Appeal — TEST-CLAIM-00095

[Hospital Letterhead]

Date: [Appeal Preparation Date]

Appeals and Grievances Department
Synthetic UHC
[Payer Address]

Re:     Formal Appeal – Prior Authorization Overage Denial
        Claim Number:       TEST-CLAIM-00095
        Payer:              Synthetic UHC
        Service Date:       May 12, 2026
        Denial Date:        June 5, 2026
        Denial Code:        CO-198 (Precertification/Authorization Exceeded)
        Billed Amount:      $3,154.89
        Denied Amount:      $3,051.99
        Procedure Codes:    CPT 76496, 76535, 82633
        Diagnosis Code:     ICD-10 S82.60
        Appeal Deadline:    September 3, 2026

Dear Appeals and Grievances Reviewer:

On behalf of [Hospital/Facility Name], we respectfully submit this formal first-level appeal contesting the denial issued on June 5, 2026, for the above-referenced claim (TEST-CLAIM-00095). Synthetic UHC denied $3,051.99 of the $3,154.89 billed under reason code CO-198, asserting that the services rendered exceeded the scope or amount of the precertification on file. For the reasons set forth below, and supported by the enclosed documentation, we respectfully request that Synthetic UHC overturn this denial, reprocess the claim, and issue payment of the full denied amount of $3,051.99.

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I. BACKGROUND

On May 12, 2026, our facility provided imaging and laboratory services (CPT codes 76496, 76535, and 82633) to a covered member presenting with a fracture of an unspecified part of the lower leg (ICD-10 S82.60). Prior to rendering services, our facility obtained the required precertification from Synthetic UHC in accordance with the plan's prior authorization requirements. The services delivered on May 12, 2026, were consistent in both clinical scope and procedural content with those submitted for and approved under that authorization.

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II. BASIS FOR DENIAL AND GROUNDS FOR APPEAL

Synthetic UHC has denied this claim under CO-198, indicating that the precertification or authorization was exceeded. We respectfully dispute this characterization. The enclosed prior authorization approval letter documents the authorization granted for the specific imaging and laboratory procedures performed on the date of service. A careful reconciliation of the authorized procedures and amounts against the enclosed itemized billing statement demonstrates that the billed services — CPT 76496, 76535, and 82633 — fall squarely within the authorized scope of service for the diagnosis of lower-leg fracture (S82.60).

Our review of the available documentation indicates that any discrepancy between the authorized amount and the billed amount is attributable to a payer-side calculation error or billing adjustment, rather than to any provider-initiated expansion of service scope beyond what was precertified. No additional procedures were added, no new diagnoses were introduced, and no services were rendered outside the clinical parameters of the approved authorization.

Pursuant to Synthetic UHC's own prior authorization limit and scope requirement, a CO-198 denial is appropriate only when a provider actually renders services that exceed the terms of the granted authorization. Where, as here, the billed services correspond directly to the authorized procedures and the claimed overage appears to result from an internal calculation discrepancy rather than a genuine scope overrun, the denial does not meet the policy standard for a CO-198 reduction and should be reversed.

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III. SUPPORTING EVIDENCE

In support of this appeal, we enclose the following documentation:

1. Prior Authorization Approval Letter – Confirming the authorization granted prior to the May 12, 2026, date of service, including the authorized procedures and applicable parameters.

2. Claim Submission Documentation – Reflecting the service date, the procedures billed, and the authorized amount at the time of submission, demonstrating alignment between the authorization and the claim.

3. Itemized Billing Statement – Providing a line-by-line reconciliation of CPT codes 76496, 76535, and 82633, with corresponding charges, confirming that no services beyond the authorized scope were billed.

4. Medical Records Supporting Medical Necessity – Clinical documentation establishing that the imaging and laboratory services were medically necessary and appropriate for the treatment of ICD-10 S82.60 (fracture of unspecified part of lower leg) on the date of service.

5. Correspondence with Payer Regarding Authorization Limits – Documentation of any prior communications with Synthetic UHC concerning the authorization terms, providing additional context for the claimed discrepancy.

Taken together, this documentation establishes that the services billed were authorized, medically necessary, and consistent in scope with the precertification on file. There is no factual or policy basis for the CO-198 denial as applied to this claim.

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IV. REQUESTED REMEDY

We respectfully request that Synthetic UHC:

1. Overturn the CO-198 denial issued on June 5, 2026, for claim TEST-CLAIM-00095;
2. Reprocess the claim in full; and
3. Issue payment of the denied amount of $3,051.99 in accordance with the member's applicable plan benefits and the provider's contractual terms.

Should additional information be required to complete the review of this appeal, please contact our Appeals and Billing Department at [Contact Name, Phone Number, and/or Email Address]. We are committed to working collaboratively with Synthetic UHC to resolve this matter promptly and accurately.

This appeal is submitted in advance of the September 3, 2026, appeal deadline.

Respectfully submitted,

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

Enclosures:
  1. Prior Authorization Approval Letter
  2. Claim Submission Documentation
  3. Itemized Billing Statement
  4. Medical Records Supporting Medical Necessity
  5. Correspondence with Payer Regarding Authorization Limits