Appeal — TEST-CLAIM-00066

Date: [Date of Submission]

Appeal Review Department
Synthetic BCBS-TX
[Payer Address]

Re: Formal Appeal of Claim Denial
Claim Number: TEST-CLAIM-00066
Payer: Synthetic BCBS-TX
Date of Service: February 14, 2026
Denial Date: April 15, 2026
Denied Amount: $1,990.78
Denial Code: CO-31
Appeal Deadline: July 14, 2026

Dear Appeals Review Officer,

This letter constitutes a formal appeal on behalf of [Hospital/Facility Name] contesting the denial issued on April 15, 2026, for Claim Number TEST-CLAIM-00066. We respectfully request that Synthetic BCBS-TX overturn this denial, reprocess the claim, and remit full payment of the denied amount of $1,990.78.

I. STATEMENT OF DENIAL

Synthetic BCBS-TX denied a portion of the above-referenced claim under denial code CO-31, citing that the patient cannot be identified as an insured member of the plan. The claim was submitted for services rendered on February 14, 2026, and billed at a total of $3,050.13, encompassing procedures CPT 15683, 96363, and 78347 performed in connection with diagnoses R07.82 (chest pain) and M17.07 (knee osteoarthritis). The denied portion of the claim amounts to $1,990.78.

We respectfully assert that this denial is without merit and is directly contradicted by documentation confirming the patient's active enrollment and eligibility with Synthetic BCBS-TX as of the date of service.

II. BASIS FOR APPEAL

The CO-31 denial rests solely on the payer's assertion that the patient could not be identified as an active insured member. However, our facility possesses contemporaneous documentation establishing that the patient was, in fact, an active, verified member of the Synthetic BCBS-TX plan at the time services were rendered on February 14, 2026. The denial does not reflect a deficiency in coverage or medical necessity; rather, it represents an administrative identification discrepancy that is fully refuted by the enclosed supporting documentation.

Synthetic BCBS-TX's eligibility verification and member identification requirements provide that a claim may be denied under CO-31 when a patient cannot be confirmed as an active insured. However, this standard equally requires that the payer give due consideration to enrollment records and member identification documentation submitted by the provider in support of an appeal. The enclosed documentation satisfies this standard and establishes eligibility beyond reasonable dispute.

III. SUPPORTING DOCUMENTATION

In support of this appeal, we are enclosing the following documents:

1. Insurance card or member ID verification — confirming the patient presented valid Synthetic BCBS-TX member identification at the time of service on February 14, 2026.

2. Enrollment verification letter from payer — payer-issued documentation confirming the patient's active enrollment status.

3. Patient demographics and registration form — our facility's registration records reflecting the member identification information collected at the time of service.

4. Explanation of Benefits (EOB) or prior authorization documentation — demonstrating payer acknowledgment of active coverage applicable to the service date.

5. Policy effective dates documentation — confirming the patient's coverage was in force as of February 14, 2026.

Collectively, these documents establish that the patient was an active, eligible member of the Synthetic BCBS-TX plan on the date services were rendered, and that our facility took appropriate steps to verify eligibility prior to and at the time of service. The CO-31 denial is therefore factually and administratively unsupported.

IV. REQUESTED REMEDY

Based on the foregoing, we respectfully request that Synthetic BCBS-TX:

1. Overturn the CO-31 denial issued on April 15, 2026, for Claim Number TEST-CLAIM-00066;
2. Reprocess the claim in full in accordance with the patient's applicable plan benefits; and
3. Remit payment of the denied amount of $1,990.78 to [Hospital/Facility Name] promptly upon completion of reprocessing.

V. CONCLUSION

Our facility is committed to working collaboratively with Synthetic BCBS-TX to resolve this matter expeditiously. The patient's eligibility as an active member of the plan on February 14, 2026, is clearly supported by the enclosed documentation, and we are confident that a thorough review will result in the reversal of this denial and full reimbursement of the denied amount.

Should you require any additional information or documentation to complete your review, please contact our appeals coordinator at [Contact Name], [Phone Number], [Email Address].

Thank you for your prompt attention to this matter.

Respectfully submitted,

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

Enclosures:
- Insurance card or member ID verification
- Enrollment verification letter from payer
- Patient demographics and registration form
- Explanation of Benefits (EOB) or prior authorization documentation
- Policy effective dates documentation