Appeal — TEST-CLAIM-00055

Date: [Date of Submission]

Appeal and Grievance Department
Synthetic Medicaid-TX
[Payer Address]
[City, State, ZIP]

Re:    Formal Appeal of Claim Denial
       Claim Number:      TEST-CLAIM-00055
       Payer:             Synthetic Medicaid-TX
       Service Date:      April 28, 2026
       Denial Date:       June 13, 2026
       Denial Reason:     CO-197 – Precertification/Authorization/Notification Absent
       Billed Amount:     $2,709.46
       Denied Amount:     $2,708.27
       Appeal Deadline:   July 13, 2026

Dear Medical Appeals Review Department,

On behalf of [Facility Name] (hereinafter "the Facility"), we hereby submit this formal appeal requesting reconsideration and reversal of the denial issued on June 13, 2026, for claim TEST-CLAIM-00055. The denial was issued under adjustment reason code CO-197, citing the absence of precertification, authorization, or notification for services rendered on April 28, 2026. For the reasons detailed below, and as supported by the enclosed documentation, we respectfully assert that this denial is not warranted and request that Synthetic Medicaid-TX reprocess the claim and remit full payment of the denied amount of $2,708.27.

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I. BACKGROUND AND BASIS FOR APPEAL

On April 28, 2026, the Facility provided medically necessary services to a covered Medicaid-TX beneficiary. The claim submitted to Synthetic Medicaid-TX included charges for procedures CPT 23979 and CPT 41091, rendered in the context of diagnoses F32.45 (Major Depressive Disorder, severe with psychotic symptoms) and F32.37 (Major Depressive Disorder, severe with suicidal ideation). These diagnoses represent serious, acute psychiatric conditions requiring prompt and clinically appropriate intervention.

Synthetic Medicaid-TX denied claim TEST-CLAIM-00055 under CO-197, indicating that precertification, authorization, or notification was absent. The Facility respectfully contests this determination. As documented in the enclosed materials, prior authorization was obtained from Synthetic Medicaid-TX prior to the delivery of services on April 28, 2026. The payer's finding that no authorization existed is directly contradicted by the documentary record.

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II. GROUNDS FOR APPEAL

A. Prior Authorization Was Obtained Prior to the Date of Service

Contrary to the basis for the CO-197 denial, the Facility secured prior authorization from Synthetic Medicaid-TX before rendering services on April 28, 2026. The enclosed prior authorization approval letter issued by Synthetic Medicaid-TX confirms that authorization was granted for the procedures at issue. Additionally, the enclosed precertification request documentation — including the submission date and confirmation number — demonstrates that the Facility followed all applicable precertification procedures in a timely manner and received affirmative confirmation from the payer.

The CO-197 denial reason — precertification or authorization absent — is therefore factually unsupported. The authorization on record directly negates the sole stated basis for denial.

B. Medical Necessity Is Well-Established and Documented

The services provided via CPT 23979 and CPT 41091 were medically necessary given the patient's documented diagnoses of Major Depressive Disorder, severe with psychotic symptoms (F32.45) and Major Depressive Disorder, severe with suicidal ideation (F32.37). The treating physician's clinical notes from April 28, 2026, set forth in detail the clinical justification for the procedures performed. The enclosed letter of medical necessity further articulates the clinical rationale supporting these services. These psychiatric conditions, in their severity, required the level of intervention provided, and the care delivered was consistent with accepted standards of treatment.

C. Payer Policy Supports Reversal Upon Presentation of Authorization Documentation

Synthetic Medicaid-TX's prior authorization requirement, under which the CO-197 denial was issued, presupposes that no authorization was obtained. The Facility's appeal is grounded in the payer's own policy framework: where authorization was in fact secured and documented prior to the service date, the precondition for a CO-197 denial is not met. Submission of the enclosed authorization approval letter and precertification confirmation directly satisfies the payer's prior authorization requirement and negates the procedural basis for the denial. Upholding a CO-197 denial in the face of valid, pre-service authorization documentation would be inconsistent with the intent and application of Synthetic Medicaid-TX's own precertification policy.

D. Proof of Timely and Proper Submission

The Facility further encloses proof of timely submission of the precertification request to Synthetic Medicaid-TX, including electronic submission receipt or equivalent confirmation. This documentation establishes that the Facility fulfilled all procedural obligations required by Synthetic Medicaid-TX prior to the April 28, 2026 service date, and that any administrative discrepancy in the payer's records does not reflect a failure on the part of the Facility.

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III. ENCLOSED SUPPORTING DOCUMENTATION

In support of this appeal, the following documents are enclosed for the reviewer's consideration:

1. Prior authorization approval letter from Synthetic Medicaid-TX
2. Precertification request documentation, including submission date and confirmation number
3. Letter of medical necessity supporting CPT 23979 and CPT 41091
4. Proof of timely submission to payer (electronic submission receipt or equivalent confirmation)
5. Treating physician's clinical notes from April 28, 2026, documenting medical necessity for the procedures performed

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IV. REQUESTED REMEDY

Based on the foregoing, the Facility respectfully requests that Synthetic Medicaid-TX:

1. Overturn the June 13, 2026 denial of claim TEST-CLAIM-00055 in its entirety;
2. Reprocess the claim in accordance with the applicable Medicaid-TX fee schedule and the terms of coverage; and
3. Issue payment of the denied amount of $2,708.27 to the Facility.

This appeal is submitted in advance of the July 13, 2026 appeal deadline. Should the appeals reviewer require additional information, clarification, or supplemental documentation, please contact the Facility's billing and appeals department at the contact information provided below.

We appreciate the reviewer's thorough consideration of this appeal and the supporting documentation provided. The Facility remains committed to resolving this matter in accordance with Synthetic Medicaid-TX policy and applicable Medicaid regulations.

Respectfully submitted,

[Authorized Representative Name]
[Title]
[Facility Name]
[Address]
[Phone Number]
[Fax Number]
[Email Address]

Enclosures (5):
1. Prior authorization approval letter from Synthetic Medicaid-TX
2. Precertification request documentation with submission date and confirmation number
3. Letter of medical necessity – CPT 23979 and CPT 41091
4. Proof of timely submission to payer
5. Physician clinical notes – April 28, 2026