Terms of Service

1. Definitions

The following terms have the meanings set out below throughout these Terms of Service.

"Agreement"

These Terms of Service, together with the Privacy Policy and any order confirmation or payment receipt issued by PatientLead Health LLC.

"Company"

PatientLead Health LLC, the operator of PriorAuthPro.

"Service"

The PriorAuthPro web-based application, including the intake form, insurer matrix ruleset, document generation engine, and all downloadable outputs accessible at priorauthpro.patientlead.health.

"User" / "you"

Any individual or entity who accesses, uses, or purchases from the Service.

"Packet"

The structured prior authorization appeal documentation set generated by the Service based on User-supplied inputs.

"Insurer Matrix"

The database of insurer-specific submission rules, deadlines, and required documentation maintained by the Company and incorporated into the Service.

"PHI"

Protected Health Information as defined under the Health Insurance Portability and Accountability Act (HIPAA), 45 C.F.R. § 160.103.

"Appeal Proceeding"

Any formal administrative or quasi-administrative proceeding initiated by a User against an insurer to contest a prior authorization or coverage denial.

"Insurer"

Any health insurance company, managed care organization, or third-party administrator whose policies or procedures are referenced in the Insurer Matrix.

"Third-Party Services"

CDN-hosted libraries (including jsPDF and jsPDF-AutoTable from Cloudflare's CDN) that the Service loads at runtime.

2. Acceptance and Eligibility

2.1  Binding Agreement

By using the Service in any manner, including browsing the website, completing the intake form, generating a Packet, or submitting payment, you represent that you have read, understood, and agree to be bound by this Agreement. If you are acting on behalf of another person (such as a family member whose appeal you are managing), you further represent that you have authority to bind that person to this Agreement.

2.2  Age Requirement

You must be at least 18 years of age to use the Service. By using the Service, you represent and warrant that you meet this requirement.

2.3  Geographic Scope

The Service is intended for use by individuals covered under health insurance plans issued or administered in the United States. The Company makes no representation that the Service is appropriate or lawful for use in other jurisdictions.

2.4  Modification of Terms

The Company reserves the right to modify these Terms at any time. Changes will be posted at priorauthpro.patientlead.health/terms with an updated effective date. Continued use of the Service after any modification constitutes acceptance of the revised Terms. For material changes, the Company will provide notice via the email address associated with your account or purchase, where applicable.

3. Description of Service and Scope Limitation

3.1  What PriorAuthPro Does

PriorAuthPro is a structured documentation service. It accepts User-supplied information about a prior authorization denial, cross-references that information against the Insurer Matrix, and generates a set of structured documents designed to assist the User in preparing a prior authorization appeal submission. The Service does not submit appeals, communicate with insurers on the User's behalf, represent the User in any proceeding, provide legal counsel, provide medical advice, or guarantee any outcome.

3.2  MVP Scope

At launch, the Service covers the following scope only:

• Supported insurers: UnitedHealthcare, Aetna, and Blue Cross Blue Shield (major commercial plans only).
• Supported denial type: Medical necessity denials.
• Supported plan types: Commercial HMO, Commercial PPO, and Marketplace (ACA) plans.
• Supported appeal level: Level 1 (Initial Appeal) only.

The Company may expand scope in future versions. The scope at the time of each User's purchase governs that User's transaction.

3.3  Procedural Tool Only

The Service is a procedural documentation tool. It organizes User-supplied information and publicly available insurer policy information into a structured format. It does not evaluate, opine on, or interpret the merits of any denial, the clinical sufficiency of any treatment plan, or the legal sufficiency of any appeal submission. All merit-based judgments remain solely with the User, the User's treating provider, and the insurer.

3.4  BCBS-Specific Disclosure

3.5  Source of Truth Principle

The denial letter or Explanation of Benefits (EOB) issued by your insurer is the primary source of truth for all submission details. Wherever a conflict exists between information in any generated Packet and information in your denial letter or EOB, your denial letter or EOB controls. The Company expressly disclaims responsibility for any adverse consequence resulting from the User's failure to verify submission details against the denial letter.

4. No Attorney-Client Relationship; No Legal Advice

4.1  Not a Law Firm

PatientLead Health LLC is not a law firm and does not employ licensed attorneys in connection with the Service. The Company is not authorized to practice law in any jurisdiction. Nothing in the Service, the Packet, these Terms, or any communication from the Company constitutes legal advice or legal representation.

4.2  No Attorney-Client Relationship

No attorney-client relationship is formed between you and PatientLead Health LLC or between you and any employee, contractor, or affiliate of the Company by virtue of your use of the Service, your purchase of a Packet, your submission of any intake form, or any communication with the Company.

4.3  Unauthorized Practice of Law Disclaimer

Prior authorization appeals are administrative proceedings with legal dimensions, including rights established under federal law (including ERISA, the ACA, and applicable CMS regulations) and applicable state law. The Company does not interpret legal requirements, evaluate legal rights, advise on legal strategy, or represent any User in connection with any Appeal Proceeding. The Service organizes information into a structured format. It does not apply legal principles to your specific facts for the purpose of advising you on your legal rights or obligations.

4.4  Consult an Attorney

If your denial involves complex legal issues, involves a self-funded (ERISA) plan, involves a benefit determination with significant financial or health consequences, or if your internal appeal has been denied and you are evaluating external review or litigation, you should consult a licensed attorney in your jurisdiction before proceeding. The Company is not a substitute for legal counsel.

4.5  State-Specific Notice

Users in California, New York, Texas, Florida, and Illinois are specifically advised that those states maintain broad unauthorized practice of law statutes that have been applied in contexts similar to document preparation services. The Company maintains this disclaimer specifically in recognition of those regulatory environments. You expressly acknowledge that no attorney-client relationship exists, that you have not received legal advice from the Company, and that the Company has not represented you in any proceeding.

5. No Medical Advice

5.1  Not a Medical Provider

PatientLead Health LLC is not a licensed healthcare provider, hospital, clinic, pharmacy, or medical professional in any jurisdiction. The Service is not a medical service.

5.2  No Clinical Interpretation

The Service does not evaluate, opine on, or interpret the clinical merits of any treatment, the medical necessity of any service, the adequacy of any diagnosis, or the clinical sufficiency of any prior therapy. The Service does not assess whether your treatment plan meets any insurer's clinical criteria. These determinations belong exclusively to licensed medical professionals and insurers.

5.3  User-Supplied Medical Information

The Packet reflects medical information as you supply it through the intake form. The Company does not verify, validate, or correct User-supplied medical information. You are solely responsible for the accuracy of the medical information you provide. You should use exact diagnosis language from your medical records or denial letter rather than lay descriptions, as the documents generated will reflect your input.

5.4  Provider Completion Required

The Letter of Medical Necessity template included in each Packet is a structured template that requires completion, review, and signature by a licensed treating provider. The template does not constitute a completed Letter of Medical Necessity and is not usable as-is in a submission. Generating a Packet does not confirm that the clinical content within it is accurate, sufficient, or appropriate for your specific circumstances.

5.5  No Reliance for Clinical Decisions

Nothing in the Service or any generated Packet should be relied upon for clinical decision-making, treatment decisions, or medical judgments of any kind. Users should consult qualified healthcare professionals for all medical questions.

6. Accuracy of Insurer Data; Limitation on Data Reliability

6.1  Nature of Insurer Data

The Insurer Matrix contains submission rules, deadlines, portal URLs, fax numbers, and related information derived from publicly available insurer policy documents, regulatory guidance, and publicly accessible insurer websites. This information is not provided by the insurers directly to the Company, is not verified by the insurers, and may not reflect the current requirements of any insurer at any given time.

6.2  Verification Cadence

The Company verifies Insurer Matrix data on a quarterly basis. Each data entry in the matrix is date-stamped with its last verification date. This date is displayed in the Packet at the time of generation. Quarterly verification does not guarantee that the information is current at the time of your submission. Insurer submission requirements, portal URLs, fax numbers, mailing addresses, and deadlines may change without notice at any time.

6.3  User Responsibility to Verify

You are responsible for independently verifying all submission details with your insurer before filing any appeal. This includes, without limitation, verifying the correct submission channel (portal, fax, or mail), the correct portal URL or fax number, the applicable filing deadline as calculated from your specific denial letter, required document formats, and any plan-specific submission requirements not captured in the Insurer Matrix. The Company's provision of this information is a convenience, not a guarantee of accuracy or completeness.

6.4  Data Age Warning

The Packet generated for you displays the matrix generation date. If the matrix data is more than 90 days old at the time of generation, the Service will display a prominent data-age warning. Regardless of whether a warning is displayed, you remain responsible for verifying current submission requirements with your insurer.

7. No Guarantee of Appeal Outcome

The Company makes no representation, warranty, or guarantee that:

• any appeal submitted using a Packet generated by the Service will be approved;
• any Packet satisfies the specific submission requirements of your insurer or plan;
• any Packet is legally or clinically sufficient for the purpose of obtaining a favorable appeal decision;
• completing the intake form or generating a Packet will result in a timely filed appeal;
• the use of the Service reduces or eliminates the risk of a procedural rejection by your insurer; or
• the information in any Packet is sufficient to satisfy your insurer's internal review criteria.

Appeal outcomes are determined solely by your insurer, based on your insurer's applicable clinical criteria, plan terms, and review processes. The Service provides structured documentation support. It does not guarantee any result.

8. Payment, Pricing, and Refund Policy

8.1  Pricing

The Service is currently offered at $59.00 per Packet. Pricing is subject to change. The price displayed at the time of your purchase governs your transaction.

8.2  Payment Processing

Payments are processed by a third-party payment processor. The Company does not store credit card numbers or financial account information. By completing a purchase, you agree to the payment processor's terms of service in addition to this Agreement.

8.3  Packet Generation

Upon successful payment, the Service will generate your Packet for immediate download. The Company does not store your Packet on its servers after generation. You are responsible for retaining your downloaded Packet.

8.4  Refund Policy

The Company offers a 30-day satisfaction refund policy. If you are unable to use your Packet for any reason, including because your insurer or plan type is not fully supported, because your appeal deadline has already passed, or because the Packet does not meet your needs, you may request a full refund within 30 days of purchase by contacting priorauthpro@patientlead.health with your order information.

The following are not eligible for a refund under this policy:

• Refund requests submitted more than 30 days after the date of purchase.
• Situations in which a refund is sought because a submitted appeal was denied by the insurer. The Company's service is Packet generation, not appeal success.

The 30-day refund policy is the User's exclusive remedy for dissatisfaction with the Service and is in lieu of all other refund, return, or chargeback remedies, to the maximum extent permitted by applicable law.

8.5  Chargebacks

Before initiating a chargeback or payment dispute with your card issuer or payment processor, you agree to contact PatientLead Health LLC at priorauthpro@patientlead.health to request a refund under Section 8.4. Your request must include your order identifier or the email address used at purchase so we can locate your transaction.

The Company will respond to all refund requests within seven (7) business days of receipt. If the Company fails to respond within that period, or if the Company denies your refund request and you believe the denial was in error, you may escalate the dispute to your card issuer or payment processor without further obligation under this Section.

If you initiate a chargeback or payment dispute without first contacting the Company and allowing the seven-business-day response period to expire, that chargeback constitutes a breach of this Agreement. In the event of such a breach, the Company reserves the right to contest the chargeback with the applicable payment processor and to recover from you the amount of the original transaction plus any chargeback dispute fees assessed against the Company by the payment processor in connection with that dispute, up to a maximum of $50.00 per disputed transaction. This recovery right does not limit any other remedy available to the Company under this Agreement or applicable law.

Nothing in this Section limits your rights under applicable federal or state consumer protection law, including your right to dispute a transaction with your card issuer for unauthorized charges or fraud.

9. Privacy and Data Handling

9.1  Browser-Side Processing

The Service is designed to process User-supplied information entirely within the User's web browser. The Company does not transmit, receive, or store the health information, denial details, treatment history, provider information, or member ID numbers entered through the intake form on Company servers. All document generation occurs client-side.

9.2  Company's Warranty Regarding PHI Transmission

The Company warrants that it does not transmit PHI entered through the intake form to Company-controlled servers. This warranty does not extend to Third-Party Services (see Section 9.3). Breach of this warranty by the Company constitutes a breach of this Agreement, and the User's remedy for such breach is limited as set forth in Section 11.

9.3  Third-Party Services

The Service loads the following third-party resources at runtime:

• jsPDF and jsPDF-AutoTable (loaded from Cloudflare's CDN) for PDF generation in the browser.

These third-party services may collect request metadata, including IP addresses and browser user-agent strings, as part of their standard operation. These connections occur while User-supplied information is present in the browser. Users who wish to avoid any incidental third-party data processing should not use the Service. By using the Service, you acknowledge and accept this limitation.

9.4  Analytics and Tracking

If the Company employs website analytics tools, such tools will be disclosed in the Privacy Policy. The Company will not use analytics tools that process PHI entered through the intake form.

9.5  Privacy Policy

The Company's Privacy Policy, available at priorauthpro.com/privacy, is incorporated into this Agreement by reference. The Privacy Policy governs the Company's collection, use, and handling of User information, including information that may be collected through the website outside of the intake form (such as IP addresses, browser type, and navigation data). Users in California, Colorado, Virginia, and other states with applicable privacy laws are encouraged to review the Privacy Policy for jurisdiction-specific disclosures.

10. User Responsibilities

10.1  Accuracy of User-Supplied Information

You are solely responsible for the accuracy and completeness of all information you supply through the intake form. The Packet reflects your input. Inaccurate, incomplete, or misleading input will produce a Packet that reflects those inaccuracies. The Company has no obligation to verify User-supplied information and shall not be liable for any consequence arising from User error in the intake form.

10.2  Verification Before Submission

You are responsible for reviewing your Packet in its entirety before submission. You are responsible for verifying the submission channel, deadline, and all required document inclusions with your insurer before filing. The Company recommends submitting your appeal no fewer than seven calendar days before your filing deadline to allow time for verification and correction.

10.3  Provider Engagement

If your appeal requires a Letter of Medical Necessity from a treating provider, you are responsible for engaging your provider, providing the LMN template from your Packet, and obtaining a completed and signed LMN. The Company does not contact providers on your behalf and does not guarantee that any provider will complete the LMN template.

10.4  Compliance with Applicable Law

You agree to use the Service only for lawful purposes and in compliance with applicable federal and state law. You agree not to use the Service to submit false or misleading information to any insurer or in any Appeal Proceeding.

10.5  Single Use Per Packet

Each Packet purchase entitles the User to one Packet generation based on the information submitted in a single intake session. Using a single Packet for multiple denials, multiple insurers, or multiple patients constitutes a breach of this Agreement.

11. Limitation of Liability

11.1  Cap on Liability

11.2  Exclusion of Consequential Damages

TO THE MAXIMUM EXTENT PERMITTED BY APPLICABLE LAW, PATIENTLEAD HEALTH LLC SHALL NOT BE LIABLE FOR ANY INDIRECT, INCIDENTAL, SPECIAL, CONSEQUENTIAL, PUNITIVE, OR EXEMPLARY DAMAGES WHATSOEVER, INCLUDING BUT NOT LIMITED TO:

• the cost of any denied medical treatment;
• lost wages, medical expenses, or other economic harm resulting from a coverage denial;
• loss of an appeal due to a missed deadline;
• procedural rejection of an appeal by an insurer;
• harm resulting from inaccurate, incomplete, or outdated insurer data in the Insurer Matrix;
• harm resulting from User error in the intake form;
• harm resulting from reliance on any Packet without independent verification; or
• any other indirect, consequential, or downstream harm.

THIS EXCLUSION APPLIES REGARDLESS OF WHETHER THE COMPANY WAS ADVISED OF THE POSSIBILITY OF SUCH DAMAGES AND REGARDLESS OF THE THEORY OF LIABILITY.

11.3  Essential Basis of Bargain

You acknowledge that the limitation of liability set forth in this Section 11 reflects a reasonable allocation of risk between you and the Company, that the limitation is an essential element of the basis of the bargain between you and the Company, and that the Company would not have provided the Service at the pricing offered absent these limitations.

11.4  State Law Variations

Some states do not permit the exclusion or limitation of incidental or consequential damages for consumer transactions. In such states, the limitations in this Section may not apply to you, and your rights may be greater than those described above. The limitations in this Section shall apply to the maximum extent permitted by applicable law in your jurisdiction.

12. Disclaimer of Warranties

THE SERVICE IS PROVIDED ON AN "AS IS" AND "AS AVAILABLE" BASIS. TO THE MAXIMUM EXTENT PERMITTED BY APPLICABLE LAW, THE COMPANY EXPRESSLY DISCLAIMS ALL WARRANTIES OF ANY KIND, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHERWISE, INCLUDING BUT NOT LIMITED TO:

• the implied warranty of merchantability;
• the implied warranty of fitness for a particular purpose;
• any warranty that the Service will meet your requirements;
• any warranty that the Service will be uninterrupted, timely, secure, or error-free;
• any warranty as to the accuracy, completeness, or currency of any information in the Insurer Matrix or any generated Packet;
• any warranty that any Packet will be accepted by your insurer or will satisfy your insurer's submission requirements; and
• any warranty that use of the Service will result in a successful appeal outcome.

The Company does not warrant that the Service will be continuously available, that the insurer matrix data will be current at any given time, or that the Packet generated for you will be free of errors attributable to changes in insurer policy that occurred between matrix verification cycles.

13. Indemnification

You agree to defend, indemnify, and hold harmless PatientLead Health LLC, its officers, directors, employees, contractors, and agents from and against any claims, damages, costs, liabilities, and expenses (including reasonable attorneys' fees) arising out of or related to:

• your use of the Service in violation of these Terms;
• any inaccurate, false, or misleading information you supplied through the intake form;
• your submission of a Packet to an insurer without independently verifying submission requirements;
• your reliance on any generated Packet without consulting an attorney or licensed medical professional where circumstances warranted such consultation; or
• any claim by a third party (including your insurer or treating provider) arising from your use of any generated document.

14. Intellectual Property

14.1  Company Ownership

The Service, the Insurer Matrix, all document templates, the software, the website design, and all associated intellectual property are owned by PatientLead Health LLC. You receive no ownership interest in any Company intellectual property by virtue of your use of the Service or your purchase of a Packet.

14.2  Limited License

Upon payment of the applicable fee, the Company grants you a limited, non-exclusive, non-transferable license to use the Packet generated for you for the sole purpose of preparing and filing a prior authorization appeal in your own name or on behalf of a person for whom you are a legal caregiver or authorized representative.

14.3  Prohibited Uses

You may not reproduce, modify, distribute, resell, sublicense, or use any Packet or Service output for commercial purposes, including but not limited to providing appeal assistance services to third parties for compensation without the Company's written consent.

15. Dispute Resolution and Arbitration

15.1  Informal Resolution First

Before initiating any formal dispute process, you agree to contact the Company at priorauthpro@patientlead.health to describe your dispute and allow the Company 30 days to attempt informal resolution. The Company will use reasonable efforts to resolve disputes informally before they proceed to arbitration.

15.2  Binding Arbitration

If informal resolution fails, any dispute, claim, or controversy arising out of or relating to this Agreement, the Service, any Packet, or any aspect of the parties' relationship (collectively, "Disputes") shall be resolved by binding arbitration administered by the American Arbitration Association (AAA) under its Consumer Arbitration Rules, as modified by this Agreement. The arbitrator's decision shall be final and binding.

15.3  Arbitration Procedures

Arbitration shall be conducted on an individual basis. The arbitration may be conducted remotely. The arbitrator shall have authority to award the same damages and relief as a court of competent jurisdiction, subject to the limitations set forth in this Agreement. The AAA Consumer Arbitration Rules are available at www.adr.org.

15.4  Class Action Waiver

15.5  Exception for Small Claims

Notwithstanding the foregoing, either party may bring an individual claim in a small claims court of competent jurisdiction if the claim qualifies for such court.

15.6  Costs

The Company will pay AAA filing fees for Disputes involving claims of $10,000 or less. For Disputes involving claims exceeding $10,000, AAA fee allocation will be governed by the AAA Consumer Arbitration Rules. Each party shall bear its own attorneys' fees except where applicable law requires otherwise or where the arbitrator finds a claim to have been frivolous or brought in bad faith.

16. Governing Law and Jurisdiction

This Agreement shall be governed by and construed in accordance with the laws of the State of Massachusetts, without regard to its conflict of laws provisions. For any Dispute that is not subject to arbitration under Section 15, the parties consent to the exclusive jurisdiction and venue of the state and federal courts located in the State of Massachusetts.

17. Termination and Suspension

The Company may suspend or terminate your access to the Service at any time, with or without notice, for any violation of these Terms or for any other reason the Company deems appropriate in its sole discretion. Upon termination, any licenses granted to you under these Terms terminate immediately. The following provisions survive termination: Sections 4, 5, 9, 11, 12, 13, 15, 16, and 18.

18. General Provisions

18.1  Entire Agreement

This Agreement, together with the Privacy Policy, constitutes the entire agreement between you and the Company with respect to the Service and supersedes all prior agreements, understandings, negotiations, and representations, whether written or oral, relating to the Service.

18.2  Severability

If any provision of this Agreement is held invalid, illegal, or unenforceable by a court of competent jurisdiction or arbitrator, that provision shall be modified to the minimum extent necessary to make it enforceable, or severed if modification is not possible, and the remaining provisions shall continue in full force and effect.

18.3  Waiver

No failure or delay by the Company in exercising any right under this Agreement shall constitute a waiver of that right. No waiver by the Company of any breach of this Agreement shall be construed as a waiver of any subsequent breach.

18.4  Assignment

You may not assign your rights or obligations under this Agreement without the Company's prior written consent. The Company may assign its rights and obligations under this Agreement to a successor entity in connection with a merger, acquisition, or sale of substantially all assets without your consent.

18.5  Notices

Notices to the Company should be sent to priorauthpro@patientlead.health. Notices to you will be sent to the email address you provided at the time of purchase, if any, or displayed through the Service interface.

18.6  Force Majeure

The Company shall not be liable for any delay or failure in performance resulting from circumstances beyond its reasonable control, including but not limited to acts of God, internet outages, third-party service failures, changes in applicable law, or government orders.

18.7  Relationship of the Parties

The parties are independent contracting parties. Nothing in this Agreement creates any partnership, joint venture, agency, employment, or franchise relationship between you and the Company.

18.8  No Third-Party Beneficiaries

This Agreement is for the sole benefit of you and the Company. Nothing in this Agreement shall create or be deemed to create any rights in any third party, including your insurer, your treating provider, or any regulatory agency.

18.9  Headings

Section headings in this Agreement are for convenience only and do not affect the interpretation of any provision.

Contact and Legal Notices