Appeal — TEST-CLAIM-00037

Date: [Date of Submission]

To: Appeals and Grievances Department
Synthetic Medicaid-TX

Re: Formal Appeal of Claim Denial
Claim Number: TEST-CLAIM-00037
Service Date: March 20, 2026
Denied Amount: $847.48
Denial Date: June 4, 2026
Appeal Deadline: July 4, 2026

Dear Appeals and Grievances Review Officer,

This letter constitutes a formal appeal on behalf of our facility regarding the denial of Claim No. TEST-CLAIM-00037, submitted to Synthetic Medicaid-TX for services rendered on March 20, 2026. The claim was denied under reason code CO-16 (Claim/service lacks information or has submission/billing error(s)), resulting in a denied amount of $847.48 of the $1,573.79 total billed. We respectfully request that this denial be overturned and that the claim be reprocessed for payment of the denied amount.

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I. NATURE OF THE DENIAL

The denial was issued under CO-16, indicating a correctable submission or billing error rather than a determination of non-coverage or lack of medical necessity. Specifically, the payer's communication has identified a coding discrepancy on the claim as submitted. Upon our internal review, we have identified that the diagnosis codes originally reported — E11.08 (Type 2 diabetes mellitus with unspecified diabetic retinopathy) and S82.62 (displaced transverse fracture of the right tibia) — were not appropriately linked to the billed procedure, CPT 43092 (endoscopic ultrasound-guided transpapillary pseudocyst drainage). This represents a diagnosis-to-procedure mismatch that does not reflect the actual clinical circumstances of the encounter and is correctable upon submission of accurate supporting documentation.

We wish to emphasize that this is a billing and coding error, not a question of whether the procedure was performed or medically warranted. The procedure was performed as documented, and corrected diagnosis coding that accurately reflects the clinical indication for CPT 43092 is supported by the medical record.

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II. BASIS FOR APPEAL

Our appeal is grounded in the following arguments:

• The CO-16 denial identifies a correctable submission error — specifically, a diagnosis-to-procedure mismatch — rather than a coverage exclusion or medical necessity issue, and is therefore fully appealable and resolvable through the submission of a corrected claim with accurate diagnosis coding and complete operative documentation.

• The operative report enclosed with this appeal confirms that CPT 43092 (endoscopic ultrasound-guided transpapillary pseudocyst drainage) was performed on the date of service, and the clinical documentation supports the corrected diagnosis codes that accurately reflect the clinical indication for this procedure.

• Synthetic Medicaid-TX's claim submission and billing accuracy requirements (CO-16 policy framework) expressly contemplate that errors of this nature are subject to correction and reprocessing; denial of payment on this basis is appropriate only where the submitting provider fails to supply the requested corrective information, which we are providing herewith.

• The itemized billing statement and corrected claim form enclosed herein reflect complete, accurate, and consistent coding across all line items, resolving the discrepancy identified by the payer.

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III. SUPPORTING DOCUMENTATION

In support of this appeal, the following documents are enclosed:

1. Corrected claim form with complete and accurate diagnosis coding, corrected to reflect the clinically supported indication for CPT 43092.
2. Operative report documenting the performance of CPT 43092 on March 20, 2026.
3. Clinical documentation supporting the corrected ICD-10 diagnosis codes as they relate to the procedure performed.
4. Itemized billing statement with line-item detail corresponding to the corrected claim.
5. Copy of the payer's denial communication identifying the specific coding error(s) at issue.

These documents collectively demonstrate that the procedure was performed, that a clinically appropriate diagnosis supports the billed procedure code, and that the original denial resulted solely from a correctable coding discrepancy.

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IV. REQUESTED REMEDY

We respectfully request that Synthetic Medicaid-TX:

1. Accept and review this appeal and the enclosed corrected claim and supporting documentation;
2. Overturn the CO-16 denial issued on June 4, 2026, with respect to Claim No. TEST-CLAIM-00037; and
3. Reprocess the claim and remit payment of the denied amount of $847.48 in accordance with the applicable Medicaid fee schedule and the terms of our provider agreement.

We believe the enclosed documentation fully resolves the basis for the CO-16 denial and that reprocessing will confirm that all conditions for payment have been met. Should the Appeals and Grievances Department require any additional information or clarification, please do not hesitate to contact our billing office at the address or telephone number listed below.

We appreciate your prompt attention to this matter and request that a determination be issued prior to the appeal deadline of July 4, 2026.

Respectfully submitted,

[Authorized Provider Representative Name]
[Title]
[Facility Name]
[Address]
[Phone Number]
[Fax Number]
[Provider NPI]

Enclosures:
- Corrected claim form
- Operative report (CPT 43092, March 20, 2026)
- Clinical documentation supporting corrected diagnosis codes
- Itemized billing statement
- Copy of payer denial communication (June 4, 2026)