Appeal — TEST-CLAIM-00002

Date: [Insert Date of Submission]

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

Re: Formal Appeal of Claim Denial — CO-18 Duplicate Claim
Claim Number: TEST-CLAIM-00002
Date of Service: 2025-12-23
Procedure Codes: CPT 71213, CPT 17100
Diagnosis Code: ICD-10 M17.51
Denied Amount: $260.30
Appeal Deadline: 2026-04-30

Dear Synthetic BCBS-TX Appeals Department,

This letter constitutes a formal appeal on behalf of [Hospital/Facility Name] regarding the denial of Claim No. TEST-CLAIM-00002, issued on January 30, 2026, under remark code CO-18 (Exact Duplicate Claim/Service). We respectfully request that Synthetic BCBS-TX reverse this denial, reprocess the claim, and issue payment of the denied amount of $260.30.

---

I. BACKGROUND AND BASIS FOR DENIAL

Synthetic BCBS-TX denied Claim No. TEST-CLAIM-00002 in the amount of $260.30, citing CO-18 — Exact Duplicate Claim/Service. The claim was submitted for services rendered on December 23, 2025, and includes CPT code 71213 (chest X-ray) and CPT code 17100 (skin lesion removal), billed under diagnosis code ICD-10 M17.51 (primary osteoarthritis, right knee).

We respectfully contest this denial. The CO-18 duplicate determination is not supported by the claim submission record, and the denial should be reversed for the reasons set forth below.

---

II. GROUNDS FOR APPEAL

Under Synthetic BCBS-TX's duplicate claim identification rule, a CO-18 denial is appropriate only when a prior paid or pending claim exists for an identical date of service, provider, and procedure codes. The payer bears the burden of demonstrating that a materially identical claim has already been paid or is currently pending adjudication. A claim that was previously denied, voluntarily withdrawn, or resubmitted to correct billing errors does not meet the standard for a valid duplicate determination.

Our review of the applicable claim submission records and claims history indicates that this submission is not an exact duplicate of a previously paid or pending claim. Specifically:

1. No Prior Paid Claim Exists for the Same Services: The enclosed claim submission records, including submission timestamps and claim reference numbers, establish that no prior claim for CPT 71213 and CPT 17100 on December 23, 2025 has been paid by Synthetic BCBS-TX. If a prior submission exists in the payer's system, it was either denied or withdrawn, and therefore cannot serve as the basis for a duplicate denial under the applicable policy standard.

2. This Submission Represents a Distinct and Valid Claim: The enclosed itemized hospital billing statement and supporting procedure documentation confirm that the services billed — CPT 71213 and CPT 17100 — were actually rendered on December 23, 2025, and are appropriately documented in the patient's medical record. The services are clinically distinct and independently supported.

3. The Payer's EOB and Claims History Do Not Support a Duplicate Finding: The enclosed Explanation of Benefits and claims history documentation should be reviewed in their entirety. To the extent any prior submission appears in the payer's system, that submission was not paid, and a denial on duplicate grounds is therefore improper. A denied or withdrawn prior claim does not constitute a "paid or pending" claim sufficient to trigger a CO-18 denial under Synthetic BCBS-TX's own duplicate claim identification rule.

4. Corrected Submissions Are Not Duplicates: To the extent this submission was made to correct a billing error present in any prior submission, such a corrected claim does not constitute an exact duplicate as a matter of both payer policy and standard industry billing practice. The claim submission records enclosed with this appeal distinguish the current submission from any prior filing.

---

III. SUPPORTING DOCUMENTATION

The following documents are enclosed in support of this appeal:

- Itemized hospital billing statement showing the December 23, 2025 date of service and procedure code breakdown
- Operative report and/or procedure note documenting the performance of CPT 71213 and CPT 17100
- Patient medical record with clinical documentation for the December 23, 2025 encounter
- Explanation of Benefits (EOB) and claims history reflecting any prior submissions related to this date of service
- Claim submission records, including submission timestamps and claim reference numbers, distinguishing this submission from any prior claims

These documents collectively establish that the services were rendered, are properly documented, and that no prior paid or pending claim for the identical services exists that would justify a CO-18 duplicate denial.

---

IV. REQUESTED REMEDY

For the foregoing reasons, [Hospital/Facility Name] respectfully requests that Synthetic BCBS-TX:

1. Reverse the CO-18 duplicate denial issued on January 30, 2026, with respect to Claim No. TEST-CLAIM-00002;
2. Reprocess the claim in full on its merits; and
3. Issue payment of the denied amount of $260.30 in accordance with the applicable plan benefits and fee schedule.

If Synthetic BCBS-TX maintains that a paid or pending claim for identical services exists, we respectfully request that the payer provide the specific claim number, payment date, and remittance detail for that prior claim so that the duplicate determination may be properly evaluated.

This appeal is being submitted in advance of the April 30, 2026 appeal deadline. Please direct any questions or requests for additional documentation to the undersigned.

Respectfully,

[Authorized Signatory Name]
[Title]
[Hospital/Facility Name]
[Address]
[Phone Number]
[Fax Number]
[Email Address]

Enclosures: As itemized in Section III above