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 PR-49 mean on my Explanation of Benefits?

PR-49 means 'this is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam,' billed as patient responsibility. In many cases this is incorrect, because the ACA requires most recommended preventive services to be covered at 100% with no cost-sharing.

Doesn't the ACA make preventive care free?

For most plans, yes. Non-grandfathered health plans must cover recommended preventive services with no out-of-pocket cost when you use an in-network provider. This includes USPSTF grade A and B services (such as many cancer screenings and blood pressure checks), routine immunizations recommended by ACIP, and HRSA-supported women's and children's preventive services. A PR-49 charge for one of these is usually a coding error.

Why was I charged for a preventive service that should be free?

The most common reason is coding. If the visit was coded as diagnostic rather than preventive, or a screening procedure was billed without the preventive modifier, the insurer processes it as a regular service with normal cost-sharing. Another reason is that a screening turned into a diagnostic procedure (for example, a screening colonoscopy that found and removed a polyp), which can change the billing, though many plans must still treat the screening portion as preventive.

How do I get a PR-49 charge corrected?

Call your provider's billing office and ask them to confirm that the preventive service was coded with the correct preventive or screening code and modifier. If it was miscoded, request a corrected claim. If the coding is already correct and the insurer still applied cost-sharing, file an appeal citing the ACA requirement that recommended preventive services be covered at 100% in-network.

What if a preventive screening became diagnostic during the visit?

If a preventive screening leads to a diagnostic procedure in the same visit, billing can become more complex. However, federal guidance has clarified that for certain screenings, such as a screening colonoscopy that results in polyp removal, the procedure should still be treated as preventive with no cost-sharing. If you are charged in this situation, appeal and reference the federal preventive services guidance.

PR-49

How to Appeal a PR-49 Routine or Preventive Service Denial

Billed for a routine or preventive service under PR-49? Under the ACA, most preventive care must be covered at 100% with no cost-sharing. Learn how to get the charge reversed.

What does PR-49 mean?

A PR-49 denial classifies a service as routine, preventive, or screening, and bills it to you as non-covered or as patient responsibility. This is one of the most commonly mis-applied codes, because under the Affordable Care Act most recommended preventive services must be covered at 100% with no deductible, copay, or coinsurance. A PR-49 charge for a recommended preventive service is frequently a coding error rather than a legitimate cost.

Why insurers issue PR-49 denials

PR-49 charges usually stem from how the visit was coded, not from a real coverage gap. If a preventive visit is coded with a diagnostic code instead of a preventive or screening code, or if a screening procedure is missing the modifier that identifies it as preventive, the insurer's system treats it as a regular service subject to cost-sharing. The ACA requires non-grandfathered plans to fully cover preventive services recommended by the U.S. Preventive Services Task Force (grades A and B), ACIP-recommended immunizations, and HRSA-supported women's and children's preventive services, with no out-of-pocket cost when delivered in-network.

Appeal strategy

Confirm the service is on the ACA-required preventive list (USPSTF grade A or B recommendations, ACIP immunizations, or HRSA women's and children's preventive services). If it is, ask your provider's billing office to verify the coding, preventive services must be coded and modified correctly, and a diagnostic code or a missing preventive modifier will trigger improper cost-sharing. Request a corrected claim. If the coding is correct and the insurer still applies cost-sharing, appeal citing the ACA's no-cost-sharing requirement for preventive services delivered in-network.

Frequently asked questions about PR-49

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)