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.

What are the five step-therapy override criteria in PA?

Contraindication, adverse reaction, expected ineffectiveness, prior failure of the required drug or same-class drug, or stability on the prescribed drug. Any one is sufficient for an override under Act 169.

How fast must the insurer respond to a step-therapy override request?

72 hours for standard, 24 hours for urgent.

Can I escalate to external review?

Yes - through PID under Act 146 within 4 months of the final adverse determination.

Step Therapy · Pennsylvania

Appeal a Step Therapy Denial in Pennsylvania

Pennsylvania Act 169 of 2022 (the Ensuring Transparency in Prior Authorization Act) created an explicit step-therapy override process. Insurers must grant the override when one of five clinical criteria is met.

PA Act 169 requires insurers to grant a step-therapy override when: (1) the required drug is contraindicated, (2) the required drug will cause an adverse reaction or harm, (3) the required drug is expected to be ineffective, (4) the patient has tried the required drug or another drug in the same class and it failed, or (5) the patient is stable on the prescribed drug.

Your appeal letter should identify which of these five criteria applies, attach the treating physician's clinical attestation, and demand the override under Act 169. The plan must respond to a step-therapy override request within 72 hours (24 hours for urgent).

If denied, escalate to internal appeal and then to external review through PID under Act 146 of 2014.

Statutes and resources cited

Pennsylvania Act 169 of 2022 (Step Therapy Reform)
40 P.S. section 991.2161 (External Review Act)
PID Bureau of Consumer Services: 1-877-881-6388

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Upload your denial. Our 5-agent AI pipeline drafts a professional step therapy appeal under Pennsylvania law in about 2 minutes, free.

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Frequently asked questions

Denial code guide

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