aid: aetna url: https://raw.githubusercontent.com/api-evangelist/aetna/refs/heads/main/apis.yml modified: '2026-04-19' name: Aetna description: >- Aetna, a CVS Health company, offers health insurance, dental, vision, and other plans for individuals, families, employers, health care providers, and insurance agents and brokers. As a major U.S. health insurer, Aetna provides federally mandated FHIR R4 APIs for patient access, provider directory, and drug formulary data under CMS Interoperability and Patient Access Final Rule (CMS-9115-F). Provider connectivity is supported through the Availity portal for EDI transactions. tags: - Health Insurance - Healthcare - FHIR - Patient Access - Provider Directory apis: - aid: aetna-patient-access-fhir-api name: Aetna Patient Access FHIR API description: >- FHIR R4 compliant Patient Access API providing members secure access to their health data including claims, clinical data, and coverage information. Required under CMS Interoperability and Patient Access Final Rule (CMS-9115-F). Supports SMART on FHIR authorization and provides access to ExplanationOfBenefit, Coverage, Patient, and related FHIR resources. tags: - FHIR - Patient Access - Health Data - Claims - CMS Mandate properties: - type: Documentation url: https://www.aetna.com/individuals-families/member-rights-resources/member-data-access.html - type: Authentication url: https://www.aetna.com/individuals-families/member-rights-resources/member-data-access.html - aid: aetna-provider-directory-fhir-api name: Aetna Provider Directory FHIR API description: >- FHIR R4 compliant Provider Directory API providing standardized access to in-network provider and facility information. Enables third-party applications to search for providers, verify network participation, and access provider details. Required under CMS Interoperability and Patient Access Final Rule for payer-to-payer data exchange. tags: - FHIR - Provider Directory - Network - Healthcare Providers - CMS Mandate properties: - type: Documentation url: https://www.aetna.com/health-care-professionals/working-with-aetna/provider-directory.html - aid: aetna-drug-formulary-fhir-api name: Aetna Drug Formulary FHIR API description: >- FHIR R4 compliant Drug Formulary API providing standardized access to plan formulary data including covered drugs, tiers, cost-sharing requirements, and prior authorization requirements. Implements the DaVinci PDEX Formulary Implementation Guide. Enables members and third-party applications to compare drug coverage across health plans. tags: - FHIR - Drug Formulary - Pharmacy - Medications - CMS Mandate properties: - type: Documentation url: https://www.aetna.com/individuals-families/member-rights-resources/member-data-access.html - aid: aetna-provider-edi-api name: Aetna Provider EDI API description: >- Electronic Data Interchange connectivity for healthcare providers enabling electronic submission of claims, eligibility verification, claim status inquiries, and remittance advice. Accessible through the Availity provider portal supporting EDI 837 (claims), 270/271 (eligibility), 276/277 (claim status), and 835 (remittance) HIPAA transactions. tags: - EDI - Claims - Eligibility - Provider Portal - HIPAA properties: - type: Documentation url: https://www.aetna.com/health-care-professionals/claims-payment/claims-submission.html - type: Portal url: https://www.availity.com common: - type: GitHubOrganization url: https://github.com/aetnahealth - type: LinkedIn url: https://www.linkedin.com/company/aetna - type: Website url: https://www.aetna.com - type: Portal url: https://www.aetna.com/health-care-professionals.html - type: Login url: https://member.aetna.com - type: Support url: https://www.aetna.com/individuals-families/contact-aetna.html - type: PrivacyPolicy url: https://www.aetna.com/legal-notices/privacy.html - type: TermsOfService url: https://www.aetna.com/legal-notices/terms-of-use.html - type: Features data: - name: FHIR R4 Compliance description: All patient-facing APIs implement HL7 FHIR Release 4 standard for interoperability. - name: SMART on FHIR Authorization description: Secure OAuth 2.0 authorization framework for patient-authorized third-party app access. - name: CMS Interoperability Compliance description: Full compliance with CMS-9115-F Interoperability and Patient Access Final Rule. - name: EDI Transaction Support description: Complete HIPAA-compliant EDI transaction set for provider administrative workflows. - name: Payer-to-Payer Data Exchange description: Supports member-directed payer-to-payer data exchange for continuity of care. - name: DaVinci Implementation Guides description: Implements HL7 DaVinci Project PDEX, PDex Drug Formulary, and Plan Net guides. - type: UseCases data: - name: Member Health Record Access description: Members use SMART on FHIR apps to access their complete health records across providers. - name: Provider Network Verification description: Developers build directory search tools to help patients find in-network providers. - name: Drug Cost Comparison description: Applications use formulary API to compare medication costs across Aetna plans. - name: Electronic Claims Submission description: Healthcare providers submit claims electronically via EDI 837 transactions through Availity. - name: Eligibility Verification description: Providers verify member eligibility and benefits in real time using 270/271 EDI transactions. - name: Remittance Processing description: Providers receive and process electronic remittance advice via EDI 835 transactions. - type: Integrations data: - name: CVS Caremark description: Integrated pharmacy benefit management for prescription drug coverage and mail-order pharmacy. - name: Availity description: Primary provider portal for EDI transactions, eligibility, claims, and authorization requests. - name: Epic Payer Platform description: EHR integration enabling clinical workflows including prior authorization and care management. - name: Apple Health description: FHIR-based integration enabling Aetna members to view health data in Apple Health app. - name: CommonWell Health Alliance description: Interoperability network participation for cross-organization health data exchange. - name: CMS Blue Button 2.0 description: Alignment with CMS Blue Button 2.0 FHIR API patterns for Medicare data access.