Pre-submission scoring across 17,440 procedures, 24+ payers, and 15 state regulatory environments. Denials prevented before they happen.
Recover millions in denied revenue with pre-submission scoring and payer-specific appeal intelligence. Purpose-built for community hospitals losing $2–4M annually.
Learn More →Give your denial management teams an intelligence edge. White-label API that integrates with your existing platform and makes your team the hero.
Learn More →Understand why your therapies get denied at the payer level. Step therapy intelligence, formulary access mapping, and drug-specific denial patterns.
Learn More →Our workflow transforms denial management from reactive firefighting into predictive strategy.
Risk-score every claim before it goes out. Our model evaluates CPT code, payer behavior, documentation completeness, clinical criteria alignment, and regulatory timing. Catch denials before they happen.
When a denial arrives, our platform identifies the exact evidence your team needs to overturn it. Payer-specific approval criteria, clinical guideline gaps, regulatory leverage — analysis in under 60 seconds.
Evidence-based appeal packages with payer-specific language, regulatory citations, and clinical guideline alignment. Your team reviews and sends — not starts from scratch.
Your revenue cycle team deserves better tools
Your team spends hours on denials that shouldn't have happened. Prior auth gaps, documentation misses, payer-specific criteria your team didn't know about — these are predictable. We predict them.
| Capability | Traditional RCM | CoverageUnlocked | Why It Matters |
|---|---|---|---|
| Denial Tracking | ✗ | ✓ | Baseline visibility — but you're already behind |
| Pre-Submission Prediction | ✗ | ✓ | Stops denials before claims go out |
| Payer Behavioral Modeling | ✗ | ✓ | Know exactly how each payer will respond |
| Automated Appeal Generation | ✗ | ✓ | Your team reviews, not starts from scratch |
| Regulatory Leverage Identification | ✗ | ✓ | 15 states of enforcement data in every appeal |
| Clinical Guideline Alignment | ✗ | ✓ | Match payer approval criteria automatically |
| Real-Time Policy Alerts | ✗ | ✓ | Stay ahead of coverage changes |
| Temporal Anomaly Detection | ✗ | ✓ | Spot denial surges before they hit |
Six systems working together. Each addresses a different failure mode in traditional denial management.
Simulates payer medical director logic. Identifies vulnerabilities and generates counter-strategies with probability scoring.
20+ payers mapped with behavioral annotations. How UnitedHealthcare, Anthem, Aetna, Cigna, Humana, and state Blues actually make decisions.
Five-factor weighted model: base rates, documentation, payer behavior, clinical criteria, timing. Catches denials before they happen.
Five specialized AI agents working in parallel: medical evidence, regulatory, financial, timeline compliance, quality review.
Three-layer model: tactical (real-time anomalies), operational (7–90 day trends), strategic (systemic patterns). Detects surges before they hit.
15 state regulatory profiles with real enforcement data. MLR compliance analysis. Automated regulatory citation for appeals.
Make your denial management teams unstoppable. Your clients expect denial prevention, not just denial management. CoverageUnlocked gives your team predictive intelligence they can't build in-house — and your clients get better outcomes. We sell through partners, not around them — CoverageUnlocked does not market directly to your clients.
Your branding, your platform. CoverageUnlocked powers the intelligence behind your denial management offering.
REST API with FHIR R4 mapping. Batch processing for 1,000+ claims. Integrates with your existing workflow in days, not months.
Built for scale. Pricing models that work for outsourced RCM — per-claim, per-client, or annual license.
Client-level isolation, role-based access, per-organization analytics. Built for enterprise service delivery.
Your therapy was denied. Again.
Step therapy hurdles, prior authorization complexity, medical necessity denials — you need payer-level intelligence to fix formulary access. We map denial patterns by drug, by payer, by state.
How This Differs from Patient-Level Appeals: We focus on payer-level formulary access, step therapy authorization criteria, and network coverage gaps — not individual patient appeals. The goal: your therapy gets faster, broader coverage access across payers and states.
PHI sanitization before AI processing. Audit logging with 7-year retention. BAA available today. SOC 2 Type II audit in progress — target Q4 2026.
Guaranteed availability with live status monitoring. Enterprise-grade infrastructure with redundant systems.
Median response: 20–40 seconds. P95: 60 seconds. 99% of analyses complete under one minute.
FHIR R4 data models. CDS Hooks for real-time alerts. Works with Epic, Cerner, MEDITECH, and any EHR with REST API.
Ned Lutz spent 20 years inside health system operations, including teams that designed denial review criteria and managed payer contract negotiations. He knows exactly what information payers need to reverse denials — because he helped architect the systems that review them in the first place.
CoverageUnlocked exists because the same patterns that cause denials are predictable. The documentation gaps, the payer-specific criteria mismatches, the regulatory leverage that goes unused — Ned built a platform that identifies all of it before your team wastes a single hour.
Connect with Ned on LinkedInRange-based: $2–4M annually for typical 200–400 bed systems. Based on CMS denial rates (30–40% of claims denied at some point), KFF data showing 75%+ overturn on appeal, and 20 years of operational pattern analysis. Exact ROI depends on claim volume, specialty mix, current denial rates, and regulatory environment. Our free 200-claim analysis demonstrates your specific potential.
Traditional RCM platforms manage denials reactively — track them, report on them, queue them for appeals. CoverageUnlocked predicts them before submission. Our system evaluates 17,440 procedures across 24+ payers with insider knowledge of how payers actually make denial decisions. We identify winnable denials with specific evidence strategies and generate appeals with regulatory citations — everything your team needs to win.
Yes. FHIR R4 native. CDS Hooks for real-time alerts. Works with Epic, Cerner, MEDITECH, and any EHR with REST API. No special integration required — standard health IT protocols. Deployment varies: 2 weeks for CSV export pilot, 4 weeks for full API integration.
Yes. All PHI is sanitized before AI processing (bracket replacement). Audit logging with 7-year retention. BAA available today. SOC 2 Type II audit in progress, target Q4 2026. We follow HIPAA Security Rule standards for all transmission and storage.
24+ payers: 6 national (Aetna (CVS Health), Anthem (Elevance Health), Blue Cross Blue Shield (Generic), Cigna (The Cigna Group), Humana, UnitedHealthcare), 10 state Blues plans, 5 Medicaid MCOs, and military (TRICARE/VA/CHAMPVA) covering 90%+ of US claims volume. Plus 15 state regulatory profiles for appeal leverage.
Phase 1 (weeks 1–2): CSV export of recent denied claims. Phase 2 (weeks 3–4): Top 15–20 claims for deep analysis. Less than 10 hours total team effort. No IT integration required to start — we can pilot with spreadsheet data while backend integration happens in parallel.
Yes. Free 200-claim analysis demonstrates value before any commitment. Takes 48 hours. Shows which claims are winnable, estimated recovery, and exact evidence strategy your team needs. No credit card required. Zero obligation.
Start Your Free AnalysisFree 200-claim analysis to start. Advisory: $35K. Annual platform: based on volume, typically $100–250K/year. No surprises — transparent, outcome-based pricing. We're happy to discuss custom arrangements for larger health systems or RCM partners.
Start Your Free AnalysisWe map drug-specific denial patterns across 20+ payers and 15 states. For each therapy, you see which payers deny most, what step therapy requirements exist, where prior auth criteria are strictest, and what documentation wins on appeal. The goal is formulary access at the payer level — not individual patient appeals.
Our platform covers denial patterns for specialty pharmaceuticals, biologics, oncology therapies, and high-cost infusion drugs. We track step therapy requirements, prior authorization criteria, and medical necessity denial patterns by payer. Drug-specific analysis is available on request.
Upload 200 denied claims. We analyze every one — win probability, evidence strategy, recovery estimate. Your team effort: under 2 hours.
Your RCM team works the top 15–20 winnable claims using our evidence checklists and appeal packages. Total team effort: under 10 hours.
API integration with your EHR. Real-time pre-submission scoring. Custom payer rules. Ongoing intelligence updates. No workflow disruption.
Upload 200 denied claims. In 48 hours, we show you which ones are winnable, how much you can recover, and exactly what evidence your team needs.
Free analysis. No commitment. Results in 48 hours.