CO-16 Missing Info Appeal Letter

[PRACTICE_NAME] [PRACTICE_ADDRESS] [PRACTICE_CITY_STATE_ZIP] [PRACTICE_PHONE] [PRACTICE_FAX] NPI: [RENDERING_PROVIDER_NPI] Tax ID: [PRACTICE_TAX_ID] [DATE] [PAYER_NAME] [PAYER_CLAIMS_DEPARTMENT] [PAYER_ADDRESS] [PAYER_CITY_STATE_ZIP] Re: Corrected Claim Resubmission -- CARC CO-16 (Claim/Service Lacks Information or Has Submission/Billing Error) Patient Name: [PATIENT_FIRST_NAME] [PATIENT_LAST_NAME] Member ID: [MEMBER_ID] Date of Service: [DATE_OF_SERVICE] Original Claim Number: [ORIGINAL_CLAIM_NUMBER] To Whom It May Concern: The above-referenced claim was returned with CARC CO-16, indicating missing or invalid information. Per CO-16 protocol, this is a corrected claim resubmission rather than a formal appeal. The original submission has been reviewed and the missing or incorrect element(s) have been corrected as detailed below. ELEMENT(S) MISSING OR INVALID ON ORIGINAL SUBMISSION: [SELECT ALL THAT APPLY -- DELETE UNUSED ITEMS] [ ] Modifier missing or invalid: [DESCRIBE_MODIFIER_ISSUE] [ ] NPI missing or incorrect: [DESCRIBE_NPI_ISSUE] [ ] Taxonomy code missing or incorrect: [DESCRIBE_TAXONOMY_ISSUE] [ ] Units reported incorrectly: [DESCRIBE_UNITS_ISSUE] [ ] Diagnosis pointer missing or incorrect: [DESCRIBE_POINTER_ISSUE] [ ] Place of service code incorrect: [DESCRIBE_POS_ISSUE] [ ] Prior authorization number missing: [DESCRIBE_AUTH_ISSUE] [ ] Other: [DESCRIBE_OTHER_ISSUE] CORRECTION APPLIED: The corrected claim enclosed reflects the following changes: - [SPECIFIC_FIELD_CORRECTED]: was [ORIGINAL_VALUE], corrected to [CORRECTED_VALUE] - [ADDITIONAL_CORRECTIONS_AS_NEEDED] The corrected claim is submitted under frequency code 7 (replacement of prior claim) and references the original claim number above. All other claim data remains unchanged from the original submission. TIMELY FILING: The original claim was submitted on [ORIGINAL_SUBMISSION_DATE], which is within the [TIMELY_FILING_DAYS]-day timely filing window. This corrected resubmission is submitted on [DATE], maintaining the original timely filing protection per [PAYER_NAME] policy on resubmission of corrected claims. ENCLOSED DOCUMENTATION: 1. Corrected claim form (frequency code 7) 2. Copy of original claim with the missing/invalid element highlighted 3. Original EOB or 277CA rejection notice dated [REJECTION_DATE] 4. Supporting documentation for the corrected element (if applicable) We respectfully request that the corrected claim be processed without resetting the timely filing clock, as the original submission was timely and the resubmission corrects the issue identified in the CO-16 response. If additional information is needed, please contact our office at [PRACTICE_PHONE]. Respectfully, [BILLING_CONTACT_NAME] [BILLING_CONTACT_TITLE] [PRACTICE_NAME] [PRACTICE_PHONE] Enclosures: [NUMBER_OF_ENCLOSURES]