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 do I file a Medicare appeal?

Original Medicare: complete CMS Form 20027 (Medicare Redetermination Request) and mail it to the Medicare Administrative Contractor (MAC) listed on your Medicare Summary Notice. Medicare Advantage: file a written 'reconsideration' request with the MA plan within 60 days of the denial. Part D: file a coverage determination request with your plan, then redetermination if denied.

How long do I have to appeal a Medicare denial?

Original Medicare Level 1 (Redetermination): 120 days from receipt of the MSN. Medicare Advantage Level 1 (Reconsideration): 60 days. Part D coverage determination: typically 60 days. Standard decision deadlines are 60 days (Original Medicare), 30 days pre-service / 60 days payment (MA), 72 hours expedited.

What is the MAXIMUS Federal Services IRE?

The Independent Review Entity is a CMS-contracted independent reviewer that handles Medicare Advantage Level 2 appeals. If your MA plan denies the reconsideration, the case is automatically forwarded to MAXIMUS - you do not need to file separately. MAXIMUS reviews the file and issues a binding decision.

Can I appeal a Medicare SNF discharge notice?

Yes. If the SNF gives you a Notice of Medicare Non-Coverage (NOMNC) saying Medicare will stop paying, you have the right to an immediate review by the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) before discharge. Call the QIO number on the NOMNC by midnight of the day before the proposed discharge.

Does Counterclaim handle Medicare Part D drug appeals?

Yes. Part D follows a coverage-determination then redetermination structure. Counterclaim drafts the coverage-determination request or redetermination at the appropriate level with the formulary exception, prior-authorization override, or step-therapy override language as applicable.

What is the Jimmo v. Sebelius settlement and how does it help my appeal?

Jimmo v. Sebelius is a 2013 federal court settlement that clarified that Medicare coverage of skilled care (skilled nursing facility, home health, outpatient therapy) does not require demonstrated patient improvement - the 'maintenance standard' applies. Coverage is appropriate when skilled care is needed to maintain the patient's condition or prevent deterioration. Cite Jimmo explicitly in SNF, home-health, and outpatient-therapy appeals where the denial is based on lack of improvement.

What is the difference between observation and inpatient admission?

Inpatient admission triggers Medicare Part A coverage with associated inpatient deductible; observation status is billed under Part B with potentially higher out-of-pocket costs. The CMS two-midnight rule generally requires inpatient admission when the physician expects the patient to need at least two midnights of hospital care. If your hospital stay was billed as observation when it should have been inpatient, the appeal can request reclassification under the two-midnight rule and the relevant Medicare benefit policy manual provisions.

How do I appeal a Medicare Advantage prior-authorization denial?

File a written 'reconsideration' request with the MA plan within 60 days of the denial. Include the member ID, the authorization number, the requested service, the clinical evidence supporting medical necessity, and a physician statement. Cite the relevant Medicare benefit policy manual section and the 2024 CMS final rule requiring MA plans to honor traditional Medicare coverage criteria. Mark expedited if delay would jeopardize health - 72-hour decision required. After plan reconsideration denial, the case auto-forwards to MAXIMUS at level 2.

What is a Medicare Notice of Medicare Non-Coverage and how do I respond?

A NOMNC is the written notice that a Skilled Nursing Facility, home-health agency, or comprehensive outpatient rehabilitation facility gives you when they intend to discharge you because they believe Medicare will no longer pay. To dispute a NOMNC, call the BFCC-QIO number on the notice by midnight of the day before the proposed discharge. The QIO conducts an immediate review and the provider cannot discharge until the QIO decides.

Medicare

Medicare Denial Appeal - Free AI Letter Generator | Counterclaim

Medicare appeals have a specific 5-level CMS structure. Upload your Medicare Summary Notice (MSN), Medicare Advantage denial, or Part D coverage determination and our 5-agent AI pipeline drafts an appeal at the correct level with the right form and deadline.

Medicare is the federal health insurance program for people aged 65 and over, and for younger people with certain disabilities or end-stage renal disease. Medicare is administered by the Centers for Medicare & Medicaid Services (CMS) within HHS, and it has four main parts: Part A (hospital inpatient), Part B (outpatient and physician services), Part C (Medicare Advantage, the private-insurer alternative to Original Medicare A+B), and Part D (prescription drug coverage). The appeal procedure depends on which part of Medicare issued the denial. Original Medicare (A and B) appeals run through Medicare Administrative Contractors (MACs), Qualified Independent Contractors (QICs), Administrative Law Judges at the Office of Medicare Hearings and Appeals (OMHA), the Medicare Appeals Council, and ultimately federal court - the classic 5-level structure. Medicare Advantage appeals run through the MA plan first (reconsideration), with auto-forwarding to MAXIMUS Federal Services as the CMS-contracted Independent Review Entity at level 2, then ALJ, MAC, and federal court. Part D follows a parallel structure starting with the plan's coverage determination. The appeal forms (CMS-20027, CMS-20033, CMS-1696 for Appointment of Representative, etc.) are specific to the level and product.

Medicare at a glance

Members served: Over 65 million beneficiaries enrolled in Medicare nationwide (per CMS public reporting), of whom roughly half are enrolled in Medicare Advantage and half in Original Medicare with optional Part D.
Headquarters: Baltimore, Maryland (CMS, the federal agency that administers Medicare)
Internal appeal deadline: Original Medicare Level 1: 120 days from receipt of the MSN. Medicare Advantage Level 1: 60 days from the denial. Part D coverage determination: typically 60 days.
Decision timeline: Standard: 60 days (Original Medicare Level 1); 30 days pre-service / 60 days payment (Medicare Advantage); 7 days standard / 24 hours expedited (Part D coverage determination). Expedited: 72 hours for urgent / expedited Medicare Advantage and Part D.
External review: Qualified Independent Contractor (QIC) at Original Medicare Level 2; MAXIMUS Federal Services at Medicare Advantage Level 2; OMHA Administrative Law Judge at Level 3; Medicare Appeals Council at Level 4; federal court at Level 5.
Parent company / structure: Centers for Medicare & Medicaid Services (CMS), HHS · Original Medicare (Parts A and B), Medicare Advantage (Part C), Medicare Part D prescription drug, and Medicare Supplement (Medigap) coordination.

Common Medicare denial patterns

These are the denial patterns we see most often from Medicare members based on publicly-reported insurer policies and regulator findings. The right appeal approach depends on which pattern matches your denial.

Skilled Nursing Facility (SNF) denials under Original Medicare and Medicare Advantage
Home health and hospice coverage denials
DME denials (CPAP, wheelchair, oxygen, glucose monitor)
Outpatient observation versus inpatient admission disputes
Part D drug coverage denials and step therapy
Medicare Advantage prior-authorization denials for specialty care
Inpatient rehabilitation facility (IRF) admission denials

How Medicare's appeal process works

Original Medicare (Parts A and B) appeals: Level 1 - Redetermination by the Medicare Administrative Contractor (MAC), 120 days to file, 60-day decision. Level 2 - Reconsideration by a Qualified Independent Contractor (QIC). Level 3 - Administrative Law Judge hearing (amount-in-controversy threshold). Level 4 - Medicare Appeals Council. Level 5 - Federal court. Medicare Advantage appeals: Level 1 - Reconsideration by the MA plan, 60 days to file, 30/60-day decision. Auto-forward to MAXIMUS Federal Services (the IRE) if denied. Part D follows a parallel path with the plan's coverage determination first.

Step 1: Identify the product. The denial - Medicare Summary Notice (MSN) for Original Medicare, MA plan denial letter for Medicare Advantage, or Part D coverage determination notice - identifies which appeal path applies. Step 2: For Original Medicare Level 1, complete CMS Form 20027 (Medicare Redetermination Request) within 120 days of the MSN and mail to the Medicare Administrative Contractor (MAC) listed on the MSN. Decision within 60 days. Step 3: For Original Medicare Level 2, file a Reconsideration Request with the Qualified Independent Contractor (QIC) within 180 days of the MAC's redetermination. Step 4: For Original Medicare Level 3, request an ALJ hearing through OMHA when the amount in controversy meets the threshold (annually adjusted by CMS). Step 5: For Medicare Advantage, file a written reconsideration request with the MA plan within 60 days of the denial. Mark expedited if urgent - 72-hour decision. Auto-forward to MAXIMUS at level 2. Step 6: For Part D, file a coverage determination request with the plan, then redetermination if denied, then auto-forward to the IRE. Use the Part D model exception form. Step 7: For SNF discharge specifically, call the BFCC-QIO number on the Notice of Medicare Non-Coverage by midnight of the day before discharge to request immediate review. Step 8: Use CMS Form 1696 if anyone other than the beneficiary (e.g. a doctor or family member) is filing the appeal as Appointed Representative.

What makes Medicare appeals succeed

Medicare appeals succeed most often when they: (1) use the correct CMS form for the level and product (CMS-20027 for Original Medicare Level 1, CMS-20033 for Level 2, etc.) and file within the level-specific deadline; (2) cite the relevant Medicare benefit policy manual section (CMS Pub. 100-02), National Coverage Determination, or Local Coverage Determination - these are the controlling authorities for coverage; (3) for SNF, home-health, and inpatient-rehab denials, cite the Jimmo v. Sebelius settlement clarifying that improvement is not required for skilled-care coverage; (4) for emergency-room denials, invoke the prudent-layperson standard; (5) for Medicare Advantage denials, cite the 2023 and 2024 CMS final rules requiring MA plans to honor coverage criteria no more restrictive than traditional Medicare; (6) for SNF discharge, exercise the BFCC-QIO immediate-review right within the strict midnight-before-discharge window; and (7) preserve the auto-forwarding right by understanding that Medicare Advantage Level 2 goes to MAXIMUS automatically without a separate filing.

Recent regulatory and public-record context

The HHS Office of Inspector General's April 2022 audit of Medicare Advantage prior-authorization denials by major plans found that 13 percent of MA prior-authorization denials met traditional Medicare coverage rules. The Senate Permanent Subcommittee on Investigations issued an October 2024 report on Medicare Advantage post-acute-care prior-authorization denials. CMS finalized rules in 2023 (CMS-4201-F) and 2024 tightening MA prior-authorization standards and requiring plans to honor traditional Medicare coverage criteria. The Jimmo v. Sebelius settlement (2013) clarified that Medicare coverage of skilled care does not require demonstrated patient improvement - this remains controlling and is regularly cited in successful SNF and home-health appeals.

Where to mail your Medicare appeal

Medicare does not publish a single national appeals address. Routing depends on your specific plan, product, or state. Use the address printed on your denial notice or on the back of your member ID card. The official appeals page is linked below.

Official Medicare appeals page

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Frequently asked questions: Medicare appeals

Denial codes most relevant to Medicare

Medical Necessity Denial (CO-50)

Prior Authorization Denial (CO-11)

Service Not Covered Denial (CO-204)

Step Therapy Denial (PR-50)

Out-of-Network Provider Denial (CO-97)

States with notable Medicare membership

Appeal in Pennsylvania

Other insurer appeal guides

Appeal a UnitedHealthcare denial

Appeal a Anthem denial

Appeal a Aetna denial

Appeal a Cigna denial

Appeal a Humana denial

Appeal a Kaiser Permanente denial