Terms of Service

1. Agreement to Terms

These Terms of Service ("Terms") constitute a legally binding agreement between you ("User," "you," or "your") and ClaimSmart ("Company," "we," "us," or "our") governing your use of the ClaimSmart platform, including all related services, features, content, and applications (collectively, the "Service").

By accessing or using our Service, you agree to be bound by these Terms and our Privacy Policy. If you do not agree to these Terms, you may not access or use the Service.

2. Definitions

• "Platform" refers to the ClaimSmart web application and all associated services
• "Healthcare Provider" refers to medical practitioners, clinics, and healthcare facilities using our Service
• "Patient Data" refers to protected health information processed through the Platform
• "Claims" refers to medical billing claims submitted to medical aid schemes
• "Medical Aid Scheme" refers to health insurance providers in South Africa and Botswana

3. Eligibility

To use ClaimSmart, you must:

• Be at least 18 years of age
• Be a licensed healthcare provider or authorized representative
• Have a valid practice number and registration in South Africa or Botswana
• Provide accurate and complete registration information
• Maintain the confidentiality of your account credentials
• Comply with all applicable healthcare regulations and laws

4. Account Registration and Security

4.1 Account Creation

You may register for an account using Google OAuth authentication. You are responsible for:

• Maintaining the security of your account and password
• All activities that occur under your account
• Immediately notifying us of any unauthorized access
• Ensuring your registration information is accurate and current

4.2 Professional Credentials

You warrant that all professional credentials, practice numbers, and registration information provided are valid, current, and belong to you. We reserve the right to verify credentials and suspend accounts pending verification.

5. Use of Service

5.1 Permitted Use

ClaimSmart is designed for:

• Managing patient encounters and clinical documentation
• Preparing and validating medical billing claims
• Submitting claims to medical aid schemes in South Africa and Botswana
• Tracking claim status and managing revenue cycle
• Generating invoices and financial reports
• Verifying patient eligibility with medical aid schemes

5.2 Prohibited Activities

You agree NOT to:

• Submit fraudulent, false, or misleading claims
• Use the Service for any unlawful purpose
• Violate any healthcare regulations or medical ethics codes
• Share your account with unauthorized users
• Attempt to circumvent security measures or access restrictions
• Upload malicious code, viruses, or harmful content
• Scrape, harvest, or collect data from the Platform without authorization
• Reverse engineer or attempt to extract source code
• Interfere with or disrupt the Service or servers
• Impersonate another healthcare provider or practice

6. Healthcare Compliance and Regulations

6.1 South Africa Compliance

When using ClaimSmart in South Africa, you agree to comply with:

• Health Professions Act, 1974
• National Health Act, 2003
• Medical Schemes Act, 1998
• Protection of Personal Information Act (POPIA), 2013
• Prescribed Minimum Benefits (PMBs) regulations
• Council for Medical Schemes (CMS) rules and regulations
• HPCSA (Health Professions Council of South Africa) ethical guidelines

6.2 Botswana Compliance

When using ClaimSmart in Botswana, you agree to comply with:

• Health Professions Act (Cap 61:02)
• Data Protection Act, 2018
• BOMAID (Botswana Medical Aid Society) submission requirements
• BHF (Botswana Health Fund) provider regulations
• Medical aid scheme rules and tariff codes
• Omang validation and identity verification requirements

6.3 Billing Code Accuracy

You are solely responsible for the accuracy of diagnosis codes (ICD-10), procedure codes, and tariff codes used in claims. Our AI suggestions are assistive tools only and do not replace professional clinical judgment. You must verify all codes before submission.

7. Data Responsibilities

7.1 Patient Consent

You warrant that you have obtained all necessary patient consents to collect, process, and share patient health information through the Platform, including consent for claim submissions to medical aid schemes.

7.2 Data Accuracy

You are responsible for ensuring all patient data, encounter information, and claim details entered into the Platform are accurate, complete, and up-to-date.

7.3 Data Security

While we implement robust security measures, you must also maintain appropriate safeguards, including secure passwords, restricted access to authorized personnel, and compliance with data protection regulations.

8. Claims Submission and Processing

8.1 No Guarantee of Approval

ClaimSmart assists with claim preparation and submission but does not guarantee claim approval or payment by medical aid schemes. Final approval decisions are made by the schemes based on their rules, coverage, and validation processes.

8.2 Validation Tools

Our AI-powered validation tools identify potential errors and suggest improvements but cannot guarantee 100% accuracy. You must review all claims before submission.

8.3 Rejected Claims

You are responsible for addressing rejected claims, providing additional documentation, and resubmitting as necessary. We provide tools to track and manage rejections but cannot control scheme decisions.

8.4 Submission Methods

ClaimSmart supports multiple submission methods:

• South Africa: Integration with Medikredit switch system
• Botswana: Email submission, XML EDI files (BOMAID), portal instructions

You must ensure proper configuration and authorization for submission methods used.

9. Fees and Payment

9.1 Subscription Fees

Access to ClaimSmart requires a paid subscription. Fees are billed according to your chosen plan (monthly or annual) and are due in advance. All fees are non-refundable except as required by law.

9.2 Fee Changes

We reserve the right to modify subscription fees with 30 days' advance notice. Continued use after fee changes constitutes acceptance.

9.3 Payment Processing

Payments are processed through secure third-party payment processors. You authorize us to charge your payment method for all applicable fees.

9.4 Late Payment

Failure to pay fees may result in account suspension or termination. We may charge late fees or interest on overdue amounts as permitted by law.

10. Intellectual Property

10.1 Our Rights

ClaimSmart and all content, features, and functionality (including but not limited to software, design, text, graphics, logos, AI models) are owned by the Company and protected by copyright, trademark, and other intellectual property laws.

10.2 License Grant

We grant you a limited, non-exclusive, non-transferable, revocable license to access and use the Service for your healthcare practice in accordance with these Terms.

10.3 Your Data

You retain all rights to your patient data and practice information. By using the Service, you grant us a license to process and store this data solely to provide the Service.

11. AI and Machine Learning Features

11.1 AI Assistance

Our AI features provide code suggestions, claim validation, and error detection based on machine learning models trained on anonymized healthcare data. These are assistive tools and should not replace professional judgment.

11.2 Model Improvement

We may use anonymized, aggregated data to improve our AI models. We never use identifiable patient information for training purposes.

11.3 No Medical Advice

ClaimSmart does not provide medical advice, diagnosis, or treatment recommendations. Our AI tools assist with billing and administrative tasks only.

12. Service Availability and Support

12.1 Uptime

We strive to maintain 99.9% uptime but do not guarantee uninterrupted service. We may perform maintenance, updates, or emergency repairs that temporarily affect availability.

12.2 Support

Technical support is available via email during business hours. Premium support options may be available for higher-tier subscriptions.

12.3 Service Modifications

We reserve the right to modify, suspend, or discontinue any feature or aspect of the Service at any time with reasonable notice.

13. Termination

13.1 By You

You may terminate your account at any time through account settings or by contacting support. Termination does not entitle you to a refund of prepaid fees.

13.2 By Us

We may suspend or terminate your account immediately if you:

• Violate these Terms or applicable laws
• Engage in fraudulent or unethical practices
• Fail to pay subscription fees
• Provide false information or credentials
• Misuse the Service or compromise security

13.3 Effect of Termination

Upon termination, your access to the Service will cease. You may request an export of your data within 30 days of termination, after which data may be permanently deleted according to our retention policy.

14. Disclaimers and Limitations of Liability

14.1 "As Is" Basis

THE SERVICE IS PROVIDED "AS IS" AND "AS AVAILABLE" WITHOUT WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, OR NON-INFRINGEMENT.

14.2 No Warranty of Accuracy

We do not warrant that the Service will be error-free, secure, or uninterrupted, or that AI suggestions will be accurate or complete.

14.3 Limitation of Liability

TO THE MAXIMUM EXTENT PERMITTED BY LAW, CLAIMSMART SHALL NOT BE LIABLE FOR:

• Rejected claims or lost revenue from claim denials
• Errors in AI suggestions or code recommendations
• Data loss due to system failures or user error
• Third-party actions (medical aid schemes, payment processors)
• Indirect, incidental, special, consequential, or punitive damages

OUR TOTAL LIABILITY SHALL NOT EXCEED THE FEES PAID BY YOU IN THE 12 MONTHS PRECEDING THE CLAIM.

15. Indemnification

You agree to indemnify, defend, and hold harmless ClaimSmart, its officers, directors, employees, and agents from any claims, liabilities, damages, losses, and expenses (including legal fees) arising from:

• Your use or misuse of the Service
• Violation of these Terms or applicable laws
• Infringement of third-party rights
• Fraudulent claims or unethical billing practices
• Failure to obtain required patient consents

16. Dispute Resolution and Governing Law

16.1 Governing Law

These Terms are governed by the laws of South Africa (for South African users) or Botswana (for Botswana users), without regard to conflict of law principles.

16.2 Arbitration

Any disputes arising from these Terms shall be resolved through binding arbitration in accordance with the rules of the Arbitration Foundation of Southern Africa (AFSA) or equivalent body in Botswana.

16.3 Exceptions

Either party may seek injunctive relief in court to protect intellectual property rights or prevent unauthorized access to the Service.

17. General Provisions

17.1 Entire Agreement

These Terms, together with our Privacy Policy, constitute the entire agreement between you and ClaimSmart regarding the Service.

17.2 Severability

If any provision of these Terms is found to be unenforceable, the remaining provisions will remain in full force and effect.

17.3 Waiver

Our failure to enforce any provision of these Terms does not constitute a waiver of that provision.

17.4 Assignment

You may not assign or transfer these Terms without our prior written consent. We may assign our rights and obligations without restriction.

17.5 Notices

All notices must be sent to the email addresses on file. We may also provide notices through the Service or on our website.

18. Changes to These Terms

We may update these Terms from time to time. Material changes will be communicated via email or prominent notice on the Platform at least 30 days before taking effect. Your continued use after changes constitute acceptance of the updated Terms.

19. Contact Us

For questions about these Terms, please contact us:

20. Acknowledgment

BY USING CLAIMSMART, YOU ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD, AND AGREE TO BE BOUND BY THESE TERMS OF SERVICE.