Appeal — TEST-CLAIM-00057

Date: [Date of Submission]

To: Appeals and Grievances Department
Synthetic Medicaid-TX

Re: Formal Appeal of Claim Denial – Timely Filing (CO-29)
External Claim ID: TEST-CLAIM-00057
Internal Claim ID: e43f3141-a143-4cb4-90fc-81602cb52dd9
Date of Service: June 1, 2026
Denial Date: June 20, 2026
Appeal Deadline: July 20, 2026
Procedure Codes: CPT 27224, 21813, 48680
Diagnosis Codes: S82.22, J45.16
Denied Amount: $1,241.24

Dear Appeals and Grievances Representative,

This letter constitutes a formal appeal on behalf of our facility regarding the above-referenced claim, which was denied on June 20, 2026 under denial reason CO-29: "The time limit for filing this claim has expired." We respectfully contest this determination and request that the claim be reprocessed and payment issued for the full denied amount of $1,241.24.

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I. BASIS FOR DENIAL

Synthetic Medicaid-TX issued a CO-29 denial, asserting that the applicable timely filing window had expired at the time the claim was submitted. We dispute this determination on the grounds that the claim was submitted within the applicable filing period, and the evidence enclosed with this appeal affirmatively demonstrates timely submission.

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II. GROUNDS FOR APPEAL

The denial of this claim on timely filing grounds is inconsistent with the submission record and with the applicable Medicaid filing deadline policy. Specifically:

1. The date of service for the procedures at issue (CPT 27224, 21813, and 48680) was June 1, 2026. Standard Texas Medicaid timely filing requirements provide a filing window of no fewer than 95 days from the date of service for initial claims, and in many instances up to 180 days or more depending on the applicable program and circumstances. A denial issued only nineteen (19) days following the date of service — on June 20, 2026 — is facially inconsistent with the assertion that the filing deadline had expired.

2. The enclosed itemized claim submission record with timestamped receipt demonstrates that this claim was transmitted to Synthetic Medicaid-TX on or before the applicable filing deadline. The hospital's billing system documentation confirms the filing date, and payer correspondence confirming claim receipt further establishes that the claim entered the payer's adjudication system within the required timeframe.

3. To the extent the payer's system generated the CO-29 denial in error — for example, due to a data entry discrepancy regarding the date of service or a system processing anomaly — the enclosed documentation directly rebuts any such error. The evidence package includes proof of the claim's presence in the payer's system consistent with timely filing.

4. In the event there was any delay in claim submission attributable to circumstances beyond our facility's control, the enclosed explanatory correspondence addresses those circumstances and supports a finding that the filing was timely or that a waiver or exception is warranted under applicable Medicaid policy.

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III. SUPPORTING DOCUMENTATION

The following documents are enclosed in support of this appeal:

- Itemized claim submission record with timestamped receipt
- Hospital billing system documentation showing claim filing date
- Payer correspondence confirming claim receipt date
- Letter explaining any delays in claim submission, if applicable
- Evidence of claim in payer's system on or before the filing deadline
- Proof of timely notice of denial and service date clarification

These documents collectively establish that the claim was filed within the applicable timely filing window and that the CO-29 denial was issued in error.

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IV. POLICY BASIS

This appeal is grounded in Synthetic Medicaid-TX's own timely filing window policy. As noted above, the denial was generated a mere nineteen days after the date of service, a period that falls well within any standard 90- to 180-day Medicaid filing deadline. Where the payer's records, once reviewed against the enclosed submission documentation, confirm that the claim was received within the filing window, denial under CO-29 is not supported and reversal is required under the applicable policy.

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V. REQUESTED REMEDY

We respectfully request that Synthetic Medicaid-TX:

1. Overturn the CO-29 timely filing denial for Claim TEST-CLAIM-00057;
2. Reprocess the claim on its merits; and
3. Issue payment of the denied amount of $1,241.24 in accordance with the applicable Medicaid fee schedule and coverage rules.

This appeal is being submitted in advance of the July 20, 2026 appeal deadline. We request written confirmation of receipt of this appeal and a determination within the timeframe required under applicable Medicaid appeals procedures.

Should additional information be required to resolve this matter, please do not hesitate to contact our billing and appeals department at the contact information provided below.

Respectfully submitted,

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

Enclosures: As listed in Section III above