May 20, 2026 Claims Appeals Department [Insurance Company Name] [Payer Address Line 1] [City, State ZIP] RE: Formal Appeal — Claim ID CLM-1008 Patient: David Kim Date of Service: 2025-04-08 Procedure Code: 99214 Billed Amount: $675.50 Denial Reason: Coordination of benefits required Appeal Reference: CLM-1008-20260520 To Whom It May Concern: We are writing on behalf of Feezza Inc. and our client facility to formally appeal the denial of the above-referenced claim. This appeal is submitted in accordance with your plan's internal appeals process and applicable federal and state regulations governing claims disputes. We have reviewed the coordination of benefits status for this patient and confirmed the correct payer order for 2025-04-08. The primary payer's explanation of benefits is attached for your review, showing the amount paid and the patient's remaining liability. We request that you process this claim in accordance with your standard COB policy and applicable state coordination of benefits regulations. The total billed amount of $675.50 should be adjudicated based on the primary payer's payment and your plan's COB calculation methodology. We respectfully request that this claim be reconsidered and reprocessed for payment in full within the timeframe required by applicable prompt pay regulations. Please confirm receipt of this appeal in writing and advise if any additional documentation is required to complete your review. Sincerely, Hospital Billing & Revenue Cycle Team Feezza Inc. | Wintora wintora.ai · legal@feezza.com Appeal Reference: CLM-1008-20260520 --- DISCLAIMER: This appeal letter was generated with the assistance of Wintora software by Feezza Inc. The clinical and administrative assertions contained herein are based on information provided by the submitting provider and have been auto-generated using established claims appeal frameworks. This letter should be reviewed by an authorized representative of the provider prior to submission. Feezza Inc. makes no warranty regarding the outcome of any appeal.