Terms of Service

1. Acceptance of Terms

By accessing and using the CoverageUnlocked platform, website, API, and services ("Service"), you agree to be bound by these Terms of Service ("Terms"). If you do not agree to these Terms, do not use the Service. Your continued use of the Service constitutes acceptance of any updates to these Terms.

These Terms apply to all users, including: individual practitioners, healthcare administrators, revenue cycle managers, health system employees, enterprise customers, and anyone else accessing the Service.

2. Description of Service

CoverageUnlocked provides an AI-powered denial management platform for healthcare organizations. The Service includes:

• Adversarial Analysis Engine: AI-driven analysis of insurance denials using payer intelligence and clinical criteria mapping
• Pre-Submission Scoring: Predictive scoring of claims before submission to identify denial risk
• Payer Intelligence Network: Real-time data on payer denial patterns, appeal success rates, and behavioral insights
• Regulatory Intelligence: State-level regulatory guidance, prompt payment laws, and external review statutes
• Appeal Support Tools: Evidence checklists, appeal letter templates, appeal pathway recommendations
• Analytics & Reporting: Denial trends, payer comparisons, appeal outcome tracking, financial projections
• API Access: Programmatic integration for enterprise customers

The Service is provided "as-is" and outputs are based on publicly available data, payer intelligence patterns, and AI analysis. The Service is not a substitute for legal advice, medical judgment, or professional human review.

3. User Accounts & Credentials

To use certain features of the Service, you must create an account. You agree to:

• Provide accurate, complete, and current information during registration
• Maintain the confidentiality of your password and account credentials
• Notify us immediately of any unauthorized access to your account
• Accept responsibility for all activities that occur under your account
• Use your account only for authorized purposes

CoverageUnlocked reserves the right to suspend or terminate accounts that violate these Terms or engage in prohibited uses.

4. Acceptable Use Policy

You agree NOT to use the Service for any of the following prohibited purposes:

1. Illegal activities: Any use that violates federal, state, or local law, including healthcare fraud, False Claims Act violations, or conspiracy to defraud insurers
2. PHI without authorization: Submitting Protected Health Information (patient names, MRNs, dates) without proper de-identification or a Business Associate Agreement in place
3. Impersonation or fraud: Posing as someone else, forging documents, or fabricating clinical information
4. Competitive intelligence abuse: Reverse-engineering the platform, scraping data, or attempting to extract proprietary payer intelligence for unauthorized use
5. System abuse: Automated attacks, denial-of-service attempts, SQL injection, or any attempt to compromise platform security or infrastructure
6. Unauthorized access: Attempting to access accounts, data, or systems you are not authorized to use
7. Harassment or abuse: Threatening, defaming, or abusing CoverageUnlocked staff, other users, or third parties through the Service
8. Malware distribution: Uploading viruses, malware, or any code designed to harm systems or data

Violation of this Acceptable Use Policy may result in immediate account termination and legal action.

5. Data Protection & Privacy

Your use of the Service is governed by our Privacy Policy (at coverageunlocked.com/privacy). Key provisions:

• Data You Provide: You are responsible for the accuracy and legality of all data you submit. We do not accept PHI unless a Business Associate Agreement is in place.
• Data We Retain: We retain analysis data for 12 months, server logs for 90 days, and billing records for 7 years. Longer retention may apply for legal compliance.
• Data We Never Collect: We do not collect full patient names, MRNs, SSNs, or complete birthdates unless de-identified per HIPAA standards or unless covered by a BAA.
• Breach Notification: If we discover a data breach, we will notify affected users within 30 days. For PHI breaches, HIPAA breach notification rules apply (60 days).
• Your Rights: You have the right to access, delete, export, or restrict processing of your data by contacting privacy@coverageunlocked.com

6. Intellectual Property Rights

6.1 CoverageUnlocked IP

CoverageUnlocked retains all intellectual property rights in:

• The platform, software, and code
• Payer intelligence database and insights
• Analysis engine, algorithms, and AI models
• Documentation, templates, and guidance materials
• Aggregated, de-identified analytics and benchmarks

You are granted a non-exclusive, non-transferable, revocable license to use the Service for your organization's internal use only.

6.2 Your Data

You retain ownership of data you submit to the Service. By submitting de-identified data, you grant us the right to use it for:

• Platform improvement and model training (de-identified only)
• Aggregate analytics and benchmarking reports
• Regulatory compliance and audit

We will not identify you or your organization in any aggregated or benchmark reports without explicit consent.

6.3 Feedback & Suggestions

Any feedback, suggestions, or feature requests you provide become the property of CoverageUnlocked and may be used without compensation or attribution.

7. Warranty Disclaimers & Limitation of Liability

7.1 AS-IS Service

THE SERVICE IS PROVIDED "AS-IS" WITHOUT WARRANTY OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING:

• Merchantability or fitness for a particular purpose
• Accuracy, completeness, or timeliness of analysis or recommendations
• That the Service will be error-free, uninterrupted, or secure
• That any output will result in successful appeals or claim approvals
• That payer behavior will match historical patterns or our predictions
• That de-identified data is truly de-identified or that breaches will not occur

7.2 AI Limitations

The Service uses artificial intelligence and machine learning. AI systems can:

• Make mistakes, including completely wrong recommendations
• Produce outputs that contradict case law or recent policy changes
• Overstate or understate denial risk
• Lack context about your specific patient or health system situation
• Change output over time as models are updated

You are responsible for human review of all AI recommendations before relying on them.

7.3 Liability Cap

IN NO EVENT SHALL COVERAGEUNLOCKED BE LIABLE FOR:

• Consequential, incidental, indirect, or punitive damages
• Lost profits, lost revenue, or lost data
• Business interruption or lost productivity
• Damages from denials that are upheld despite using the Service
• Regulatory penalties or government enforcement actions
• Reputational harm or patient complaints

CoverageUnlocked's total liability is limited to the fees you paid in the 12 months preceding the claim, or $100, whichever is greater. This limitation applies even if CoverageUnlocked has been advised of the possibility of such damages.

8. Term & Termination

8.1 Term

These Terms are effective upon your acceptance and continue as long as you use the Service, unless earlier terminated.

8.2 Termination by User

You may terminate your account at any time by contacting ned@coverageunlocked.com. Upon termination, your account data is retained for 30 days in backups, then deleted (except as required by law).

8.3 Termination by CoverageUnlocked

CoverageUnlocked may terminate or suspend your account or access to the Service:

• For violation of these Terms or any law
• For non-payment of fees for 30+ days
• For use of prohibited features or abuse of the Service
• At any time for any reason with 30 days written notice (except for violations, which are immediate)

8.4 Effects of Termination

Upon termination: your access to the Service ceases; all analysis data is deleted after 30 days; payment obligations continue; and survival provisions (liability, IP, confidentiality) remain in effect.

9. Payment Terms

9.1 Fees

Use of the Service is subject to fees as stated in your subscription agreement or pricing page. Fees are non-refundable except where required by law.

9.2 Payment Processing

Payments are processed by Stripe. You authorize Stripe to charge your payment method for all fees owed. Payment methods are subject to Stripe's terms of service.

9.3 Currency & Taxes

All fees are in USD. You are responsible for any applicable sales tax, VAT, or other taxes. We will add applicable taxes to invoices.

9.4 Non-Payment

If payment fails or is not received within 30 days, we may:

• Suspend your account and access to the Service
• Charge late fees at 1.5% monthly interest (18% annually)
• Pursue collection or legal action for unpaid amounts
• Terminate your account and delete data after 90 days of non-payment

10. Privacy Policy

Your use of the Service is also governed by our Privacy Policy at coverageunlocked.com/privacy. In case of conflict between these Terms and the Privacy Policy, the Privacy Policy governs data handling.

11. Dispute Resolution & Governing Law

11.1 Governing Law

These Terms are governed by the laws of the State of Oregon, without regard to conflict of laws principles.

11.2 Mandatory Arbitration

Any dispute arising from or relating to these Terms, the Service, or your use of it shall be resolved by binding arbitration in Bend, Oregon, administered by JAMS. Each party pays its own attorney fees and costs, and arbitration fees are split equally.

Arbitration is final and binding, with limited appeal rights. There is no jury trial, class action, or class arbitration.

11.3 Class Action Waiver

YOU AND COVERAGEUNLOCKED AGREE THAT DISPUTES SHALL BE RESOLVED INDIVIDUALLY, NOT AS A CLASS ACTION, CLASS ARBITRATION, OR REPRESENTATIVE ACTION. You waive any right to participate in class litigation or class arbitration.

11.4 Exceptions to Arbitration

The following are not subject to arbitration:

• Claims for injunctive relief to prevent IP infringement or confidentiality breaches
• Small claims court disputes (under Oregon limits)
• Regulatory investigations or enforcement actions

12. Miscellaneous

12.1 Entire Agreement

These Terms, along with the Privacy Policy and any separate Service Agreement, constitute the entire agreement between you and CoverageUnlocked regarding the Service. All prior agreements and understandings are superseded.

12.2 Amendments

CoverageUnlocked may modify these Terms at any time. Material changes will be posted on this page and a notice sent to your email. Continued use after changes constitutes acceptance.

12.3 Severability

If any provision of these Terms is found to be invalid or unenforceable, that provision is severed and the remaining provisions remain in effect.

12.4 Waiver

Failure to enforce any provision of these Terms does not constitute a waiver of that provision or any other provision.

12.5 Assignment

You may not assign your rights under these Terms without written consent from CoverageUnlocked. CoverageUnlocked may assign these Terms in connection with a merger, acquisition, or sale of assets.

12.6 Survival

The following provisions survive termination: Intellectual Property Rights, Warranty Disclaimers, Limitation of Liability, Dispute Resolution, and any other provisions that by their nature should survive.

Contact & Questions

For questions about these Terms, contact:

CoverageUnlocked LLC
Email: ned@coverageunlocked.com
Address: Bend, Oregon, USA

By using the Service, you acknowledge you have read, understood, and agree to be bound by these Terms of Service.