Appeal — TEST-CLAIM-00050

Date: [Insert Date of Submission]

Via: [Insert Submission Method — Certified Mail / Payer Portal]

Synthetic Medicaid-TX
Appeals and Grievances Department
[Payer Address]

Re: Formal Appeal of Claim Denial
External Claim ID: TEST-CLAIM-00050
Internal Claim Reference: f9410d75-1423-41eb-be0a-1075830218bd
Payer: Synthetic Medicaid-TX
Service Date: April 10, 2026
Procedure Code(s): CPT 75836
Diagnosis Code(s): E11.56, E11.67
Billed Amount: $3,931.67
Denied Amount: $3,834.86
Denial Date: June 12, 2026
Appeal Deadline: July 12, 2026

To Whom It May Concern:

This letter constitutes a formal first-level appeal submitted on behalf of the undersigned facility regarding the denial of the above-referenced claim. Synthetic Medicaid-TX issued a CO-45 denial — "Charges exceed your contracted/legislated fee arrangement" — resulting in a denied amount of $3,834.86. After careful review of the applicable contract terms, the current Medicaid fee schedule, and the clinical record supporting this service, the facility respectfully contends that the denial is incorrect and requests that the claim be reprocessed and paid at the appropriate allowable amount.

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I. BACKGROUND AND BASIS FOR DENIAL

On April 10, 2026, the facility rendered services to a patient presenting with Type 2 diabetes with hypoglycemia with coma (ICD-10: E11.56) and concurrent Type 2 diabetes with hyperglycemia (ICD-10: E11.67). In the context of this clinically complex diabetic emergency, CPT 75836 (diagnostic angiography) was performed. The total billed amount for the service was $3,931.67.

Synthetic Medicaid-TX processed the claim and applied a CO-45 adjustment, reducing payment and leaving $3,834.86 unresolved. CO-45 denials indicate that the payer determined the billed charges exceeded the contracted or legislated fee schedule allowable. The facility disputes the rate applied and asserts that either (a) an incorrect fee schedule rate was applied to CPT 75836, or (b) a current contract amendment or updated Medicaid fee schedule establishes an allowable rate higher than the amount paid.

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II. GROUNDS FOR APPEAL

The facility advances the following arguments in support of this appeal:

1. INCORRECT FEE SCHEDULE RATE APPLIED

The facility has reason to believe that the allowable rate applied by Synthetic Medicaid-TX to CPT 75836 does not reflect the current contracted fee schedule or the most recently published Texas Medicaid fee schedule rate for this procedure code. The facility has attached the current fee schedule or applicable contract amendment, which it respectfully requests the payer review in conjunction with this appeal. Should the payer's adjudication system have applied an outdated or incorrect rate, the claim should be reprocessed at the correct allowable.

2. CLINICAL COMPLEXITY AND APPROPRIATE CHARGE LEVEL

The patient's presentation — involving simultaneous hypoglycemic coma (E11.56) and hyperglycemia (E11.67) — represents a clinically complex diabetic emergency requiring advanced diagnostic evaluation. The facility's charges for CPT 75836 reflect the clinical complexity, provider credentials, and facility resource requirements associated with this presentation. The enclosed letter of explanation and itemized billing statement detail the specific components underlying the billed amount. Additionally, the enclosed peer-reviewed clinical guidelines and AMA Relative Value Unit (RVU) documentation substantiate the appropriateness of the charge level for the level of service rendered.

3. SUPPORTING DOCUMENTATION ESTABLISHES CORRECT ALLOWABLE

The facility has compiled and enclosed the following supporting documents:

   a. Current fee schedule or contract amendment with Synthetic Medicaid-TX applicable to CPT 75836 as of the service date of April 10, 2026;
   b. Itemized billing statement with a component-level breakdown of charges;
   c. Peer-reviewed clinical guidelines and AMA RVU documentation supporting the billed amount for CPT 75836;
   d. Letter of explanation detailing the basis for charges, including clinical complexity, provider credentials, and facility requirements; and
   e. Comparison analysis reflecting contracted rates at peer institutions for CPT 75836.

Taken together, this documentation demonstrates that the charges billed are consistent with the applicable fee schedule or contract terms and that the CO-45 reduction was applied in error.

4. APPEAL IS TIMELY AND CLAIM IS RECOVERABLE

This appeal is submitted within the appeal deadline of July 12, 2026, as identified in the payer's denial correspondence dated June 12, 2026. The facility acknowledges that CO-45 adjustments reflecting a correct fee schedule application represent a contractual write-off; however, the facility's position — supported by the enclosed documentation — is that the rate applied here was not correct under the current fee schedule, making the denied amount recoverable.

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III. REQUESTED REMEDY

The facility respectfully requests that Synthetic Medicaid-TX:

1. Review the enclosed fee schedule and supporting documentation;
2. Reprocess claim TEST-CLAIM-00050 at the correct contracted or legislated allowable rate for CPT 75836 as of April 10, 2026; and
3. Issue payment of the denied amount of $3,834.86, or such other amount as established by the correct allowable rate, within the timeframe required under applicable state prompt-pay requirements.

If additional information is needed to resolve this appeal, the facility requests written notification of the specific deficiency so that supplemental documentation may be provided.

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Thank you for your prompt attention to this matter. The facility remains committed to resolving this dispute through the appropriate administrative process and trusts that a thorough review of the enclosed documentation will result in a favorable determination.

Respectfully submitted,

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

Enclosures:
1. Current fee schedule or contract amendment (CPT 75836, effective as of April 10, 2026)
2. Itemized billing statement with component breakdown
3. Peer-reviewed clinical guidelines and AMA RVU documentation
4. Letter of explanation (clinical complexity, provider credentials, facility requirements)
5. Peer institution contracted rate comparison analysis for CPT 75836