How does Counterclaim generate an insurance appeal letter?

Counterclaim uses a 5-agent AI pipeline. The Reader extracts claim data from your document. The Researcher identifies applicable state insurance law. The Writer drafts a formal appeal letter. The Adversary identifies weaknesses. The Editor rewrites the letter to eliminate all weaknesses. The final letter is ready to print and mail in minutes.

Is Counterclaim free to use?

Yes - Counterclaim is free during the launch period. Upload your denial letter and receive a complete adversary-tested appeal letter at no cost. No account required.

What types of insurance denials can Counterclaim handle?

Counterclaim handles all major denial types: medical necessity (CO-50), prior authorization (CO-11), experimental treatment (PR-1), fee schedule (CO-45), timely filing (PR-27), not covered (CO-4), step therapy (PR-50), and missing information (CO-16).

What file formats does Counterclaim accept?

Counterclaim accepts PDF files, JPG and PNG photos, and scanned documents of your denial letter or Explanation of Benefits (EOB).

Does Counterclaim provide legal advice?

No. Counterclaim generates appeal letters based on publicly available legal and clinical information but does not constitute legal advice. For complex cases, consult a licensed healthcare attorney or certified patient advocate.

How does the Texas IRO process work?

After internal appeal denial, the patient or provider files an IRO request with the insurer. The insurer forwards the file to TDI which randomly assigns an IRO. The IRO decision is binding.

Can I get a same-specialty peer reviewer in Texas?

Yes - HMO plans under chapter 1271 must offer a peer-to-peer with a reviewer in the same specialty. Request this in writing.

Does the IRO process apply to my self-funded ERISA plan?

No. Self-funded ERISA plans use the federal external-review process or the plan's contracted IRO. Only fully insured TDI-regulated plans use the chapter 4202 IRO process.

Medical Necessity · Texas

Appeal a Medical Necessity Denial in Texas

Texas patients have one of the strongest external-review processes in the country. Texas Insurance Code chapter 4202 establishes the IRO process, and the IRO's decision is binding on the insurer.

When a Texas insurer denies care as not medically necessary, the patient (or provider with patient consent) can request IRO review after exhausting the internal appeal. Chapter 4202 specifies that the IRO is randomly assigned by TDI, the patient does not pay, and the insurer pays the IRO fee.

Your appeal letter should identify the specific UM criterion the insurer applied (insurers must provide UM criteria on request under chapter 4201), establish how the patient's case meets that criterion (or how the criterion conflicts with current standard of care), and request IRO escalation if the internal appeal is denied.

For HMO plans, Texas Insurance Code chapter 1271 also gives the patient the right to a peer-to-peer reviewer in the same specialty as the patient's treating physician.

Statutes and resources cited

Texas Insurance Code chapter 4202 (Independent Review Organizations)
Texas Insurance Code chapter 4201 (Utilization Review Agents - UM criteria disclosure)
Texas Insurance Code chapter 1271 (HMO peer reviewer in same specialty)
TDI IRO Information Line: 1-866-554-4926

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Frequently asked questions

Denial code guide

Other high-intent guides

Appeal a Prior Authorization Denial in California

Appeal an Experimental Treatment Denial in New York

Appeal a Mental Health Parity Denial in Florida

Appeal an Out-of-Network Denial in Illinois

Appeal a Step Therapy Denial in Pennsylvania

Appeal a Balance Bill in Georgia