing and claims department corroborate the original filing date and document the submission workflow for this claim.

3. Payer Communication (if applicable): Any acknowledgment of claim receipt from Synthetic Humana, if available, is enclosed as further evidence that the claim entered the payer's system within the applicable period.

4. Explanation of Extenuating Circumstances (if applicable): To the extent that any delay was attributable to insurance verification issues, payer-side processing errors, or other circumstances outside the Facility's control, a written explanation and supporting documentation are enclosed.

5. Applicable Filing Deadline Authority: The enclosed plan document extract and/or state timely-filing statute confirms the applicable filing window governing this claim, against which the Facility's submission date should be measured.

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III. POLICY BASIS FOR REVERSAL

It is well established under Synthetic Humana's own policy framework that CO-29 denials are subject to reversal upon submission of contemporaneous evidence demonstrating that the claim was submitted within the contractually required timely filing period. Specifically, documentation such as a clearinghouse confirmation, electronic transmission log, or postal receipt constitutes sufficient proof of timely submission. Furthermore, where system failures, payer-side errors, or other extenuating circumstances contributed to any perceived delay, such factors may toll the applicable deadline and independently support reversal of the denial.

The Facility has provided precisely the class of evidence contemplated by this policy. Accordingly, the denial should not stand.

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IV. REQUESTED REMEDY

The Facility respectfully requests that Synthetic Humana:

1. Overturn the CO-29 denial on Claim TEST-CLAIM-00045;
2. Reprocess the claim on its merits; and
3. Issue payment of the denied amount of $1,857.17 in accordance with the applicable contract terms.

This appeal is submitted in advance of the appeal deadline of June 21, 2026. The Facility requests written confirmation of receipt of this appeal and a determination within the timeframe required by applicable plan terms and governing law.

Should additional information be required to resolve this matter, please contact the Facility's billing department at the address or telephone number listed below.

Respectfully submitted,

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

Enclosures:
- Clearinghouse confirmation, electronic transmission log, and/or postal receipt
- Internal billing and claims department records
- Explanation of extenuating circumstances and supporting documentation (if applicable)
- Payer acknowledgment of claim receipt (if available)
- Applicable plan document extract and/or timely-filing statute