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 is a PR-1 denial and does it mean I owe money?

PR-1 means 'deductible amount' - your insurer is applying the billed amount to your annual deductible rather than paying it. Yes, this typically means you owe the provider the deductible amount. However, you should verify the calculation is correct before paying - deductible tracking errors are common.

What counts toward my deductible?

Most covered medical services count toward your deductible: hospital stays, surgeries, specialist visits, imaging, lab work, and prescriptions (depending on your plan). Preventive care services required by the ACA (annual physicals, cancer screenings, immunizations) do not count toward the deductible - they must be covered at 100% with no cost-sharing. Check your plan's Summary of Benefits for your specific deductible rules.

Can I appeal if I think my deductible accumulation is calculated incorrectly?

Yes. Request a complete year-to-date deductible accumulation ledger from your insurer. Compare each credit against your EOBs for the year. Common errors include: missing credits from claims at the start of the plan year; incorrect assignment of claims to individual vs. family deductible; errors when coordination of benefits applies; or failure to credit deductible accumulation from a mid-year plan change.

Do I have separate in-network and out-of-network deductibles?

Many plans have separate in-network and out-of-network deductibles, and in-network payments typically do not count toward your out-of-network deductible and vice versa. If you received out-of-network care, verify which deductible is being applied and confirm the insurer is not misclassifying in-network care as out-of-network - which would prevent it from accumulating toward your lower in-network deductible.

Is there a family deductible limit?

Most family plans have both individual and family deductibles. Once the family aggregate deductible is met (by combining all family members' expenses), the plan begins paying for all family members' covered services regardless of individual deductible status. If your family has collectively paid enough to meet the aggregate family deductible, no individual family member should continue to have claims applied to their individual deductible.

PR-1

Understanding and Appealing a 'Deductible Not Met' Denial (PR-1)

Got a PR-1 denial because your deductible hasn't been met? Learn what counts toward your deductible, when insurers make errors, and how to appeal if the amount is wrong.

What does PR-1 mean?

A PR-1 denial means your insurer is applying your claim amount toward your annual deductible rather than paying it - because you have not yet met your deductible for the year. Unlike most denial codes that signal an error, PR-1 is often a correct application of your plan's cost-sharing structure. However, it is also the site of some of the most common insurer calculation errors.

Why insurers issue PR-1 denials

Deductibles are annual amounts you must pay out-of-pocket before your insurer begins paying for most covered services. PR-1 denials appear because the claim was applied to the deductible rather than paid by the insurer. While this is often correct, errors occur when: out-of-network payments are incorrectly excluded from accumulation; family deductible vs. individual deductible calculations are wrong; prior-year services are incorrectly counted; or the insurer fails to credit prior payments from another insurer (for plans that coordinate benefits).

Appeal strategy

Request a year-to-date deductible accumulation statement and compare it against all your EOBs for the year. Common errors include: failure to credit deductible accumulation from an earlier insurer when you changed plans mid-year; incorrect application of out-of-network vs. in-network deductibles; family deductible calculation errors when the aggregate family deductible has been met. If you find a discrepancy, submit an appeal with your payment records and prior EOBs documenting the correct accumulation.

Frequently asked questions about PR-1

CO-50

Medical Necessity Denial (CO-50)

CO-11

Prior Authorization Denial (CO-11)

CO-55

Experimental Treatment Denial (CO-55)

CO-45

Exceeds Fee Schedule Denial (CO-45)