Appeal — TEST-CLAIM-00046

Date: [Date of Submission]

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

Re: Formal Appeal of Timely Filing Denial
External Claim ID: TEST-CLAIM-00046
Claim ID (Internal): 7e89d6dd-aede-46b4-bbee-f1ac102d7499
Payer: Synthetic BCBS-TX
Date of Service: April 4, 2026
Denial Date: June 19, 2026
Denied Amount: $1,527.64
Procedure Codes: CPT 11792, 82384, 63476
Diagnosis Code: ICD-10 J45.14
Appeal Deadline: September 17, 2026

Dear Appeals and Grievances Review Department,

This letter constitutes a formal first-level appeal on behalf of [Hospital Name] regarding the denial of Claim No. TEST-CLAIM-00046, issued by Synthetic BCBS-TX on June 19, 2026. The claim was denied under adjustment reason code CO-29, indicating that the time limit for filing has expired. We respectfully contest this determination and request that the claim be reprocessed and paid in full for the denied amount of $1,527.64.

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I. BASIS FOR DENIAL AND GROUNDS FOR APPEAL

The denial asserts that the claim for services rendered on April 4, 2026 was submitted outside the contractually permissible timely filing window. We dispute this assertion on the following grounds:

• The hospital's billing system records and electronic submission logs demonstrate that the claim was submitted within the applicable filing deadline as defined by the payer's contract and/or applicable state insurance regulations. The enclosed hospital billing system records document the precise filing date and confirm timely submission.

• Electronic transmittal records and/or payer receipt acknowledgment documentation — enclosed herewith — provide affirmative proof that the claim reached Synthetic BCBS-TX within the required timeframe. A CO-29 denial cannot be sustained where the provider holds evidence of timely receipt by the payer.

• To the extent any delay in the claim reaching final processing occurred, the enclosed documentation of claim resubmissions and, where applicable, the explanatory letter addressing any contributing factors (including but not limited to system errors, retroactive authorization processing, or payer-side processing delays) supports application of the timely filing exception provisions recognized under Synthetic BCBS-TX's own timely filing policy.

• The payer's timely filing policy explicitly contemplates exceptions where documented evidence — such as electronic submission logs, transmittal records, or payer receipt acknowledgments — demonstrates that the provider acted within the required period, or where extenuating circumstances contributed to any delay. The evidence enclosed satisfies this standard.

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II. SUPPORTING DOCUMENTATION ENCLOSED

In support of this appeal, [Hospital Name] has enclosed the following documents:

1. Hospital billing system records showing the claim filing date for Claim No. TEST-CLAIM-00046
2. Proof of timely claim submission, including electronic submission logs and/or claim transmittal records
3. Payer correspondence or system-generated acknowledgment confirming receipt of the claim
4. Documentation of any claim resubmissions, with corresponding dates
5. Letter explaining any factors that may have contributed to filing or processing delays, if applicable
6. Relevant provisions of the provider contract and/or applicable state insurance regulations defining the filing deadline and exception criteria

These documents collectively establish that the claim was filed within the permissible window, or alternatively, that any deviation qualifies for exception under the applicable policy provisions.

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III. POLICY AND CONTRACTUAL BASIS

The CO-29 denial reason code is properly subject to appeal where the provider can produce affirmative evidence of timely submission. Synthetic BCBS-TX's timely filing policy, as reflected in the governing provider agreement and applicable regulatory framework, recognizes that a denial on timely filing grounds is not appropriate when the provider holds documentation — including electronic submission logs, transmittal records, or payer receipt acknowledgments — confirming submission within the required period. Furthermore, the policy acknowledges that payer-side delays, system errors, or retroactive authorization processing may constitute valid grounds for exception. The enclosed evidence directly addresses each of these criteria.

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IV. REMEDY REQUESTED

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

1. Overturn the CO-29 timely filing denial issued on June 19, 2026 with respect to Claim No. TEST-CLAIM-00046;
2. Reprocess the claim in its entirety for services rendered on April 4, 2026, under CPT codes 11792, 82384, and 63476; and
3. Issue payment of the denied amount of $1,527.64 in accordance with the applicable contract rates.

We ask that this appeal be reviewed and a determination rendered prior to the appeal deadline of September 17, 2026. Should additional information be required to complete this review, please contact the undersigned at the information provided below at your earliest convenience.

Thank you for your prompt attention to this matter. [Hospital Name] remains committed to resolving this dispute through the appropriate appeals process and appreciates the opportunity to present this documentation for reconsideration.

Respectfully submitted,

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

Enclosures: As listed in Section II above