Appeal — TEST-CLAIM-00017

Date: [Insert Date of Submission]

To: Appeals and Grievances Department
Synthetic Medicaid-TX

Re: Formal Appeal of Claim Denial — Claim No. TEST-CLAIM-00017
Denial Reason: CO-18 (Exact Duplicate Claim/Service)
Denial Date: June 9, 2026
Service Date: March 23, 2026
Total Billed Amount: $1,812.15
Denied Amount: $1,054.09
Appeal Deadline: July 9, 2026

Dear Appeals and Grievances Department,

This letter constitutes a formal appeal on behalf of the submitting facility against the denial issued on June 9, 2026, for Claim No. TEST-CLAIM-00017, filed with Synthetic Medicaid-TX. The claim was denied under remark code CO-18 (Exact Duplicate Claim/Service), resulting in non-payment of $1,054.09 of the $1,812.15 total billed amount. We respectfully contest this denial and request that the claim be reprocessed and payment issued in full for the denied amount.

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I. BASIS FOR DENIAL AND GROUNDS FOR APPEAL

The CO-18 denial designation asserts that this claim represents an exact duplicate of a previously submitted or adjudicated claim. Upon thorough internal review, the facility has determined that this characterization is factually unsupported. The claim in question reflects a single, integrated episode of care rendered on March 23, 2026, encompassing two distinct procedure codes — CPT 82667 (laboratory work) and CPT 26683 (open reduction of fracture, metacarpal) — in connection with the documented diagnosis of S82.85 (fracture of other part of lower leg). These procedures represent clinically separate and medically necessary components of one cohesive treatment encounter, not a re-submission of a previously adjudicated claim.

For a CO-18 duplicate denial to be valid under Synthetic Medicaid-TX's duplicate claim submission rule, there must exist a prior claim submission containing the identical combination of service date, procedure codes, and diagnosis codes that has already been adjudicated or paid. Our internal records do not reflect any such prior adjudication for this specific combination of services, and we have found no evidence that payment was previously made or a prior claim for this exact encounter was processed.

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II. SUPPORTING EVIDENCE

In support of this appeal, the following documentation is enclosed:

1. Claim Submission History and Timestamps — Demonstrating that this claim was submitted once and identifying the specific submission record associated with Claim No. TEST-CLAIM-00017. This record refutes any assertion that a duplicate submission was made.

2. Original Explanation of Benefits (EOB) or Claim Adjudication Record — Provided to identify any prior adjudication record cited as the basis for the CO-18 denial. If Synthetic Medicaid-TX possesses a specific prior claim that is alleged to be the duplicate, we respectfully request that this information be disclosed so it may be addressed directly.

3. Itemized Bill — Showing service date of March 23, 2026, with distinct procedure codes CPT 82667 and CPT 26683 billed separately and appropriately, confirming this is a multi-procedure, single-encounter submission.

4. Patient Medical Record Excerpt — Documenting the clinical encounter on March 23, 2026, confirming that both the laboratory work (CPT 82667) and the surgical procedure (CPT 26683) were individually performed, medically necessary, and constitute a single integrated episode of care related to the treatment of S82.85.

5. Proof of Prior Denial or Non-Payment — Confirming no prior remittance or payment has been received for this claim or any claim containing this identical combination of procedure codes, diagnosis code, and service date.

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III. POLICY ANALYSIS

Under Synthetic Medicaid-TX's duplicate claim submission rule, a CO-18 denial is warranted only when an identical claim — matching on service date, procedure codes, diagnosis codes, and provider — has previously been submitted and adjudicated. The presence of two distinct procedure codes (CPT 82667 and CPT 26683) within a single claim for a single date of service does not, on its face, constitute a duplicate. Rather, it reflects appropriate multi-procedure billing for an integrated care episode. Without evidence of a prior adjudicated claim for this exact combination of services, the duplicate designation is not substantiated, and the denial does not meet the threshold required under the applicable policy.

Furthermore, to the extent that any system-generated duplicate flag was triggered in error — for example, due to a partial match on certain claim elements without a true exact match — this constitutes an erroneous application of the CO-18 remark code and warrants correction upon manual review.

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IV. REQUESTED REMEDY

We respectfully request that Synthetic Medicaid-TX:

1. Conduct a thorough manual review of the claim submission history for Claim No. TEST-CLAIM-00017;
2. Identify and disclose the specific prior claim, if any, that serves as the alleged duplicate basis for this denial;
3. Overturn the CO-18 denial in its entirety;
4. Reprocess Claim No. TEST-CLAIM-00017 for payment of the full denied amount of $1,054.09 in accordance with the applicable fee schedule and covered benefits.

If additional documentation or clarification is required to complete this review, please contact the facility's appeals coordinator at the address or contact information provided in the header of this correspondence.

This appeal is submitted in advance of the appeal deadline of July 9, 2026. We trust that upon review of the enclosed documentation, Synthetic Medicaid-TX will agree that the CO-18 denial was issued in error and that reprocessing and payment of the denied amount is warranted.

Thank you for your prompt attention to this matter.

Respectfully submitted,

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

Enclosures:
- Claim submission history and timestamps
- Original EOB or claim adjudication record
- Itemized bill
- Patient medical record excerpt
- Proof of prior denial or non-payment