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 request an IRO review in Texas?

After your insurer denies the internal appeal, you have the right to request an Independent Review Organization through your insurer. The insurer is statutorily required to provide the IRO request form with the final adverse determination notice under chapter 4202. Submit the form to your insurer; the insurer must forward the request to TDI within one working day. TDI randomly assigns an IRO from its certified roster. The IRO reviews medical records, applicable coverage criteria, and evidence-based guidelines, then issues a binding written determination within 20 days for standard cases or 3-8 days for expedited cases.

What is the Texas prudent layperson emergency standard?

Texas Insurance Code section 1271.155 (for HMOs) and section 1301.0053 (for PPOs) require coverage of emergency services if a prudent layperson with average knowledge of medicine and health would have believed that an emergency existed at the time care was sought. This protects against retroactive denial of ER visits the insurer later determines were non-emergent based on the final diagnosis. If your insurer denies an ER claim citing the discharge diagnosis, the prudent layperson standard is your first appeal ground.

Does the Texas IRO process apply to self-funded ERISA plans?

No. Self-funded ERISA plans (most large employer plans) are governed by federal law and use the federal external review process under 29 CFR section 2590.715-2719 or the plan's contracted IRO. Fully insured plans regulated by TDI use the state IRO process under chapter 4202. Your summary plan description identifies whether the plan is self-funded; the DOL Form 5500 will confirm. State employee plans (ERS, TRS-Care) have their own appeal procedures.

Where do I file a complaint about an insurer in Texas?

Call the TDI Consumer Help Line at 1-800-252-3439 or file online at tdi.texas.gov/consumer/complfrm.html. The TDI complaint process is separate from the IRO clinical review and addresses regulatory violations like delays, improper denials, bad-faith claim handling, and prompt-pay violations. You can pursue a complaint and an IRO review in parallel - they do not conflict.

How long do I have to file an internal appeal in Texas?

Most Texas insurers allow at least 180 days from the date on the denial notice for internal appeals, consistent with the federal ACA floor adopted in TDI rules. Your specific deadline is on the EOB, the denial notice, and the member handbook. Missing the internal appeal deadline forfeits IRO eligibility, so file promptly.

How are surprise out-of-network bills handled in Texas?

Senate Bill 1264 (2019) and Texas Insurance Code chapter 1467 remove patients from disputes between out-of-network providers and insurers for emergency services and certain non-emergency facility-based services. The patient's responsibility is limited to the in-network cost-sharing amount. Disputes between provider and insurer are resolved through TDI-administered baseball-style final-offer arbitration. If you receive a balance bill in violation of chapter 1467, file a complaint with TDI.

What is the Texas gold-carding law for prior authorization?

House Bill 290 (2023) created a gold-carding program where physicians with consistently high prior authorization approval rates (90%+ over six months in a specific service category) are exempted from PA requirements for that category for a defined period. If your physician is gold-carded for the service in question and the insurer still demands PA, that is grounds for a complaint to TDI in addition to your appeal.

Are Texas IRO decisions binding on insurers?

Yes. Under Texas Insurance Code section 4202.002, an IRO determination is binding on the insurer for fully insured plans. There is no further administrative appeal. The insurer must implement an overturn determination promptly. Failure to comply is grounds for TDI enforcement action.

Texas Insurance Appeal Letter Generator - Cite Texas Insurance Code

Texas operates one of the most rigorous Independent Review Organization programs in the country under chapter 4202 of the Texas Insurance Code. The Texas Department of Insurance randomly assigns IROs and IRO decisions are binding on insurers. Upload your denial and our 5-agent AI pipeline drafts an appeal citing the right Texas statute and the right IRO route.

Texas insurance regulator

TDI regulates fully insured commercial health plans in Texas. Self-funded ERISA plans are governed by federal law and the U.S. Department of Labor. The state operates the IRO process for adverse determinations on medical necessity, experimental treatment, and similar clinical issues. Texas has a strong prudent layperson emergency standard codified at Texas Insurance Code section 1271.155 (HMO) and 1301.0053 (PPO), and a robust surprise billing dispute resolution process at chapter 1467.

Texas Department of Insurance (TDI)File a TX insurance complaint

External review in Texas

Independent Review Organization (IRO) process administered by TDI under chapter 4202 of the Texas Insurance Code. The IRO is randomly assigned by TDI from the certified roster. IRO decisions are binding on insurers for fully insured plans. Free to the patient. The insurer is required to provide the IRO request form with the final adverse determination.

Internal appeal timing in Texas

TDI rules require insurers to acknowledge appeals within 5 days, decide standard pre-service appeals within 30 days, post-service appeals within 60 days, and expedited appeals within 72 hours under 28 TAC section 19.1709. Patients can request an IRO review after the internal appeal is denied. IRO standard determinations are issued within 20 days; expedited within 3 days (or 8 days for life-threatening conditions involving experimental treatment).

Statutes Counterclaim cites for Texas appeals

Texas Insurance Code chapter 1271 (HMO coverage)
Texas Insurance Code chapter 1301 (PPO coverage)
Texas Insurance Code chapter 4201 (Utilization Review Agents)
Texas Insurance Code chapter 4202 (Independent Review Organizations)
Texas Insurance Code section 1271.155 and chapter 1259 (prudent layperson emergency standard)
Texas Insurance Code section 1301.0053 (PPO emergency coverage)
Texas Insurance Code chapter 1467 (independent dispute resolution for balance billing)

Generate your Texas appeal letter

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

Upload my denial · Free

Frequently asked questions: Texas appeals

California appeal letter

Florida appeal letter

New York appeal letter

Pennsylvania appeal letter

Illinois appeal letter

Ohio appeal letter