Appeal — TEST-CLAIM-00014

Date: [Date of Submission]

Via: [Submission Method]

Synthetic UHC
Appeals and Grievances Department
[Payer Address]

Re: Formal Appeal of Claim Denial
External Claim ID: TEST-CLAIM-00014
Internal Claim Reference: 7a7dab51-973f-4d76-b2a0-88242c4a84d0
Payer: Synthetic UHC
Service Date: 2026-03-22
Denial Date: 2026-04-08
Denied Amount: $2,225.21
Billed Amount: $4,495.18
Procedure Code: 46585
Diagnosis Codes: G43.51, G43.42
Appeal Deadline: 2026-07-07

Dear Synthetic UHC Appeals and Grievances Department,

This letter constitutes a formal first-level appeal on behalf of the provider of record regarding the denial of Claim TEST-CLAIM-00014, issued on 2026-04-08. The claim was denied in part under CARC CO-27 (Expenses incurred after coverage terminated), with $2,225.21 of the $4,495.18 total billed amount denied on eligibility grounds. We respectfully contest this determination and request that Synthetic UHC reprocess and pay the denied portion of this claim in full.

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I. BASIS FOR DENIAL AND GROUNDS FOR APPEAL

Synthetic UHC denied a portion of Claim TEST-CLAIM-00014 under CO-27, asserting that some or all services were rendered after the member's coverage had terminated. The services at issue — specifically procedure code 46585 (anoscopy with biopsy) rendered in connection with diagnoses G43.51 and G43.42 — were delivered on 2026-03-22.

We respectfully submit that this denial is factually unsupported and should be overturned for the following reasons:

1. The member maintained active coverage as of the date of service, 2026-03-22, as documented in the enclosed member eligibility verification report, which was obtained as of that specific service date. This contemporaneous verification directly contradicts the payer's assertion that coverage had lapsed prior to or on the date services were rendered.

2. The payer's own partial adjudication undermines the CO-27 denial rationale. Synthetic UHC processed and did not deny the remaining portion of this same claim — representing $2,270.97 of the $4,495.18 billed. All services reflected on this claim were rendered on the same service date of 2026-03-22. If coverage had in fact terminated prior to that date, the payer would have had grounds to deny the claim in its entirety. The fact that only a portion was denied on eligibility grounds strongly suggests that Synthetic UHC itself recognized the member's active coverage status as of the service date, raising a significant internal inconsistency in the denial rationale.

3. The insurance policy document enclosed herein reflects the member's coverage effective and termination dates. The policy's stated terms support the position that coverage was in force on 2026-03-22, and that no termination event had occurred prior to the delivery of the services at issue.

4. Hospital records documenting the actual delivery of services on 2026-03-22 are enclosed and confirm that all billed services were rendered on a single, consistent date of service, further reinforcing that the CO-27 partial denial cannot be reconciled with the claim's own internal facts.

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II. SUPPORTING DOCUMENTATION

In support of this appeal, please refer to the following enclosed documents:

- Member eligibility verification report as of the service date (2026-03-22), confirming active coverage status
- Insurance policy document reflecting the member's coverage effective and termination dates
- Explanation of Benefits (EOB) or coverage termination notice identifying the exact termination date as reported by the payer
- Hospital records documenting the actual service delivery date of 2026-03-22
- Communication records between the hospital and Synthetic UHC regarding coverage status at the time of service

Taken together, these documents establish a clear factual record that the member was covered on the date of service and that the CO-27 denial is not supported by the available eligibility information.

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III. APPLICABLE POLICY AND REGULATORY BASIS

Under Synthetic UHC's own policies governing eligibility and coverage termination date determination, a CO-27 denial requires that the payer affirmatively establish the coverage termination date and demonstrate that it preceded the date of service. As set forth in the enclosed policy documentation, no such termination had occurred as of 2026-03-22. Furthermore, the payer's internal inconsistency — denying only a portion of a single-date-of-service claim on eligibility grounds — suggests a factual or administrative error in the termination date used to adjudicate this claim.

We respectfully submit that the payer's eligibility determination does not withstand scrutiny when weighed against the contemporaneous verification records and the payer's own partial payment of the same claim.

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IV. REQUESTED REMEDY

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

1. Reopen and reprocess Claim TEST-CLAIM-00014 in full;
2. Reverse the partial CO-27 denial and issue payment of the denied amount of $2,225.21; and
3. Provide written confirmation of the corrected adjudication and the applicable coverage termination date used in the original determination.

We request that this appeal be resolved prior to the appeal deadline of 2026-07-07. Should additional information or a peer-to-peer discussion be required, please contact the provider's billing and appeals team at the contact information listed below.

Thank you for your prompt attention to this matter. We trust that upon review of the enclosed documentation, Synthetic UHC will agree that the partial CO-27 denial was issued in error and that payment of the denied amount is warranted.

Respectfully submitted,

[Provider Representative Name]
[Title]
[Provider Name]
[Provider Address]
[Provider NPI]
[Phone Number]
[Email Address]

Enclosures:
1. Member eligibility verification report (as of 2026-03-22)
2. Insurance policy document (coverage effective and termination dates)
3. Explanation of Benefits (EOB) or coverage termination notice
4. Hospital records confirming service delivery date
5. Communication records regarding coverage status at time of service