Appeal — TEST-CLAIM-00000

Date: [Date of Submission]

Synthetic BCBS-TX
Appeals and Grievances Department
[Payer Address]

Re: Formal Appeal of Claim Denial
Claim Number: TEST-CLAIM-00000
Internal Claim ID: de21187b-9d07-45ee-bb82-ba4e799d8e31
Payer: Synthetic BCBS-TX
Service Date: February 5, 2026
Denial Date: April 17, 2026
Denied Amount: $752.09
Procedure Codes: CPT 82603, CPT 40161, CPT 87128
Diagnosis Code: M17.09
Appeal Deadline: July 16, 2026

Dear Appeals and Grievances Department,

On behalf of the undersigned facility, we are writing to formally appeal the denial issued on April 17, 2026, for Claim Number TEST-CLAIM-00000, submitted to Synthetic BCBS-TX. The claim covers services rendered on February 5, 2026, under procedure codes CPT 82603, CPT 40161, and CPT 87128, with a primary diagnosis of M17.09. The claim was denied in the amount of $752.09 under reason code CO-197: Precertification/authorization/notification absent.

We respectfully contend that this denial is factually incorrect and should be overturned. Prior authorization was properly obtained in advance of the February 5, 2026, service date, and the documentation necessary to confirm this is enclosed with this appeal.

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I. BASIS FOR DENIAL AND GROUNDS FOR APPEAL

The CO-197 denial reason asserts that precertification or authorization was absent for the billed services. However, our records — and, we submit, the payer's own records — reflect that a prior authorization request was submitted to Synthetic BCBS-TX in advance of the service date, that the payer acknowledged receipt of that request, and that authorization was approved prior to the rendering of services on February 5, 2026.

The denial therefore does not accurately reflect the administrative record and should be reversed.

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II. SUPPORTING DOCUMENTATION

The following documents are enclosed in support of this appeal:

1. Prior Authorization Approval Letter — This document, issued by Synthetic BCBS-TX, confirms that authorization was granted for the services at issue prior to the February 5, 2026, service date.

2. Precertification Request Documentation — This record identifies the date and method by which the authorization request was submitted to Synthetic BCBS-TX, establishing that precertification was sought in a timely manner before services were rendered.

3. Payer Correspondence Acknowledging Receipt — This document confirms that Synthetic BCBS-TX received the authorization request, further demonstrating that the precertification process was properly initiated and completed.

4. Hospital Internal Authorization Tracking Records — These internal records corroborate the timeline of submission and approval, confirming that all required authorization steps were completed prior to the February 5, 2026, service date.

5. Medical Records Demonstrating Medical Necessity — Enclosed medical records support the clinical appropriateness of the services rendered under CPT 82603, CPT 40161, and CPT 87128 for the diagnosis of M17.09, and are provided as additional context should any further review be required.

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III. POLICY BASIS

Synthetic BCBS-TX's prior authorization requirements are intended to ensure that covered services are reviewed and approved before they are rendered. In this instance, those requirements were satisfied. The enclosed prior authorization approval letter, precertification request documentation, and payer acknowledgment collectively demonstrate that the facility complied fully with the payer's prior authorization policy prior to the February 5, 2026, service date. The CO-197 denial code — which presupposes the complete absence of precertification — is therefore inapplicable to this claim. The payer's own records should corroborate that authorization was in place at the time services were provided.

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IV. REQUESTED REMEDY

Based on the foregoing, we respectfully request that Synthetic BCBS-TX:

1. Overturn the April 17, 2026, denial issued under CO-197 for Claim Number TEST-CLAIM-00000;
2. Reprocess the claim in full in accordance with the member's applicable benefits; and
3. Issue payment of the denied amount of $752.09.

We ask that this appeal be reviewed and a determination issued prior to the appeal deadline of July 16, 2026. Should additional information be required to complete this review, please contact the undersigned facility at the contact information provided below.

Thank you for your prompt attention to this matter. We remain committed to resolving this issue in a timely and cooperative manner.

Respectfully submitted,

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

Enclosures:
- Prior authorization approval letter from payer
- Precertification request documentation showing submission date and method
- Payer correspondence acknowledging receipt of authorization request
- Hospital internal authorization tracking records
- Medical records demonstrating medical necessity for CPT 82603, CPT 40161, and CPT 87128