Appeal — TEST-CLAIM-00047

Date: [Date of Letter]

Appeals and Grievances Department
Synthetic Medicaid-TX
[Payer Address]

Re: Formal Appeal of Claim Denial — Timely Filing (CO-29)
External Claim ID: TEST-CLAIM-00047
Payer: Synthetic Medicaid-TX
Date of Service: March 19, 2026
Denial Date: June 4, 2026
Procedure Codes: CPT 73242, 71894
Diagnosis Code: R07.70
Denied Amount: $6,077.73

Dear Appeals and Grievances Department,

On behalf of [Hospital/Facility Name], we are submitting this formal appeal in response to the denial of the above-referenced claim. Synthetic Medicaid-TX issued a denial on June 4, 2026, citing CO-29 — "The time limit for filing this claim has expired." We respectfully contest this determination and request that the claim be reprocessed and payment issued for the full denied amount of $6,077.73.

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I. GROUNDS FOR APPEAL

The timely filing denial is not supported by the facts of this claim. The enclosed claim submission documentation demonstrates that this claim was transmitted to Synthetic Medicaid-TX within the applicable timely filing window following the date of service of March 19, 2026. The denial should therefore be overturned on the basis that the claim was filed in a timely and compliant manner.

Specifically, we assert the following:

  • The claim was submitted within the payer's required timely filing period. The enclosed hospital billing system records and claim transmission documentation establish the date on which this claim was transmitted to Synthetic Medicaid-TX. That transmission date falls within the applicable filing deadline, and the CO-29 denial is therefore factually inaccurate.

  • Electronic submission acknowledgment confirms payer receipt. The enclosed electronic submission acknowledgment or payer claim receipt confirmation provides objective, system-generated evidence that Synthetic Medicaid-TX received this claim. This acknowledgment constitutes proof of timely filing and directly rebuts the basis for the CO-29 denial code.

  • Any delay between transmission and payer processing is attributable to clearinghouse or payer-side processing, not to late filing by the hospital. Should any gap exist between the hospital's transmission date and the payer's internal receipt date, the enclosed documentation of clearinghouse transmission records demonstrates that such a delay was outside the hospital's control. Under standard Medicaid timely filing policy, delays attributable to clearinghouse or payer processing should not be counted against the submitting provider.

  • The services rendered — imaging procedures (CPT 73242 and 71894) performed for a patient presenting with chest pain (ICD-10 R07.70) — were medically appropriate and covered under the applicable benefit plan, and there is no clinical or coverage basis for denial.

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II. POLICY BASIS

Synthetic Medicaid-TX's timely filing policy requires that claims be submitted within a defined period from the date of service. As set forth above, the enclosed submission records confirm that this claim was transmitted in compliance with that requirement. Where a provider presents documentary evidence of timely submission — including system-generated billing records and electronic acknowledgment — payer policy and applicable Medicaid guidelines require that the claim be accepted and adjudicated on the merits rather than denied on procedural grounds.

A CO-29 denial is appropriate only when no credible evidence of timely submission exists. In this case, such evidence exists and is enclosed with this letter.

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III. SUPPORTING DOCUMENTATION ENCLOSED

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

  1. Claim submission receipt or tracking documentation
  2. Hospital billing system records reflecting the claim transmission date
  3. Payer claim receipt confirmation or electronic submission acknowledgment
  4. Clearinghouse transmission records (if applicable), documenting any processing intervals outside the hospital's control
  5. Letter of explanation regarding the circumstances of submission (if applicable)

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IV. REQUESTED REMEDY

We respectfully request that Synthetic Medicaid-TX:

  1. Overturn the CO-29 timely filing denial for Claim ID TEST-CLAIM-00047;
  2. Reprocess the claim on its merits in accordance with the applicable coverage guidelines; and
  3. Issue payment of the denied amount of $6,077.73 to [Hospital/Facility Name].

Please note that the appeal deadline for this matter is July 4, 2026. We respectfully request a timely response to allow for any further action if necessary.

If additional information is required to complete the review of this appeal, please do not hesitate to contact the undersigned at [Contact Name, Phone Number, and/or Email Address].

Thank you for your prompt attention to this matter.

Respectfully submitted,

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