Appeal — TEST-CLAIM-00034

Date: [Date of Submission]

Via: [Submission Method]

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

Re: Formal Appeal of Claim Denial
External Claim ID: TEST-CLAIM-00034
Internal Claim Reference: fe98d71b-e3ba-41d6-aad2-17a870006ab1
Payer: Synthetic Medicaid-TX
Service Date: January 9, 2026
Denial Date: March 21, 2026
Denied Amount: $2,233.86
Appeal Deadline: April 20, 2026

Dear Synthetic Medicaid-TX Appeals and Grievances Department,

This letter constitutes a formal first-level appeal on behalf of [Hospital Name] regarding the above-referenced claim, which was denied on March 21, 2026, under reason code CO-31: "Patient cannot be identified as our insured." We respectfully request that Synthetic Medicaid-TX overturn this denial, reprocess the claim in full, and remit payment of the denied amount of $2,233.86.

---

I. BACKGROUND AND BASIS FOR DENIAL

On January 9, 2026, [Hospital Name] rendered medically necessary services to a patient presenting under Synthetic Medicaid-TX coverage. Services billed include procedures CPT 41890, 50135, and 97026, with associated diagnoses R07.70 and G43.44. The total billed amount for this claim is $4,908.31, of which $2,233.86 was denied.

On March 21, 2026, Synthetic Medicaid-TX issued a denial under CO-31, indicating that the patient could not be identified as an insured member. [Hospital Name] respectfully contests this determination. The available documentation demonstrates that the patient was an actively enrolled Synthetic Medicaid-TX beneficiary on the date of service, and that any identity mismatch that may have triggered the denial is the result of an administrative discrepancy rather than a true absence of coverage.

---

II. GROUNDS FOR APPEAL

A. The Patient Was an Actively Enrolled Medicaid-TX Beneficiary on the Date of Service

Synthetic Medicaid-TX's eligibility verification and member identity matching requirements are designed to ensure that claims are adjudicated only for enrolled beneficiaries. These requirements are not intended to result in denial of valid claims where enrollment was confirmed and any identification discrepancy is reconcilable through documentation. As Synthetic Medicaid-TX's own policy acknowledges, administrative identification errors constitute a well-recognized basis for appeal when active enrollment can be substantiated.

The enclosed supporting documentation collectively establishes that this patient was an enrolled Synthetic Medicaid-TX beneficiary on January 9, 2026, and that covered services were appropriately rendered and billed:

- The enclosed copy of the patient's insurance card (front and back) reflects the member identification information presented at the time of service.
- The enclosed patient eligibility verification report obtained from the payer confirms the patient's enrollment status and coverage details applicable to the date of service.
- The enclosed hospital registration and admission records document the patient identifiers — including name, date of birth, and member ID — as captured during the registration process.
- The enclosed proof of active policy status on January 9, 2026, directly contradicts the basis for the CO-31 denial by confirming that coverage was in effect on the service date.
- The enclosed correspondence from Synthetic Medicaid-TX, where available, further supports reconciliation of any identifying information discrepancies.

B. Any Identity Discrepancy Is Administrative in Nature and Does Not Negate Coverage

CO-31 denials arising from identity mismatches frequently result from minor administrative discrepancies — such as a transposed digit in a member ID, a name suffix variation, or a date-of-birth entry difference — rather than from a genuine absence of enrollment. The enclosed documentation reconciles these potential discrepancies and demonstrates that the patient receiving services on January 9, 2026, is the same individual enrolled under Synthetic Medicaid-TX. Denial of a valid claim on the basis of a reconcilable administrative error would be inconsistent with the payer's own eligibility verification policy and with standard Medicaid program integrity principles.

C. The Billed Services Were Medically Necessary and Appropriately Rendered

The procedures rendered on January 9, 2026 (CPT 41890, 50135, and 97026) were medically necessary for the treatment of the patient's documented conditions. The enclosed letter of medical necessity and supporting clinical documentation further substantiate the appropriateness of the services provided. While the denial is grounded in eligibility rather than medical necessity, [Hospital Name] provides this documentation to present a complete record for the payer's review.

---

III. REQUESTED REMEDY

[Hospital Name] respectfully requests that Synthetic Medicaid-TX:

1. Overturn the CO-31 denial issued on March 21, 2026, for External Claim ID TEST-CLAIM-00034;
2. Reprocess the claim in full upon confirmation of the patient's enrollment and identity as supported by the enclosed documentation; and
3. Issue payment of the denied amount of $2,233.86 in accordance with the applicable Synthetic Medicaid-TX fee schedule and the terms of the provider agreement.

Please note that this appeal must be resolved no later than April 20, 2026, per the stated appeal deadline.

---

IV. ENCLOSED DOCUMENTATION

The following documents are enclosed in support of this appeal:

1. Copy of patient insurance card (front and back)
2. Patient eligibility verification report from payer
3. Hospital registration and admission records with patient identifiers
4. Proof of active policy status on January 9, 2026
5. Correspondence from payer confirming patient identity match (if available)
6. Letter of medical necessity
7. This appeal letter

---

We appreciate Synthetic Medicaid-TX's thorough review of this appeal. [Hospital Name] is committed to resolving this matter collaboratively and in accordance with applicable Medicaid policy. Should your appeals department require any additional information or clarification, please contact our Billing and Appeals Department at [Contact Name, Phone Number, and/or Email].

Respectfully submitted,

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