Appeal — TEST-CLAIM-00080

Date: [Date of Submission]

To: Appeals and Grievances Department
Synthetic UHC
[Payer Address]

Re: Formal Appeal of Claim Denial – Timely Filing
External Claim ID: TEST-CLAIM-00080
Internal Claim ID: b3d4aa9d-8a4a-46d1-a83e-78dcff684536
Payer: Synthetic UHC
Date of Service: April 29, 2026
Denial Date: June 1, 2026
Denied Amount: $4,057.18
Procedure Codes: CPT 74764, 70811, 83889
Diagnosis Codes: F32.82, F32.41
Appeal Deadline: August 30, 2026

Dear Appeals and Grievances Department,

This letter constitutes a formal first-level appeal on behalf of [Hospital/Facility Name] regarding the denial of Claim TEST-CLAIM-00080, issued by Synthetic UHC on June 1, 2026. The claim was denied under CARC CO-29, citing expiration of the applicable timely filing limit. We respectfully contest this denial and request that the claim be reprocessed and payment of $4,057.18 be issued in full.

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I. GROUNDS FOR APPEAL

The CO-29 denial asserts that Claim TEST-CLAIM-00080 was submitted outside of Synthetic UHC's required filing window. We dispute this determination. The enclosed documentation demonstrates that the claim was submitted to Synthetic UHC within the applicable timely filing period following the date of service of April 29, 2026. The denial, issued as early as June 1, 2026, itself suggests that the claim was received and processed by Synthetic UHC within a short interval following service, which is consistent with timely submission.

The applicable payer policy governing timely filing requires that claims be received within the plan's designated filing window from the date of service. As evidenced by the documents enclosed herein, the original claim submission was made on a date that falls within that window. The CO-29 denial is therefore not supported by the facts of record and should be overturned.

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II. SUPPORTING EVIDENCE

In support of this appeal, the following documentation is enclosed:

1. Claim Submission Records – Hospital billing department records documenting the original submission date, method of submission, and workflow confirmation, establishing that the claim was transmitted to Synthetic UHC within the required filing period.

2. Proof of Timely Submission – Certified mail receipts and/or carrier tracking confirmation, or electronic submission acknowledgment, demonstrating that the claim was delivered to or received by Synthetic UHC within the applicable filing window.

3. Payer Correspondence or Acknowledgment – Any available Explanation of Benefits (EOB) or initial claim acknowledgment from Synthetic UHC dated within the filing period, corroborating that the claim was in the payer's possession prior to expiration of the deadline.

4. Evidence of Payer or Third-Party Processing Delays – To the extent that any delay in processing is attributable to Synthetic UHC or a third-party intermediary rather than to the submitting facility, this documentation is included to establish that the provider acted in good faith and in a timely manner.

Taken together, these records establish that [Hospital/Facility Name] fulfilled its obligation to submit the claim within the applicable timeframe, and that the CO-29 denial is factually unsupported.

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III. POLICY BASIS FOR OVERTURN

Under Synthetic UHC's timely filing policy, a denial on the basis of CO-29 is properly contestable when the provider can produce documentary proof of original submission — including but not limited to certified mail receipts, carrier tracking confirmation, electronic submission records, or payer acknowledgment — demonstrating that the claim was received or submitted within the required filing window. The enclosed records satisfy this standard. Where such proof exists, the timely filing denial lacks a valid basis and the claim must be reprocessed as if timely filed.

Furthermore, to the extent that any processing delay was caused by factors outside the control of [Hospital/Facility Name], including payer-side processing errors or third-party intermediary issues, applicable provider agreement terms and regulatory guidance further support reversal of the denial.

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IV. REQUESTED REMEDY

Based on the foregoing, [Hospital/Facility Name] respectfully requests that Synthetic UHC:

1. Overturn the CO-29 timely filing denial issued on June 1, 2026, for Claim TEST-CLAIM-00080;
2. Reprocess the claim in its entirety for CPT codes 74764, 70811, and 83889, rendered on April 29, 2026; and
3. Issue payment of the denied amount of $4,057.18 in accordance with the applicable contracted rate and plan benefits.

We respectfully ask that this appeal be reviewed and resolved prior to the appeal deadline of August 30, 2026. Should additional information be required to complete this review, please contact the undersigned at the information provided below.

Thank you for your prompt attention to this matter.

Respectfully submitted,

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

Enclosures:
- Claim submission records (billing department documentation)
- Proof of timely mailing or electronic submission (certified mail receipt / carrier tracking / clearinghouse confirmation)
- Payer correspondence or claim acknowledgment dated within the filing period
- Evidence of any payer or third-party processing delays
- Hospital billing workflow records