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 does CO-45 mean on my Explanation of Benefits?

CO-45 stands for 'Charges exceed your contracted/legislated fee arrangement.' It is not always a traditional 'denial', it is a payment adjustment that reduces the allowed amount to your insurer's fee schedule. What happens next depends on whether your provider is in or out of network.

Do I have to pay the CO-45 balance if my doctor is in-network?

No. When a provider is in-network, they have a contract with your insurer agreeing to accept the fee schedule as payment in full. They may not legally bill you for the CO-45 balance. If you receive a bill for this balance from an in-network provider, call your insurer and report the incorrect billing.

What is the No Surprises Act and how does it protect me?

The federal No Surprises Act (effective January 2022) protects patients from surprise medical bills in emergency situations and for certain non-emergency services at in-network facilities. Under the NSA, out-of-network providers at in-network facilities cannot charge patients more than their in-network cost-sharing amount.

Can I negotiate a CO-45 out-of-network balance bill?

Yes, out-of-network providers will often negotiate. Ask the provider to accept the insurer's allowable amount as payment in full, or negotiate a reduction. You can also request an itemized bill to identify any billing errors. Many hospitals have financial assistance programs that can further reduce or eliminate the balance.

When should I appeal a CO-45 reduction?

Appeal CO-45 reductions when: (1) you received emergency care and believe NSA protections apply; (2) the provider was in-network but coded incorrectly; (3) the insurer applied the wrong fee schedule; or (4) the service is being denied as non-covered when it should be covered at the contracted rate.

CO-45

How to Handle a CO-45 'Exceeds Fee Schedule' Insurance Denial

Got a CO-45 denial? Your insurer says the billed amount exceeds their allowable fee. Learn what this means, when to appeal, and how to negotiate the balance you owe.

What does CO-45 mean?

A CO-45 denial means the amount billed by your provider exceeds the maximum amount your insurer will pay for that service (the 'allowable amount' or 'fee schedule'). The difference, called the 'balance', may be billed to you if you saw an out-of-network provider, or it may be a contractual write-off that the provider cannot legally collect if they are in-network.

Why insurers issue CO-45 denials

Insurance companies negotiate contracted rates with in-network providers. When an in-network provider bills more than the contracted rate, CO-45 reduces the payment to the agreed amount, the provider is contractually obligated to write off the rest and cannot bill you. When an out-of-network provider bills more than the allowable, you may owe the balance (balance billing), unless your state has balance billing protections.

Appeal strategy

First determine if the provider is in-network or out-of-network. If in-network, the provider cannot bill you the CO-45 balance, file a complaint with your insurer if they try. If out-of-network, check whether your state has balance billing protection laws (the No Surprises Act covers many emergency situations). If the service was provided in an emergency, federal NSA protections cap your out-of-pocket obligation.

Frequently asked questions about CO-45

CO-50

Medical Necessity Denial (CO-50)

CO-11

Prior Authorization Denial (CO-11)

CO-55

Experimental Treatment Denial (CO-55)

PR-27

Filing Deadline Denial (PR-27)