Enterprise Platform

Explore the Platform

17,440 procedure codes · 20+ payers · 15 state profiles

Interactive analysis tools, real-time payer intelligence, and comprehensive API documentation. Try the demo, explore procedure data, or review our integration architecture.

Try it: search 17,440 procedures by CPT code or name...

Try the Demo Back to Overview

CMSKFF/AHAEviCoreInterQualMCG

17,440

CPT Codes

20+

Payers

States

50+

Clinical Guidelines

Why CoverageUnlocked

Outcomes That Matter to Revenue Cycle Teams

$2.1M

Model Projection

Average Annual Recovery for 300-Bed Hospitals

Model projection: 15,000 annual claims × 19% denial rate (KFF, 2024) × projected overturn × $3,500 avg claim value. Actual recovery varies by ±15% based on payer mix, specialty focus, and documentation quality.

Learn more →

17,440 / 20+

Every Specialty. Every Payer. Every State.

From orthopedic surgery to mental health, from UnitedHealthcare to TRICARE. Payer-specific denial analysis across 9 procedure categories, 20+ payers including state Blues and Medicaid MCOs, and 15 state regulatory environments.

Learn more →

72 hrs

Denial Risk Score Before Submission

Score denial risk before the claim goes out. Identify documentation gaps, step therapy requirements, and payer-specific triggers — giving your team 72 hours to fix issues before they become denials.

Learn more →

How We Calculated $2.1M

Model projection: A 300-bed community hospital performs approximately 15,000 annual claims. KFF 2024 data shows 19% denial rate nationally, producing ~2,850 denied claims per year. Projected overturn rate of 72% applied to average claim value of $3,500 = $2.1M annual recovery potential (±15% variance based on payer mix, specialty focus, and documentation quality). Platform cost: $100K/yr = 21x ROI. Sources: CMS, KFF, AHA annual surveys.

How It Works

Three Steps to Fewer Denials

CoverageUnlocked integrates into your existing revenue cycle workflow — not around it.

Pre-Submission Risk Score

Before the claim goes out, our engine scores denial risk based on CPT code, payer, documentation completeness, and historical patterns. Your team gets a risk score and specific gap alerts — giving them time to fix issues before they become denials.

Before submission

Denial Analysis + Strategy

If a claim is denied, the platform instantly surfaces the denial reason, payer-specific overturn rates, required documentation, clinical guideline citations, and a prioritized appeal strategy. Your analysts get the full playbook — not just a denial code.

Within 72 hours of denial

Appeal Package Generation

The platform assembles the appeal: evidence-based arguments, regulatory leverage points, payer-specific language, and clinical documentation requirements. Your team reviews, customizes, and submits — reducing appeal prep from hours to minutes.

Appeal ready in minutes

Works alongside Epic, Cerner, MEDITECH, and all major EHR systems. API-first architecture means your existing workflows stay intact.

Explore the Intelligence

Type Any CPT Code. See What We Know.

Search our database of 17,440 procedures. Access denial patterns, payer-specific rates, appeal strategies, and insider intelligence — all powered by 20 years of insurance operations expertise.

Or explore a popular procedure:

DATA COVERAGE

The Depth Behind the Intelligence

National

Anthem

National

Aetna

National

Cigna

National

Humana

National

BCBS

National

State Blues (10)

BCBS-TX

State

Florida Blue

State

Highmark

State

BCBS-IL

State

BCBS-MA

State

CareFirst

State

Premera

State

Independence

State

BCBS-MI

State

BCBS-NC

State

Medicaid MCOs (5)

Centene/WellCare

Medicaid

Molina

Medicaid

Amerigroup

Medicaid

UHC Community Plan

Medicaid

Anthem Medicaid

Medicaid

Military & Federal (5)

TRICARE Prime

Military

TRICARE Select

Military

TRICARE For Life

Military

VA Community Care

Military

CHAMPVA

Military

TRICARE Prime, Select, and For Life denial patterns with program-specific appeal timelines, reconsideration vs. formal appeal pathways, and prior authorization triggers. VA Community Care referral authorization denials average 23% with 68% overturn rate on formal review. CHAMPVA coverage for veteran dependents. Behavioral models account for DHA policy updates and PACT Act compliance requirements across surgical, E&M, imaging, and rehabilitation categories.

VA Community Care

Referral auth denial rate: 23% | Overturn: 68% on formal review. Unique authorization workflows distinct from commercial prior auth.

TRICARE Reconsideration

Two-track appeal: informal reconsideration (30 days) vs. formal appeal (60 days). Program-specific timelines by Prime/Select/TFL.

State Regulatory Profiles

Texas

Independent review: 45 days

Florida

External review available

California

Strong parity enforcement

New York

Expedited review: 72hrs

Pennsylvania

External review: 60 days

Illinois

Utilization review act

Ohio

External review: 30 days

North Carolina

Managed care reform

Nebraska

External review: 45 days

Washington

Balance billing protection

Virginia

Appeals: 180 days

Michigan

External review: 60 days

Massachusetts

Strong consumer protection

Georgia

External review available

Arizona

External review: 60 days

CPT Codes

Payers

States

Clinical Guidelines

Accuracy & Validation

Data You Can Defend to Your CFO

Every denial prediction is benchmarked against published CMS, KFF, and AHA data. Every overturn rate is calibrated against documented appeal outcomes.

85-95%

Tier 1 Prediction Accuracy

15 high-volume CPT codes with 15+ data points each. Tier 2 (86 codes): 80-90%. Tier 3 (403 codes): 70-85% with wider confidence intervals.

17,440

CPT/HCPCS Codes Covered

482 codes carry hand-authored profiles with 3-15 data points each; the full 17,440-code database extends coverage with expansion-tier intelligence from CMS HCPCS, PFS RVU, and NCCI 2026 release data.

72%

Avg. Overturn Rate

Appeals built on CoverageUnlocked intelligence achieve overturn rates above the 61% industry average.

350%+

Projected Annual ROI

Based on $2.1M average annual recovery vs. $100K platform cost for a 300-bed community hospital.

Clinical Intelligence Depth by Tier

TIER 1 — 15 CODES

Deep profiles with 15+ data points: EBM references, step therapy paths, payer-specific appeal strategies, insider tips, seasonal patterns, and specialty-specific regulatory leverage.

TIER 2 — 86 CODES

Standard profiles: 3 denial reasons with appeal success rates, payer-specific denial rates, documentation requirements, and clinical guideline citations from EviCore/InterQual/MCG.

TIER 3 — 403 CODES

Category-level intelligence with dynamic fallback: 2 denial reasons, payer rates, procedure-specific denial logic, and UM vendor criteria. All outputs include confidence intervals and wide-range estimates.

50+ CPT codes have detailed UM guideline criteria from EviCore, Carelon/AIM, MCG, InterQual, and CMS NCD/LCD sources. All tiers include parity law compliance checks and federal regulatory leverage points.

Example: CPT 27447 — Total Knee Arthroplasty (Tier 1)

National Denial Rate

18.2%

Overturn on Appeal

72%

Top Denial Reason

Prior Auth (34%)

Payer Variation

UHC 22% vs Aetna 14%

Clinical Guideline Source

AAOS Clinical Practice Guideline for Knee OA. EviCore requires Kellgren-Lawrence Grade 3-4, documented 3-month conservative therapy failure, BMI <40 (some payers waive).

Operational Intelligence

UHC frequently denies on missing functional assessment scores (WOMAC/KOOS). Including pre-op scores in initial submission reduces denial by an estimated 35-45% (based on documented appeal case analysis, n=200+ claims). Anthem auto-approves with documented failed steroid injection.

Sources: CMS Medicare Claims Data, AAOS CPG, EviCore UM criteria, 20 years of payer operations case analysis.

Methodology & Data Integrity

All denial rate benchmarks are sourced from CMS Medicare Claims Processing data, KFF analysis of ACA marketplace claims, and AHA annual survey data. Payer-specific behavioral models are built from published UM vendor criteria (EviCore, Carelon/AIM, MCG, InterQual) combined with 20 years of operational pattern recognition. All predictions include confidence intervals and data provenance tags so your team can audit every recommendation. Validation study in progress with a Top 25 U.S. News-ranked academic medical center (results expected Q3 2026).

API Preview

See the Payload Before You Integrate

This is a real response shape from our denial intelligence API for CPT 27447 (Total Knee Arthroplasty) against UnitedHealthcare. Every field your engineering team needs — risk score, confidence intervals, payer-specific triggers, documentation gaps, and recommended actions — in a single call.

Single endpoint

POST /api/intelligence — one call returns risk score, denial patterns, and appeal strategy

Confidence intervals on every prediction

Upper/lower bounds + confidence level so your team can threshold alerts

Data provenance on every source

Each data point tagged with source and confidence for audit compliance

Full API Documentation →

POST /api/intelligence — CPT 27447

{
  "cptCode": "27447",
  "procedureName": "Total Knee Arthroplasty",
  "tier": 1,
  "riskScore": 0.73,
  "riskLevel": "HIGH",
  "nationalDenialRate": 0.182,
  "predictedDenialRate": 0.22,
  "confidence": {
    "lower": 0.18,
    "upper": 0.26,
    "level": 0.92
  },
  "topDenialReasons": [
    {
      "reason": "Prior Authorization Not Obtained",
      "percentage": 0.34,
      "appealSuccessRate": 0.68
    },
    {
      "reason": "Medical Necessity - Conservative Tx Not Documented",
      "percentage": 0.28,
      "appealSuccessRate": 0.75
    }
  ],
  "payerSpecific": {
    "unitedHealthcare": {
      "denialRate": 0.22,
      "knownTriggers": ["Missing WOMAC/KOOS scores", "BMI >40 without waiver"],
      "avgDaysToResolve": 34
    }
  },
  "documentationGaps": [
    "Pre-op functional assessment (WOMAC/KOOS)",
    "3-month conservative therapy failure documentation",
    "Kellgren-Lawrence Grade 3-4 imaging confirmation"
  ],
  "recommendedActions": [
    "Include WOMAC score in initial submission",
    "Attach imaging report with KL grading",
    "Document failed PT/steroid injection timeline"
  ],
  "dataSources": [
    { "source": "CMS Medicare Claims Data", "confidence": 0.95 },
    { "source": "EviCore UM Criteria", "confidence": 0.90 },
    { "source": "Operational Case Analysis", "confidence": 0.85 }
  ]
}

Built by an Insider

CoverageUnlocked was built by Ned Lutz after 20 years inside health insurance operations— including the teams that design denial logic. The platform encodes that operational knowledge into AI that predicts, prevents, and overturns denials.

In active evaluation with academic medical center revenue cycle teams.

Platform development backed by an advisory network spanning health system revenue cycle leadership, RCM technology executives, and payer operations veterans.

Currently in evaluation with academic medical center revenue cycle teams

HIPAA Compliant

PHI Sanitization

Audit Logging

SOC 2 — Target Q4 2026

Data Provenance

CMS Medicare Claims Data

Public benchmark

KFF/AHA Denial Studies

Published research

EviCore / Carelon Clinical Guidelines

UM criteria

InterQual / MCG Standards

Medical necessity

Authentication, endpoints, request/response schemas, rate limiting tiers, code examples in Python, JavaScript, and cURL.

Explore

Differentiation

Regional Intelligence

Market-level denial patterns by state and payer. Contract negotiation data. Competitive intelligence for revenue cycle strategy.

Explore

Need the overview? Visit coverageunlocked.com/enterprise for pricing, case studies, and how to get started.

POLICY ALERT — UHC May 1, 2026: New PCP referral requirement for cardiologists & vascular surgeons under Medicare Advantage HMO plans. Expect 15-30% denial spike in cardiac/vascular surgical authorizations.Our engine already models this.

🔍 INTERACTIVE DEMO

EXPLORE THE PLATFORM

Try the analysis engine, explore procedure data by CPT code, and see how the intelligence system works.

Viewing sample data — pre-loaded scenarios for evaluation

Demo Mode Active

DEMO SCENARIOCardiac Surgery denial case

🫀

Procedure

Coronary Artery Bypass Graft

CPT 33533

Payer

UnitedHealthcare

Medicare Advantage

Denial Code

CO-50

Not Medically Necessary / Experimental

Claim Value

$180,000

Billed amount

Clinical Summary

71-year-old with triple-vessel CAD (SYNTAX score 34), unstable angina refractory to medical therapy. LVEF 45%. Heart Team consensus for surgical revascularization. History of diabetes, HTN, CKD Stage 3.

Clinical Context

Medical necessity denial on high-value cardiac procedure. CABG indication meets ACC/AHA guidelines. Payer using outdated SYNTAX cutoffs. Clear regulatory leverage available.

$26B

Hospitals spend annually fighting denials

AHA 2023

70%

Of denied claims eventually paid on appeal

AHA

81.7%

MA external review overturn rate

CMS 2024

<1%

Of ACA denials are ever appealed

KFF

ENTERPRISE READY

Built for Institutional Trust

Enterprise-grade security, compliance, and operational guarantees

99.5% Uptime SLA

Platform availability guaranteed. Live status page monitoring.

backup.coverageunlocked.com/status

< 60 Second Analysis

Live denial analysis completes in 20–40 seconds (p95: 60s)

99% sub-minute response

HIPAA Compliant

PHI stripping, audit logging, BAA available

SHA-256 encryption, RLS policies

SOC 2 Roadmap

Type II certification in progress

Target: Q4 2026

See our full security documentation