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.

Should I file my California appeal with DMHC or CDI?

If your plan is an HMO or most managed care plans (Kaiser, Anthem Blue Cross HMO, Blue Shield HMO, Health Net, L.A. Care, Inland Empire Health Plan, etc.), file with the DMHC at HealthHelp.ca.gov or 1-888-466-2219. If your plan is a PPO indemnity product or fee-for-service insurance policy, file with the California Department of Insurance at insurance.ca.gov or 1-800-927-4357. The back of your member ID card and your Evidence of Coverage identify the regulator. Misfiling delays your appeal but does not forfeit it - both agencies redirect misfiled cases.

How does Independent Medical Review work in California?

After your plan denies your internal grievance or fails to respond within 30 days, you can request IMR through the DMHC at no cost. The DMHC reviews your application for eligibility, then assigns an independent physician panel in the relevant clinical specialty. The panel reviews medical records, the plan's coverage criteria, and applicable evidence-based guidelines, then issues a binding written decision. The plan must implement an overturn within 5 working days. Standard IMR decisions are issued within 30 days of assignment; expedited IMR within 3 to 7 days for urgent cases under Cal. H&S Code section 1374.33.

Does California have stronger mental health parity protections than federal law?

Yes. SB 855 (Wiener, 2020), codified at Cal. H&S Code section 1374.72, requires every California-regulated commercial plan to cover medically necessary treatment of all mental health and substance use disorders using generally accepted standards of care, including residential treatment, partial hospitalization, applied behavioral analysis, and medication-assisted treatment. The DMHC's Behavioral Health Investigations Unit enforces parity with public settlements against major carriers, and SB 855 violations are an independent appeal ground in addition to medical necessity arguments.

How long do I have to file a California appeal?

Plans must give members at least 180 days from the date on the denial notice to file the internal grievance under federal ACA standards adopted in California. After grievance denial or 30 days without plan resolution, you have 180 days to request IMR with the DMHC under section 1374.30. Your specific deadlines are stated on the denial notice. Missing the internal-appeal deadline forfeits IMR rights, so file promptly.

Can I file an expedited appeal in California?

Yes. Urgent grievances must be decided by the plan within 72 hours under section 1368 and 28 CCR section 1300.68. Urgent IMR is decided within 7 days, or within 3 days when there is an imminent serious threat to health, under Cal. H&S Code section 1374.33. Mark the appeal urgent in writing and have your treating physician submit a written statement of clinical urgency identifying the specific harm that delay would cause.

Are California IMR decisions binding on my insurance plan?

Yes. Under Cal. H&S Code section 1374.34, an IMR decision in favor of the patient is binding on the health plan, and the plan must implement the decision within 5 working days for non-urgent cases or 24 hours for urgent cases. Failure to comply is grounds for DMHC enforcement action including administrative penalties.

Where can I see prior California IMR decisions to support my appeal?

The DMHC publishes searchable IMR decisions at imrsearch.dmhc.ca.gov. Filtering by carrier, treatment category, and outcome lets you find precedents for your specific clinical situation. Citing analogous overturned decisions by case number in your appeal is procedurally permissible and substantively persuasive.

What if my California plan misses the 30-day grievance deadline?

Under section 1368, if the plan fails to issue a written decision on a standard grievance within 30 days, the grievance is deemed denied and you can request IMR immediately. Document the missed deadline in your IMR application; deemed denials are independently grounds for a DMHC complaint.

California Insurance Appeal Letter Generator - Cite California Law

California gives consumers two of the strongest appeal paths in the country: the Department of Managed Health Care's Independent Medical Review for Knox-Keene plans, and the Department of Insurance external review for PPOs. Upload your denial and our 5-agent AI pipeline drafts an appeal that routes correctly and cites the controlling California statute.

California insurance regulator

Most California HMOs and many PPOs are regulated by the Department of Managed Health Care under the Knox-Keene Health Care Service Plan Act. PPOs and indemnity products from CDI-licensed carriers are regulated by the California Department of Insurance. The DMHC operates the Help Center at HealthHelp.ca.gov, including Independent Medical Review for medical necessity denials and active enforcement of SB 855 mental health parity.

California Department of Managed Health Care (DMHC)File a CA insurance complaint

External review in California

Independent Medical Review (IMR) through the DMHC: free, decided by independent physician reviewers, binding on the health plan within five working days. File at HealthHelp.ca.gov or 1-888-466-2219. Available after the plan's internal grievance is denied or 30 days have elapsed, or sooner in urgent or experimental treatment cases. CDI-regulated PPOs use a parallel external review under Insurance Code section 10169.

Internal appeal timing in California

California requires plans to acknowledge grievances within 5 days, decide standard grievances within 30 days, and decide urgent grievances within 72 hours. Members can request IMR after the internal grievance is denied or after 30 days without resolution. The internal grievance filing window is at least 180 days from the denial.

Statutes Counterclaim cites for California appeals

California Knox-Keene Health Care Service Plan Act of 1975 (Health & Safety Code section 1340 et seq.)
California Health & Safety Code section 1368 (grievance procedures)
California Health & Safety Code section 1370.4 (medical necessity reviews)
California Health & Safety Code section 1374.30 (Independent Medical Review)
California Health & Safety Code section 1374.33 (expedited IMR)
California Insurance Code section 10169 (external review for PPOs)
California Health & Safety Code section 1374.72 (mental health parity / SB 855)

Generate your California appeal letter

Upload your denial. Our 5-agent AI pipeline drafts a professional appeal citing the right California statute in about 2 minutes, free.

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Frequently asked questions: California appeals

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