Appeal — TEST-CLAIM-00022

Date: [Date of Submission]

Appeals Department
Synthetic Humana
[Payer Address]

Re: Formal Appeal of Claim Denial
Claim Number: TEST-CLAIM-00022
Payer: Synthetic Humana
Service Date: December 11, 2025
Denial Date: February 17, 2026
Denied Amount: $8,554.29
Denial Code: CO-197

To Whom It May Concern:

This letter constitutes a formal appeal on behalf of our facility regarding the denial of Claim TEST-CLAIM-00022, issued by Synthetic Humana on February 17, 2026. The claim, totaling $9,217.53 billed for services rendered on December 11, 2025, was denied in the amount of $8,554.29 under denial code CO-197: Precertification/authorization/notification absent. We respectfully contest this denial and request that the claim be reprocessed and paid in full, as the basis for denial is factually incorrect.

I. DENIAL REASON AND BASIS FOR APPEAL

Synthetic Humana applied denial code CO-197, asserting that precertification or prior authorization was absent for the procedures performed on December 11, 2025. The procedures at issue include CPT 72216 (lumbar spine imaging), CPT 68991 (eyelid surgery), and CPT 43972 (endoscopic retrograde cholangiopancreatography), rendered in connection with primary diagnosis K21.98 (gastro-esophageal reflux disease).

This denial is factually erroneous. Prior authorization was obtained prior to or contemporaneously with the December 11, 2025 service date. The application of CO-197 directly contradicts documentation in our records demonstrating that precertification requirements were satisfied in accordance with Synthetic Humana's prior authorization policy. Accordingly, the denial should be overturned and the claim reprocessed for payment.

II. SUPPORTING EVIDENCE

In support of this appeal, we are enclosing the following documentation:

1. Prior Authorization Approval Letter from Payer — This document confirms that authorization was granted by Synthetic Humana for the procedures at issue prior to or contemporaneous with the December 11, 2025 service date, directly refuting the CO-197 denial.

2. Pre-Service Authorization Request Documentation — This documentation establishes that our facility submitted a timely and complete authorization request to Synthetic Humana in advance of the service date, consistent with plan requirements.

3. Evidence of Authorization Request Submission — Fax confirmation records and/or payer portal submission records are enclosed to corroborate the date and method of the authorization request submission.

4. Physician's Letter of Medical Necessity — The enclosed letter of medical necessity, prepared by the treating physician, supports the clinical appropriateness of the procedures performed and the medical necessity of the services billed.

5. Service Date Medical Records — The operative report and/or procedure note from December 11, 2025 are enclosed to document that services were rendered as billed and consistent with the authorized procedures.

6. Explanation of Benefits (EOB) / Denial Notice — The EOB issued by Synthetic Humana is enclosed for reference, confirming the denial code and denied amount under dispute.

Taken together, these documents establish a clear and complete record that prior authorization was obtained, that notification was provided to Synthetic Humana, and that the payer's application of CO-197 is not supported by the facts of this claim.

III. POLICY ANALYSIS AND BASIS FOR REVERSAL

Synthetic Humana's prior authorization policy requires precertification for the procedures at issue. Our facility acknowledges and complied with this requirement. As the enclosed prior authorization approval letter and pre-service authorization request documentation demonstrate, precertification was secured in a timely manner consistent with plan rules. The payer's own records should reflect this authorization.

Where a prior authorization has been duly obtained and is on file, the application of CO-197 constitutes a factual error. Denial codes under CO-197 are appropriate only when authorization was genuinely absent — not when authorization was obtained and the payer's internal records have failed to associate it with the submitted claim. We respectfully request that Synthetic Humana review the authorization records on file and reconcile them with this claim accordingly.

IV. REQUESTED REMEDY

Based on the foregoing, we respectfully request that Synthetic Humana:

1. Overturn the CO-197 denial issued on February 17, 2026, for Claim TEST-CLAIM-00022;
2. Reprocess the claim in full in accordance with the applicable plan benefits and the prior authorization on file; and
3. Issue payment of the denied amount of $8,554.29 consistent with the provider's contractual terms.

Please note that the appeal deadline for this claim is April 18, 2026. We respectfully request that this appeal be reviewed and a determination issued well in advance of that date.

If additional information is needed to resolve this appeal, please do not hesitate to contact our appeals department at the address or phone number listed below. We appreciate your prompt attention to this matter and look forward to a favorable resolution.

Respectfully submitted,

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

Enclosures:
- Prior Authorization Approval Letter from Payer
- Pre-Service Authorization Request Documentation
- Evidence of Authorization Request Submission (fax confirmation or portal records)
- Physician's Letter of Medical Necessity
- Service Date Medical Records (operative report or procedure note)
- Explanation of Benefits (EOB) / Denial Notice