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 an external review in Pennsylvania?

After exhausting the insurer's internal appeals, file an external review request with PID within 4 months of the final adverse determination under 40 P.S. section 991.2161. PID assigns an IRO from its certified roster on a random rotation. The decision is binding on the insurer.

Where do I file a Pennsylvania insurance complaint?

PID Bureau of Consumer Services at 1-877-881-6388 or online at insurance.pa.gov/Consumers/FileAComplaint. The complaint process is separate from the external review and addresses regulatory violations like delays, prompt-pay violations, and improper denial conduct.

Does Pennsylvania have stronger consumer protections than federal law?

Yes. Pennsylvania's Quality Health Care Accountability and Protection Act gives patients robust internal appeal procedural rights, including the right to all documents the insurer relied on, the right to a peer-to-peer reviewer in the same specialty under section 991.2152, and continuity of care under section 991.2117. Act 119 of 2020 strengthened mental health parity reporting.

How long does Pennsylvania external review take?

Standard external review is decided within 45 days of the IRO assignment. Expedited external review is decided within 72 hours when delay would seriously jeopardize health.

Can I file expedited external review in Pennsylvania?

Yes - within 72 hours under 40 P.S. section 991.2162 when delay would seriously jeopardize health. Mark the request urgent and provide a written physician statement of clinical urgency identifying the specific harm delay would cause.

What is the Pennsylvania peer-to-peer review right?

Under 40 P.S. section 991.2152, before issuing a final adverse determination, the insurer must provide an opportunity for a peer-to-peer review with a same-specialty physician. This is procedurally separate from the formal appeal and can reverse adverse determinations before external review becomes necessary. Demand peer-to-peer review in writing if the insurer fails to offer it.

Are Pennsylvania external review decisions binding on my insurer?

Yes. Under Act 146 of 2014, the IRO determination is binding on the insurer. There is no further administrative appeal. The insurer must implement the determination promptly. Failure to comply is grounds for PID enforcement action.

Does Pennsylvania have a surprise billing law?

Yes. Act 146 of 2020 (a different statute from the 2014 external review act) provides surprise billing protections that complement the federal No Surprises Act for services not federally covered, including certain ground ambulance billing. If you receive a balance bill that violates state or federal surprise billing law, file a complaint with PID.

Pennsylvania Insurance Appeal Letter Generator - Cite 40 P.S. and Act 146

The Pennsylvania Insurance Department administers the Independent External Review Program established by Act 146 of 2014 and codified at 40 P.S. section 991.2161 et seq. Decisions are binding and IRO assignment is randomized. Upload your PA denial and our 5-agent AI pipeline drafts an appeal citing 40 P.S. and the right external review path.

Pennsylvania insurance regulator

PID regulates fully insured commercial health plans in Pennsylvania. The Department of Health retains some managed care plan oversight under 28 Pa. Code chapter 9. PA's external review program is administered by PID under Act 146 of 2014, codified at 40 P.S. section 991.2161 et seq.

Pennsylvania Insurance Department (PID)File a PA insurance complaint

External review in Pennsylvania

Independent External Review through PID under Act 146 of 2014 and 40 P.S. section 991.2161 et seq. Decided by an Independent Review Organization randomly assigned by PID. Free, binding. Standard reviews are decided within 45 days; expedited within 72 hours.

Internal appeal timing in Pennsylvania

Pennsylvania insurers must respond within 30 days for pre-service standard appeals, 60 days post-service, and 72 hours expedited under 40 P.S. section 991.2141. Patients have 4 months from the final adverse determination to request external review under Act 146.

Statutes Counterclaim cites for Pennsylvania appeals

40 P.S. section 991.2161 et seq. (Pennsylvania Independent External Review Act)
40 P.S. section 991.2102 (Quality Health Care Accountability and Protection Act)
40 P.S. section 991.2141 et seq. (internal grievance procedures)
Act 146 of 2014 (independent external review program)
31 Pa. Code chapter 154 (managed care plan regulations)
40 P.S. section 991.2117 (continuity of care)

Generate your Pennsylvania appeal letter

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

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Frequently asked questions: Pennsylvania appeals

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