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-97 mean on my Explanation of Benefits?

CO-97 means 'the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated' - but in common usage when applied to out-of-network situations, it signals that the claim was reduced or denied because the provider is not in your plan's network. Always read the Remittance Advice remark codes alongside CO-97 for specifics.

Does the No Surprises Act protect me from out-of-network bills?

Yes, for many situations. The No Surprises Act (effective January 1, 2022) prohibits balance billing in three situations: (1) emergency care at any facility; (2) non-emergency care at in-network facilities by out-of-network providers when you did not receive advance notice and consent; (3) air ambulance services from out-of-network providers. In these cases, you owe only your in-network cost-sharing amount.

Can I get an in-network exception for an out-of-network provider?

Yes. Most insurers must grant an in-network exception (also called a 'gap exception') when no in-network provider with the necessary expertise is available within a reasonable distance or timeframe. Request this in writing, document that in-network alternatives were unavailable or inadequate, and have your treating physician write a medical necessity letter supporting the exception.

What if I didn't know my provider was out-of-network?

This is a strong basis for appeal. If your insurer's directory listed the provider as in-network and you relied on that information, the insurer may be estopped from denying coverage at the out-of-network rate. File a complaint with your state insurance commissioner for inaccurate network directory information, and cite this reliance in your appeal letter.

What is balance billing and is it legal?

Balance billing is when an out-of-network provider charges you the difference between their billed rate and what your insurer paid. It is prohibited in emergencies and surprise billing situations under the No Surprises Act. Many states have additional balance billing protections for non-emergency services. If you receive a balance bill that you believe is unlawful, contact your state insurance commissioner and file a complaint with the federal No Surprises Help Desk (1-800-985-3059).

CO-97

How to Appeal an Out-of-Network Insurance Denial (CO-97)

Claim denied because your provider was out-of-network (CO-97)? The No Surprises Act and state balance billing laws may protect you. Learn how to appeal and reduce your out-of-pocket costs.

What does CO-97 mean?

A CO-97 out-of-network denial means your insurer paid at a reduced rate (or nothing) because the provider who treated you is not in their contracted network. CO-97 is one of the most common and most financially damaging denial types, often leaving patients with bills thousands of dollars higher than they expected.

Why insurers issue CO-97 denials

Insurers build networks by contracting with providers at negotiated rates. When you see a provider outside that network - whether by choice, by necessity in an emergency, or unknowingly at an in-network facility - the insurer pays little or nothing and expects you to cover the gap. However, federal and state laws have dramatically expanded patient protections against surprise out-of-network bills since 2022.

Appeal strategy

First determine if the No Surprises Act applies: it protects patients from surprise out-of-network bills in emergencies and from out-of-network providers at in-network facilities (e.g., an out-of-network anesthesiologist at an in-network hospital). If NSA applies, your cost-sharing is capped at the in-network amount. Check your state's balance billing laws - over 30 states have additional protections. If you were unaware your provider was out-of-network, submit a network adequacy complaint and request an in-network exception.

Frequently asked questions about CO-97

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)