Appeal — TEST-CLAIM-00056

Date: [Letter Date]

To: Appeals and Grievances Department
Synthetic Medicaid-TX

Re: Formal Appeal of Claim Denial
External Claim ID: TEST-CLAIM-00056
Internal Claim ID: a4d60d49-0da7-4f8f-9b0a-79e1d9cdc656
Payer: Synthetic Medicaid-TX
Date of Service: February 12, 2026
Denial Date: April 2, 2026
Procedure Code(s): CPT 93442
Diagnosis Code(s): ICD-10 F32.32
Billed Amount: $5,182.23
Denied Amount: $4,463.73
Appeal Deadline: May 2, 2026

Dear Appeals and Grievances Department,

This letter constitutes a formal first-level appeal on behalf of the undersigned facility regarding the denial of the above-referenced claim. Synthetic Medicaid-TX issued a denial on April 2, 2026, citing CO-16: "Claim/service lacks information or has submission/billing error(s)." For the reasons set forth below, and supported by the enclosed documentation, we respectfully request that this denial be overturned and the claim reprocessed for payment of the full denied amount of $4,463.73.

I. BASIS FOR DENIAL

The denial was issued under CO-16, indicating that the claim was rejected on technical or administrative grounds — specifically, that the claim lacked required information or contained a submission or billing error. This denial does not reflect a determination of medical necessity, but rather a correctable technical deficiency. Accordingly, the claim is appropriate for appeal and/or corrected resubmission with remedied documentation.

II. GROUNDS FOR APPEAL

Our facility has conducted a thorough review of the original submission and has identified and addressed the submission deficiencies cited under CO-16. We respectfully assert the following:

• Corrected Claim and Submission Errors Resolved: A corrected claim has been prepared with all required data elements fully and accurately populated. The specific submission deficiency or billing error that prompted the CO-16 denial has been identified and rectified, as detailed in the enclosed clarification letter. The corrected claim accurately reflects the services rendered on February 12, 2026.

• CPT 93442 Is Properly Documented and Supported: The echocardiography procedure billed under CPT 93442 was performed on the date of service and is substantiated by complete procedural documentation. The enclosed operative/procedural report and medical record excerpt confirm that the procedure was performed in accordance with applicable clinical standards.

• ICD-10 Diagnosis Code F32.32 Is Clinically Appropriate and Supported: The diagnosis of major depressive disorder (ICD-10 F32.32) is supported by the enclosed clinical documentation. We recognize that the linkage between a psychiatric diagnosis and a cardiac diagnostic procedure may require additional clinical justification, and we have therefore included the enclosed medical record excerpt and letter of medical necessity, which together explain the clinical rationale for performing echocardiography in the context of this patient's documented condition.

• The Denial Is Technical in Nature and Does Not Reflect Lack of Medical Necessity: Synthetic Medicaid-TX's claim submission and billing accuracy requirements under CO-16 address administrative and coding defects, not the clinical appropriateness of the service. The provider's intent and the medical necessity of CPT 93442 on February 12, 2026, are both well-supported by the enclosed documentation. Denial of payment based solely on a correctable submission error, where the underlying service is fully documented and medically justified, is not appropriate under applicable payer policy.

III. SUPPORTING DOCUMENTATION ENCLOSED

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

1. Corrected claim submission with complete and accurate coding information
2. Clarification letter identifying and correcting the specific submission error(s) underlying the CO-16 denial
3. Operative report or procedural documentation supporting CPT 93442
4. Clinical documentation supporting ICD-10 diagnosis code F32.32
5. Medical record excerpt demonstrating medical necessity for the procedure performed on February 12, 2026
6. Itemized billing statement showing service line details

IV. REQUESTED REMEDY

Our facility respectfully requests that Synthetic Medicaid-TX:

1. Overturn the April 2, 2026, denial issued under CO-16 for Claim TEST-CLAIM-00056;
2. Reprocess the corrected claim in its entirety; and
3. Issue payment of the denied amount of $4,463.73 in accordance with the applicable Medicaid fee schedule and provider agreement.

We believe the enclosed documentation fully resolves the technical deficiencies cited and demonstrates that the services billed were rendered, properly coded, and medically necessary. We respectfully ask that this appeal be reviewed and adjudicated within the timeframe required under applicable Medicaid appeal regulations.

Should the reviewer require any additional information or clarification, please contact the undersigned facility's billing and appeals department at the contact information provided below.

Respectfully submitted,

[Authorized Facility Representative Name]
[Title]
[Facility Name]
[Facility Address]
[Phone Number]
[Fax Number]
[Date]