Appeal — TEST-CLAIM-00026

Date: [Date of Submission]

Synthetic Medicaid-TX
Provider Appeals Department
[Payer Address]

Re: Formal Appeal — Request for Claim Reprocessing and Payment
Claim Reference Number: TEST-CLAIM-00026
Internal Claim ID: ab2cc8b5-7563-4a67-90ac-528c7df8cded
Payer: Synthetic Medicaid-TX
Date of Service: 2026-02-17
Denial Date: 2026-05-01
Denied Amount: $3,750.58
Appeal Deadline: 2026-05-31

To Whom It May Concern:

This letter constitutes a formal first-level appeal on behalf of the billing and rendering provider regarding the denial of Claim TEST-CLAIM-00026. The provider respectfully requests that Synthetic Medicaid-TX overturn the denial issued on 2026-05-01 and reprocess the claim for full payment of the denied amount of $3,750.58.

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I. STATEMENT OF DENIAL

The above-referenced claim was denied under reason code CO-226, indicating that information requested from the billing/rendering provider was not provided. The claim pertains to services rendered on 2026-02-17, encompassing the following procedure codes and associated diagnoses:

  - CPT 13552 — Complex wound repair / skin graft
  - CPT 21003 — Palatal approach procedure
  - CPT 94246 — Respiratory mechanics evaluation
  - Diagnosis Code I10.59 — Secondary hypertension, unspecified
  - Diagnosis Code I10.06 — Hypertensive heart and chronic kidney disease

The total billed amount for the claim is $5,250.53, of which $3,750.58 was denied.

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II. BASIS FOR APPEAL

The provider respectfully contests this denial on the following grounds:

  • The CO-226 denial reflects a documentation submission deficiency, not an absence of documentation. The clinical records, operative reports, and billing materials supporting all three procedures exist and are enclosed herewith. The denial does not reflect a finding that the services were medically unnecessary, non-covered, or improperly coded — only that the payer had not received the requested supporting documentation at the time of adjudication.

  • All services rendered on 2026-02-17 were medically necessary and clinically appropriate. The enclosed clinical documentation, including operative and procedure notes, supports the medical necessity of CPT 13552, CPT 21003, and CPT 94246 in the context of the patient's documented diagnoses.

  • The enclosed itemized billing statement provides detailed service descriptions for all billed procedures, satisfying the payer's documentation submission requirement as contemplated under Synthetic Medicaid-TX's applicable documentation submission policy.

  • The complete documentation package is being provided within the appeal deadline of 2026-05-31, affording the payer the opportunity to review and adjudicate the claim in full accordance with its stated requirements.

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III. SUPPORTING DOCUMENTATION ENCLOSED

The following documents are enclosed in support of this appeal:

  1. Operative report and/or procedure notes for services rendered on 2026-02-17
  2. Clinical documentation supporting medical necessity for all billed procedures
  3. Itemized billing statement with detailed service descriptions
  4. Relevant patient medical record excerpts pertaining to the billed procedures and diagnoses
  5. Physician certification or attestation of services rendered
  6. Any prior payer correspondence requesting specific information (if available)
  7. This formal appeal letter

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IV. POLICY BASIS

Synthetic Medicaid-TX's documentation submission requirement, as applicable to CO-226 denials, contemplates that a provider may cure a documentation deficiency by supplying the requested information through the formal appeals process. The denial does not assert that the services were not rendered, were not medically necessary, or are excluded from coverage — it asserts only that documentation was not received. The submission of complete clinical and billing records with this appeal directly addresses and satisfies the stated deficiency, and the claim should therefore be reprocessed and paid in accordance with the applicable fee schedule.

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V. REQUESTED REMEDY

The provider respectfully requests that Synthetic Medicaid-TX:

  1. Accept the enclosed documentation as fulfillment of the CO-226 information request;
  2. Reprocess Claim TEST-CLAIM-00026 in its entirety; and
  3. Issue payment of the denied amount of $3,750.58 in accordance with the applicable contracted rate or Medicaid fee schedule.

Should additional information be required to complete the review of this appeal, please contact the provider's billing department at the information on file. The provider is committed to cooperating fully and promptly with any further requests.

Thank you for your prompt attention to this matter.

Respectfully submitted,

[Authorized Provider Representative Name]
[Title]
[Provider Name]
[Provider NPI]
[Provider Address]
[Phone Number]
[Date]