Appeal — TEST-CLAIM-00059

Date: [Date of Submission]

Via: [Submission Method]

Synthetic Humana
Appeals and Grievances Department
[Payer Address]

RE: Formal Appeal of Claim Denial — CO-29 Timely Filing
Claim Number: TEST-CLAIM-00059
Service Date: 2026-02-10
Denial Date: 2026-03-07
Denied Amount: $2,549.04
Appeal Deadline: 2026-05-06

To Whom It May Concern:

On behalf of [Hospital/Facility Name], we are submitting this formal first-level appeal contesting the denial of Claim TEST-CLAIM-00059, issued by Synthetic Humana on 2026-03-07. The claim was denied under reason code CO-29, citing expiration of the timely filing limit. For the reasons set forth below, we respectfully request that Synthetic Humana overturn this denial and reprocess the claim for payment of the denied amount of $2,549.04.

---

I. BACKGROUND

Services were rendered to the patient on 2026-02-10, encompassing procedures billed under CPT codes 44362, 86619, and 59941, with associated diagnoses E11.86 and J45.60. The total billed amount for this claim is $3,306.24, of which $2,549.04 was denied. The denial was issued just 25 days following the date of service.

---

II. BASIS FOR APPEAL

A. The Denial Was Issued Only 25 Days After the Date of Service

The CO-29 denial was generated on 2026-03-07 — a mere 25 days after the service date of 2026-02-10. This interval is, by any standard contractual measure, well within the universally recognized timely filing windows applicable to participating providers. Standard contractual timely filing periods in the industry range from 90 to 365 days from the date of service. A denial for untimely filing issued 25 days post-service is facially inconsistent with Synthetic Humana's own timely filing deadline policy, and we respectfully assert that the CO-29 denial code has been applied in error.

B. The Claim Was Submitted Within the Contractual Filing Period

The enclosed itemized claim submission proof, which is date-stamped, demonstrates that the claim was submitted to Synthetic Humana within the applicable contractual timely filing window. Additionally, the enclosed hospital claim submission log confirms the date on which the claim was transmitted to the payer. These records directly rebut the assertion that the time limit for filing had expired at the time of submission.

C. Payer Acknowledgment Confirms Receipt

The enclosed evidence of claim receipt — including the Explanation of Benefits and/or claim acknowledgment records — confirms that Synthetic Humana received and processed this claim. The fact that the payer issued a denial response on 2026-03-07 itself constitutes acknowledgment of receipt and further underscores that the claim was in the payer's possession well within any applicable filing deadline.

D. Payer Policy Does Not Support This Denial

Pursuant to Synthetic Humana's timely filing window policy, claims must be submitted within the contractual period measured from the date of service. As documented in the enclosed payer's timely filing deadline policy documentation, no standard interpretation of that policy could reasonably result in a CO-29 denial for a claim filed within 25 days of service. Applying the CO-29 denial code under these circumstances is inconsistent with the plain terms of the governing policy and the contractual agreement between Synthetic Humana and this facility.

---

III. SUPPORTING DOCUMENTATION ENCLOSED

The following documents are enclosed in support of this appeal:

1. Itemized claim submission proof (date-stamped)
2. Medical records documenting service date of 2026-02-10
3. Payer's timely filing deadline policy documentation
4. Evidence of claim receipt by payer (EOB and/or claim acknowledgment)
5. Hospital claim submission log or system records confirming submission date
6. Any correspondence demonstrating submission within the contractual timeframe

---

IV. REQUESTED REMEDY

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

1. Overturn the CO-29 timely filing denial on Claim TEST-CLAIM-00059;
2. Reprocess the claim in full in accordance with the applicable contractual terms and benefit provisions; and
3. Issue payment of the denied amount of $2,549.04 to [Hospital/Facility Name].

We further request written confirmation of receipt of this appeal and a determination within the timeframe required under applicable state and federal regulations and the terms of the provider agreement.

Should additional information be required to resolve this matter, please contact the Provider Relations/Appeals department at [Hospital Contact Name, Phone, and Address].

Thank you for your prompt attention to this appeal.

Respectfully submitted,

[Authorized Signature]
[Name and Title]
[Hospital/Facility Name]
[Address]
[Phone and Fax]
[Date]