Appeal — TEST-CLAIM-00089

Date: [Date of Submission]

To: Appeals and Grievances Department
Synthetic Medicaid-TX

Re: Formal Appeal of Claim Denial – Timely Filing (CO-29)
Claim ID: TEST-CLAIM-00089
Internal Claim Reference: e71f594e-45c6-48d9-96d6-b61c94e332f2
Date of Service: March 18, 2026
Denial Date: May 30, 2026
Denied Amount: $12,673.81
Procedure Codes: CPT 31241, CPT 36174
Diagnosis Code: ICD-10 K21.06

Dear Appeals and Grievances Department,

On behalf of [Hospital Name], we are submitting this formal appeal contesting the denial issued by Synthetic Medicaid-TX on May 30, 2026, for Claim ID TEST-CLAIM-00089. The claim was denied under CO-29, citing expiration of the applicable timely filing deadline. We respectfully assert that this denial is not warranted and request that the claim be reconsidered, reprocessed, and paid in the denied amount of $12,673.81.

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I. BASIS FOR APPEAL

The CO-29 denial asserts that this claim was submitted outside the payer's timely filing window. We dispute this determination on the following grounds:

1. The claim pertains to services rendered on March 18, 2026, and the denial was issued on May 30, 2026 — only 73 days following the date of service. This relatively brief interval between the service date and the denial date strongly suggests that the claim was, in fact, submitted within any standard or contractually specified timely filing period. A denial issued so shortly after the date of service raises significant questions regarding the basis upon which a timely filing violation was assessed.

2. The enclosed claim submission records include timestamped proof of filing that documents the date and time this claim was transmitted to Synthetic Medicaid-TX. These records affirmatively demonstrate that the claim was submitted within the applicable filing window and that the CO-29 denial is inconsistent with the actual submission timeline.

3. The enclosed hospital billing system records further corroborate the claim processing timeline, establishing the internal workflow from service completion through claim generation and submission. These records confirm there was no undue delay on the part of [Hospital Name] in initiating or completing the filing of this claim.

4. The enclosed payer correspondence documenting receipt date and claim status — to the extent such records reflect acknowledgment of the claim by Synthetic Medicaid-TX — provides additional confirmation that the claim was received by the payer in a manner consistent with timely filing requirements. Should this documentation reveal any payer-side processing delay or system issue that contributed to a discrepancy in the recorded receipt date, we assert that such a circumstance constitutes a qualifying good-faith exception to the timely filing deadline, as recognized under applicable Medicaid claims processing guidelines.

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II. CLINICAL CONTEXT

The services billed under CPT codes 31241 and 36174, with a primary diagnosis of ICD-10 K21.06, represent medically necessary procedures provided to the patient on March 18, 2026. The enclosed letter of medical necessity provides clinical justification for these services. The denial does not appear to contest medical necessity; rather, it is based solely on the procedural ground of timely filing. Accordingly, once the timeliness issue is resolved in favor of [Hospital Name], there is no outstanding clinical or coverage basis that should preclude payment.

Additionally, the enclosed documentation of any prior authorization requests or communications with the payer is provided to establish the full scope of interactions between [Hospital Name] and Synthetic Medicaid-TX surrounding this claim, including any circumstances — such as prior authorization holds or payer-directed delays — that may have affected the claim submission timeline.

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III. REQUESTED REMEDY

For the reasons stated above and supported by the enclosed documentation, we respectfully request that Synthetic Medicaid-TX:

1. Overturn the CO-29 timely filing denial for Claim ID TEST-CLAIM-00089;
2. Reprocess the claim in full; and
3. Issue payment of the denied amount of $12,673.81 in accordance with the applicable fee schedule and covered benefits.

We ask that this appeal be adjudicated prior to the appeal deadline of June 29, 2026. If additional information is required to complete this review, please contact [Hospital Billing Contact Name] at [Phone Number / Email Address].

Enclosures:
- Claim submission records with timestamped proof of filing
- Hospital billing system records showing claim processing timeline
- Payer correspondence documenting receipt date and claim status
- Letter of medical necessity / clinical justification for service
- Documentation of prior authorization requests or communications with payer

Respectfully submitted,

[Authorized Signatory Name]
[Title]
[Hospital Name]
[Address]
[Phone Number]
[Date]