aid: amerihealth-caritas name: AmeriHealth Caritas description: >- AmeriHealth Caritas is one of the largest Medicaid managed care organizations in the United States, serving roughly five million members across Medicaid, Children's Health Insurance Program (CHIP), dual-eligible Medicare-Medicaid (D-SNP), Medicare-Medicaid LTSS, and Marketplace lines of business across thirteen states plus the District of Columbia. The company is owned jointly by Independence Blue Cross (majority) and Blue Cross Blue Shield of Michigan, operates state health plans under brands such as Keystone First, Select Health of South Carolina, Blue Cross Complete of Michigan, AmeriHealth Caritas Next, AmeriHealth Caritas VIP Care, and PerformCare, and exposes a set of HL7 FHIR R4 APIs through its developer portal at developer.amerihealthcaritas.com to satisfy the CMS Interoperability and Patient Access final rule (CMS-9115-F). url: https://raw.githubusercontent.com/api-evangelist/amerihealth-caritas/refs/heads/main/apis.yml type: Index image: https://kinlane-productions2.s3.amazonaws.com/apis-json/apis-json-logo.jpg tags: - Healthcare - Health Insurance - Managed Care - Medicaid - Medicare - Dual Eligible - CHIP - LTSS - Behavioral Health - Pharmacy Benefits - Interoperability - FHIR - CMS - SMART On FHIR - Patient Access - Provider Directory created: '2024-01-01' modified: '2026-05-23' specificationVersion: '0.19' apis: - aid: amerihealth-caritas:patient-access-api name: AmeriHealth Caritas Patient Access FHIR API description: >- HL7 FHIR R4 (4.0.1) Patient Access API published to satisfy the CMS Interoperability and Patient Access final rule (CMS-9115-F). Provides member-authorized access to clinical, claims, encounter, coverage, medication, immunization, and demographic resources for the AmeriHealth Caritas family of Medicaid, CHIP, D-SNP, LTSS, and Marketplace health plans. Member data is protected by SMART on FHIR / OAuth 2.0 with PKCE; production access requires developer registration, app review, and member consent. Per-plan FHIR base URLs are exposed under api-ext.amerihealthcaritas.com keyed by a four-digit plan code (0100, 0500, 0900, 2400, 2600 confirmed public). humanURL: https://developer.amerihealthcaritas.com/ baseURL: https://api-ext.amerihealthcaritas.com/0500/patient-api tags: - Patient Access - FHIR - SMART On FHIR - Medicaid - CMS properties: - type: Portal url: https://developer.amerihealthcaritas.com/ - type: Documentation url: https://developer.amerihealthcaritas.com/dvp/v1/apiadditionaldocsinfo/ - type: CapabilityStatement url: https://api-ext.amerihealthcaritas.com/0500/patient-api/metadata - type: BaseURL url: https://api-ext.amerihealthcaritas.com/0100/patient-api - type: BaseURL url: https://api-ext.amerihealthcaritas.com/0500/patient-api - type: BaseURL url: https://api-ext.amerihealthcaritas.com/0900/patient-api - type: BaseURL url: https://api-ext.amerihealthcaritas.com/2400/patient-api - type: BaseURL url: https://api-ext.amerihealthcaritas.com/2600/patient-api - type: AuthorizeURL url: https://member.amerihealthcaritas.com/patientaccesssvc/oauth2/v1/authorize - type: TokenURL url: https://eapics.amerihealthcaritas.com/oauth2/v1/token - type: OpenAPI url: openapi/amerihealth-caritas-patient-access-openapi.yml - type: SpectralRules url: rules/amerihealth-caritas-rules.yml - type: NaftikoCapability url: capabilities/amerihealth-caritas-patient-access.yaml - type: NaftikoCapability url: capabilities/amerihealth-caritas-claims-and-eob.yaml - type: NaftikoCapability url: capabilities/amerihealth-caritas-medications-and-formulary.yaml - type: JSONSchema url: json-schema/amerihealth-caritas-patient-schema.json - type: JSONSchema url: json-schema/amerihealth-caritas-coverage-schema.json - type: JSONSchema url: json-schema/amerihealth-caritas-explanation-of-benefit-schema.json - aid: amerihealth-caritas:provider-directory-api name: AmeriHealth Caritas Provider Directory FHIR API description: >- HL7 FHIR R4 (4.0.1) Provider Directory API satisfying the CMS Provider Directory requirements of the Interoperability and Patient Access final rule. Publishes Practitioner, PractitionerRole, Organization, OrganizationAffiliation, Location, and InsurancePlan resources for the AmeriHealth Caritas family of plans. No authentication is required; the directory is publicly queryable. Per-plan endpoints are exposed at api-ext.amerihealthcaritas.com under plan codes including 0100, 0500, 0900, 1200, 2100, 2400, and 2600. humanURL: https://developer.amerihealthcaritas.com/ baseURL: https://api-ext.amerihealthcaritas.com/1200/provider-api tags: - Provider Directory - FHIR - Healthcare - CMS properties: - type: Portal url: https://developer.amerihealthcaritas.com/ - type: Documentation url: https://developer.amerihealthcaritas.com/dvp/v1/apiadditionaldocsinfo/ - type: CapabilityStatement url: https://api-ext.amerihealthcaritas.com/1200/provider-api/metadata - type: SwaggerUI url: https://api-ext.amerihealthcaritas.com/1200/provider-api/swagger-ui/?page=All - type: BaseURL url: https://api-ext.amerihealthcaritas.com/0100/provider-api - type: BaseURL url: https://api-ext.amerihealthcaritas.com/0500/provider-api - type: BaseURL url: https://api-ext.amerihealthcaritas.com/0900/provider-api - type: BaseURL url: https://api-ext.amerihealthcaritas.com/1200/provider-api - type: BaseURL url: https://api-ext.amerihealthcaritas.com/2100/provider-api - type: BaseURL url: https://api-ext.amerihealthcaritas.com/2400/provider-api - type: BaseURL url: https://api-ext.amerihealthcaritas.com/2600/provider-api - type: OpenAPI url: openapi/amerihealth-caritas-provider-directory-openapi.yml - type: SpectralRules url: rules/amerihealth-caritas-rules.yml - type: NaftikoCapability url: capabilities/amerihealth-caritas-provider-directory.yaml - type: JSONSchema url: json-schema/amerihealth-caritas-practitioner-schema.json - type: JSONSchema url: json-schema/amerihealth-caritas-organization-schema.json - type: JSONSchema url: json-schema/amerihealth-caritas-location-schema.json - aid: amerihealth-caritas:formulary-api name: AmeriHealth Caritas Formulary FHIR API description: >- HL7 FHIR R4 Formulary API published to satisfy CMS-9115-F drug formulary publication requirements for Medicaid managed care and D-SNP populations. Covered drug lists, tier information, and prior authorization indicators are exposed through FHIR MedicationKnowledge and List resources. Documented at developer.amerihealthcaritas.com as a public, no-authentication surface; the canonical public base URL is not separately published at api-ext.amerihealthcaritas.com and formulary resources are currently surfaced inside the Patient Access API under MedicationKnowledge / List. humanURL: https://developer.amerihealthcaritas.com/dvp/v1/apiadditionaldocsinfo/ baseURL: https://api-ext.amerihealthcaritas.com/0500/patient-api tags: - Formulary - Drug Formulary - FHIR - Pharmacy Benefits - CMS properties: - type: Portal url: https://developer.amerihealthcaritas.com/ - type: Documentation url: https://developer.amerihealthcaritas.com/dvp/v1/apiadditionaldocsinfo/ - type: NaftikoCapability url: capabilities/amerihealth-caritas-medications-and-formulary.yaml - aid: amerihealth-caritas:website name: AmeriHealth Caritas Corporate Website description: >- Public corporate website for AmeriHealth Caritas, hosting the family-of-plans health plan finder, solutions overview, careers, member and provider portals for the federated state plans, and pointers to the CMS Interoperability developer portal. humanURL: https://www.amerihealthcaritas.com baseURL: https://www.amerihealthcaritas.com tags: - Website - Corporate properties: - type: Website url: https://www.amerihealthcaritas.com - type: HealthPlanFinder url: https://www.amerihealthcaritas.com/find-a-health-plan - type: Solutions url: https://www.amerihealthcaritas.com/health-care-solutions - type: Careers url: https://careers.amerihealthcaritas.com/us/en - type: DeveloperPortal url: https://developer.amerihealthcaritas.com/ common: - type: Portal url: https://developer.amerihealthcaritas.com/ - type: Website url: https://www.amerihealthcaritas.com - type: Documentation url: https://developer.amerihealthcaritas.com/dvp/v1/apiadditionaldocsinfo/ - type: GettingStarted url: https://developer.amerihealthcaritas.com/dvp/v1/apiadditionaldocsinfo/ - type: Authentication url: https://developer.amerihealthcaritas.com/dvp/v1/apiadditionaldocsinfo/ - type: CMSFinalRule url: https://www.cms.gov/priorities/key-initiatives/burden-reduction/interoperability - type: CARINBlueButton url: https://hl7.org/fhir/us/carin-bb/history.html - type: DaVinciPDex url: https://hl7.org/fhir/us/davinci-pdex/history.html - type: USCDI url: https://www.healthit.gov/isp/united-states-core-data-interoperability-uscdi#uscdi-v1 - type: SMARTAppLaunch url: https://hl7.org/fhir/smart-app-launch/1.0.0/ - type: HealthPlanFinder url: https://www.amerihealthcaritas.com/find-a-health-plan - type: ContactUs url: https://www.amerihealthcaritas.com/contact-us - type: Careers url: https://careers.amerihealthcaritas.com/us/en - type: NewsBlog url: https://www.amerihealthcaritas.com/newsroom - type: TransparencyInCoverage url: https://www.amerihealthcaritas.com/about-us/transparency-in-coverage.aspx - type: GitHub url: https://github.com/amerihealth - type: Plans url: plans/amerihealth-caritas-plans-pricing.yml - type: RateLimits url: rate-limits/amerihealth-caritas-rate-limits.yml - type: FinOps url: finops/amerihealth-caritas-finops.yml - type: Vocabulary url: vocabulary/amerihealth-caritas-vocabulary.yml - type: JSONLDContext url: json-ld/amerihealth-caritas-context.jsonld - type: Features data: - name: HL7 FHIR R4 Patient Access API description: >- SMART on FHIR / OAuth 2.0 secured member access to AllergyIntolerance, Claim, Condition, Coverage, Encounter, ExplanationOfBenefit, HealthcareService, Immunization, InsurancePlan, List, Location, Medication, MedicationDispense, MedicationKnowledge, MedicationRequest, Observation, Organization, OrganizationAffiliation, Patient, Practitioner, PractitionerRole, and Procedure FHIR R4 resources across the AmeriHealth Caritas family of plans. - name: HL7 FHIR R4 Provider Directory API description: >- Public, unauthenticated FHIR Provider Directory exposing Practitioner, PractitionerRole, Organization, OrganizationAffiliation, Location, and InsurancePlan resources for member, broker, and care-management consumers. - name: HL7 FHIR R4 Drug Formulary API description: >- CMS-mandated public Drug Formulary surface for AmeriHealth Caritas managed Medicaid and dual-eligible plans, exposed via FHIR MedicationKnowledge and List resources. - name: Per-Plan FHIR Endpoint Routing description: >- FHIR base URLs are routed per state plan using a four-digit plan code (for example 0100, 0500, 0900, 1200, 2100, 2400, 2600) on api-ext.amerihealthcaritas.com so each Medicaid / D-SNP / Marketplace plan is reachable independently while sharing one developer registration. - name: SMART App Launch 1.0.0 OAuth 2.0 description: >- Standard authorization code and PKCE authorization code flows backed by token, authorize, introspect, revoke, and session management endpoints under fhir.amerihealthcaritas.com. - name: CARIN Blue Button & Da Vinci PDex Conformance description: >- Implementation aligns with the CARIN Blue Button Implementation Guide and the Da Vinci Payer Data Exchange (PDex) IG referenced from the developer portal best-practices section. - name: USCDI Data Coverage description: >- Data elements published map to the United States Core Data for Interoperability (USCDI v1) to support clinical data exchange to consumer apps. - name: Developer Portal Self-Service description: >- Developers register, attest, and receive Client ID and Client Secret credentials from developer.amerihealthcaritas.com; once approved, sandbox patient credentials are issued for testing. - type: UseCases data: - name: Member Health Record Aggregation description: >- Third-party consumer apps allow Medicaid, D-SNP, and Marketplace members to download and aggregate claims, encounters, medications, immunizations, and care plan data from AmeriHealth Caritas plans into one personal health record. - name: Provider Directory Lookups description: >- Care navigation apps, broker tools, and benefits portals query the public Provider Directory FHIR API to find AmeriHealth-Caritas-contracted Practitioners, PractitionerRoles, Organizations, and Locations by specialty, location, or network. - name: Drug Formulary Browsing description: >- Members and prescribers query the public Drug Formulary FHIR API to confirm whether a medication is covered, the tier, and any prior authorization requirements before filling. - name: Care Coordination Across Dual-Eligible Plans description: >- D-SNP / dual-eligible care managers reconcile Medicare and Medicaid coverage, ExplanationOfBenefit, and Encounter data to coordinate Long-Term Services and Supports (LTSS) and behavioral health services. - name: Payer-To-Payer Data Sharing description: >- When a member switches plans, the Patient Access surface can inform payer-to-payer exchange workflows aligned with Da Vinci PDex to migrate clinical history. - name: Population Health Reporting description: >- State Medicaid agencies and quality reporting partners consume aggregated, member-authorized FHIR data to support HEDIS, quality measure, and SDOH reporting. - type: Integrations data: - name: Independence Blue Cross description: >- AmeriHealth Caritas is majority-owned by Independence Blue Cross (Philadelphia) and shares brand and operational relationships with the Independence family. - name: Blue Cross Blue Shield of Michigan description: >- Blue Cross Blue Shield of Michigan is a co-owner of AmeriHealth Caritas and the joint sponsor of Blue Cross Complete of Michigan, the Michigan Medicaid managed care plan operated by AmeriHealth Caritas. - name: CMS Interoperability Framework description: >- APIs exist to satisfy the CMS-9115-F Interoperability and Patient Access final rule for Medicaid managed care, CHIP, and D-SNP populations. - name: HL7 FHIR R4 description: >- All three APIs implement HL7 FHIR 4.0.1 with SMART App Launch 1.0.0 security, CARIN Blue Button, and Da Vinci PDex guidance. - name: USCDI v1 description: >- Patient Access data set is profiled against USCDI v1 elements for clinical, encounter, medication, and care team data. - name: SMART on FHIR / OAuth 2.0 / OIDC / PKCE description: >- Standard SMART App Launch authorization code flow and PKCE flow back the Patient Access security model. - name: State Medicaid Agencies description: >- Each AmeriHealth Caritas state plan operates under contract with a state Medicaid agency (PA DHS, LA LDH, NC DHHS, OH ODM, FL AHCA, NH DHHS, MI MDHHS, DE DHSS, SC DHHS, NJ DHS). - type: Solutions data: - name: Medicaid Managed Care description: >- Full-risk Medicaid managed care plans operated for state Medicaid agencies in PA, DE, DC, NC, NH, OH, LA, FL, MI, and SC under brands including AmeriHealth Caritas Pennsylvania, Keystone First, AmeriHealth Caritas DC, AmeriHealth Caritas Delaware, AmeriHealth Caritas Louisiana, AmeriHealth Caritas North Carolina, AmeriHealth Caritas New Hampshire, AmeriHealth Caritas Ohio, AmeriHealth Caritas Florida, First Choice by Select Health of South Carolina, and Blue Cross Complete of Michigan. - name: Dual-Eligible Special Needs Plans (D-SNP) description: >- AmeriHealth Caritas VIP Care, Keystone First VIP Choice, and First Choice VIP Care D-SNP plans serve members eligible for both Medicare and Medicaid across multiple states. - name: Long-Term Services and Supports (LTSS) description: >- Community HealthChoices plans (AmeriHealth Caritas Pennsylvania Community HealthChoices, Keystone First Community HealthChoices) deliver LTSS-managed care to dual eligibles and individuals with long-term care needs. - name: Children's Health Insurance Program (CHIP) description: >- Keystone First CHIP and other CHIP plans provide state-administered coverage for children in eligible families. - name: Individual & Family Marketplace description: >- AmeriHealth Caritas Next and First Choice Next plans on state-based and federal Marketplaces in DE, FL, LA, NC, and SC. - name: Behavioral Health description: >- PerformCare (Pennsylvania) and PerformCare New Jersey deliver behavioral health managed care and contracted services for state and county programs. - name: Pharmacy Benefits Management description: >- PerformRx, a wholly-owned pharmacy benefits manager, administers pharmacy benefits for AmeriHealth Caritas plans and external clients. - name: Third-Party Administration description: >- AmeriHealth Administrators provides third-party administration services for self-funded employer health plans. - type: LLMsTxt url: https://developer.amerihealthcaritas.com/llms.txt maintainers: - FN: Kin Lane email: kin@apievangelist.com