Appeal — TEST-CLAIM-00009

Date: [Insert Date of Submission]

Via: [Insert Submission Method — Certified Mail / Payer Portal / Fax]

Synthetic Cigna
Appeals and Grievances Department
[Payer Address]

Re:    Formal Appeal of Claim Denial
       Claim Number:       TEST-CLAIM-00009
       Payer:              Synthetic Cigna
       Service Date:       February 6, 2026
       Denial Date:        March 5, 2026
       Denial Reason:      CO-31 — Patient Cannot Be Identified as Insured
       Denied Amount:      $2,308.78
       Appeal Deadline:    July 3, 2026

To Whom It May Concern:

This letter constitutes a formal first-level appeal on behalf of our facility regarding the denial of Claim TEST-CLAIM-00009, issued by Synthetic Cigna on March 5, 2026. The claim was denied under adjustment reason code CO-31, asserting that the patient cannot be identified as an insured member of Synthetic Cigna. Our facility respectfully contests this denial in its entirety and requests that the claim be reprocessed and paid at the contracted rate for the denied amount of $2,308.78.

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I. BACKGROUND AND BASIS FOR DENIAL

Services were rendered to the patient on February 6, 2026, under CPT code 54942 and diagnosis code ICD-10 K21.64. Following adjudication, Synthetic Cigna issued a denial citing CO-31 — that the patient could not be identified as a covered insured under the plan. Our facility maintains that this denial is factually unsupported and constitutes a payer-side identification or system error, as the patient was an active, enrolled member of Synthetic Cigna on the date of service.

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II. GROUNDS FOR APPEAL

The CO-31 denial rests on the assertion that the patient's insurance status could not be confirmed. The supporting documentation enclosed with this appeal directly and comprehensively rebuts that assertion. Specifically:

1. Active Enrollment Confirmed by Payer-Issued Documentation
The enclosed enrollment verification letter from Synthetic Cigna confirms that the patient held active coverage under the plan. This document is issued by Synthetic Cigna itself and constitutes authoritative confirmation of the patient's insured status.

2. Real-Time Eligibility Verification Performed at or Near Time of Service
Prior to rendering services, our facility conducted an insurance eligibility verification. The enclosed eligibility verification report, dated on or near February 6, 2026, confirms that the patient was identified as an active covered member under Synthetic Cigna's plan at the time services were provided. Our facility relied in good faith on this confirmation when delivering care.

3. Patient Identity Verified Through Government-Issued Identification and Insurance Card
The enclosed copy of the patient's insurance card (front and back) and government-issued identification document confirm the patient's identity and membership. These documents, presented at the time of registration and admission, are consistent with the information submitted on the claim.

4. Prior Accepted Claims Establish Established Coverage History
The enclosed Explanation of Benefits or claims history documentation demonstrates that Synthetic Cigna has previously accepted and adjudicated claims for this patient under the same policy. This prior course of dealing further confirms that the patient's membership was active and recognized by the payer, and it underscores that the CO-31 denial does not reflect a genuine lapse in eligibility but rather an administrative or system-level error on the payer's part.

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III. POLICY BASIS

Synthetic Cigna's member eligibility verification requirements provide the framework for resolving eligibility disputes. Under those requirements, when a provider presents enrollment verification, a real-time eligibility confirmation, valid insurance credentials, and a prior claims history — all of which are enclosed herein — the payer is obligated to recognize the patient's coverage and adjudicate the claim accordingly. The evidence presented satisfies any reasonable standard of identity and eligibility confirmation contemplated by that policy. The denial therefore cannot stand on its stated grounds.

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IV. ENCLOSED SUPPORTING DOCUMENTATION

The following documents are enclosed in support of this appeal:

   1. Copy of patient insurance card (front and back)
   2. Patient identification document (government-issued ID)
   3. Enrollment verification letter from Synthetic Cigna
   4. Patient registration and admission records from the service date
   5. Insurance eligibility verification report dated on or near February 6, 2026
   6. Explanation of Benefits or claims history reflecting prior accepted claims under the same policy

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V. REQUESTED REMEDY

Based on the foregoing, our facility respectfully requests that Synthetic Cigna:

   (1) Overturn the CO-31 denial in full;
   (2) Reprocess Claim TEST-CLAIM-00009 in accordance with the applicable contracted terms; and
   (3) Issue payment of the denied amount of $2,308.78.

Should Synthetic Cigna require any additional documentation or clarification in order to resolve this matter, please contact our Provider Relations and Billing department at the information provided below at your earliest convenience. We are committed to cooperating fully to achieve a prompt and equitable resolution.

This appeal is being submitted within the applicable appeal filing deadline of July 3, 2026.

Respectfully submitted,

[Authorized Signatory Name and Title]
[Facility Name]
[Facility Address]
[Facility NPI]
[Contact Phone Number]
[Contact Email Address]

Enclosures: As listed in Section IV above