aid: unitedhealthcare url: >- https://raw.githubusercontent.com/api-evangelist/unitedhealthcare/refs/heads/main/apis.yml name: UnitedHealthcare description: >- UnitedHealthcare is one of the largest health insurance providers in the United States, offering employer-sponsored health benefits, individual and family plans, Medicare and Medicaid plans, and managed care services. UnitedHealthcare provides APIs for healthcare providers through the UHC API Marketplace for eligibility verification, claims management, and prior authorization, and FHIR R4-compliant Interoperability APIs for patient data access and provider directory services per CMS mandates. tags: - Health Insurance - Healthcare - FHIR - Claims - Eligibility type: Company image: https://kinlane-productions.s3.amazonaws.com/apis-json/apis-json-logo.jpg access: 3rd-Party created: '2025-03-01' modified: '2026-05-03' position: Consuming specificationVersion: '0.19' apis: - aid: unitedhealthcare:provider-api name: UnitedHealthcare Provider API tags: - Health Insurance - Healthcare - Eligibility - Claims - Prior Authorization humanURL: https://apimarketplace.uhcprovider.com/#/ baseURL: https://api.uhcprovider.com description: >- The UnitedHealthcare Provider API provides real-time access to eligibility verification, claims management, prior authorization, and provider directory services through the UHC API Marketplace. Enables healthcare providers to verify member coverage, check claim status, validate claims before submission, check prior authorization requirements, and access provider demographic data. properties: - url: https://apimarketplace.uhcprovider.com/#/ type: Documentation - url: openapi/unitedhealthcare-provider-api-openapi.yml type: OpenAPI - url: json-schema/provider-eligibility-response-schema.json type: Schema - url: json-schema/provider-claim-inquiry-response-schema.json type: Schema - url: json-ld/unitedhealthcare-provider-api-context.jsonld type: JSON-LD Context - url: examples/provider-eligibility-response-example.json type: Example - aid: unitedhealthcare:interoperability-api name: UnitedHealthcare Interoperability API tags: - Health Insurance - Healthcare - FHIR - Patient Access - Provider Directory - Formulary humanURL: https://www.uhc.com/legal/interoperability-apis baseURL: https://api.uhc.com/fhir/R4 description: >- The UnitedHealthcare Interoperability APIs provide FHIR R4-compliant access to patient health data in compliance with CMS Interoperability and Patient Access final rule (CMS-9115-F). Includes Patient Access API for member claims history, coverage, and health records, Provider Directory API for network provider search, and Formulary API for drug coverage information. properties: - url: https://www.uhc.com/legal/interoperability-apis type: Documentation - url: openapi/unitedhealthcare-interoperability-api-openapi.yml type: OpenAPI - url: json-schema/interoperability-fhir-bundle-schema.json type: Schema - url: json-schema/interoperability-fhir-patient-schema.json type: Schema - url: json-ld/unitedhealthcare-interoperability-api-context.jsonld type: JSON-LD Context - url: examples/interoperability-fhir-bundle-example.json type: Example features: - name: Real-Time Eligibility Verification description: >- Verify UnitedHealthcare member eligibility and benefits in real time at the point of care, reducing claim denials and improving patient financial transparency. - name: Claim Pre-Check description: >- Validate claims before submission to identify errors, missing authorizations, and billing issues that would cause denials, accelerating payment cycles. - name: Prior Authorization Check description: >- Determine prior authorization requirements for procedures and check existing authorization status to streamline clinical workflows. - name: FHIR R4 Patient Access description: >- CMS-mandated FHIR R4 APIs enabling patients and authorized applications to access claims history, coverage data, and clinical information. - name: Provider Directory description: >- FHIR R4 Provider Directory implementing Da Vinci PDex Plan Net IG for searching UnitedHealthcare network providers, organizations, and locations. - name: Drug Formulary description: >- FHIR-based formulary API providing drug coverage tier information, prior authorization requirements, and quantity limits for prescription medications. - name: Claims Inquiry description: >- Real-time claim status inquiry returning payment details, denial reasons, adjustment codes, and explanation of benefits data. useCases: - name: Point-of-Care Eligibility description: >- Verify patient UnitedHealthcare coverage and benefits at check-in using the real-time eligibility API to collect accurate copays and reduce billing errors. - name: Revenue Cycle Management description: >- Integrate claim pre-check and claim inquiry APIs into practice management systems to automate claim validation and track payment status. - name: Prior Authorization Workflows description: >- Embed prior authorization checking in clinical workflows to immediately determine if approval is needed before scheduling procedures or prescribing medications. - name: Patient Portal Integration description: >- Enable patient portals to display claims history, coverage details, and EOBs using the FHIR Patient Access API for transparent member engagement. - name: Provider Search Applications description: >- Build provider search tools and care coordination apps using the FHIR Provider Directory API to find in-network physicians, specialists, and facilities. - name: Formulary Management description: >- Integrate the Formulary API into EHR and e-prescribing workflows to check drug coverage tiers and authorization requirements at point of prescribing. integrations: - name: Epic Systems description: >- UnitedHealthcare APIs integrate with Epic EHR for real-time eligibility verification, prior authorization, and FHIR-based data exchange. - name: Cerner/Oracle Health description: >- FHIR R4 Interoperability APIs integrate with Cerner for patient data access and provider directory services. - name: Change Healthcare description: >- Provider APIs complement Change Healthcare clearinghouse services for comprehensive claims management and eligibility verification. - name: Availity description: >- UnitedHealthcare participates in Availity's real-time eligibility and claims network providing additional access pathways for providers. artifacts: openapi: - name: UnitedHealthcare Provider API url: openapi/unitedhealthcare-provider-api-openapi.yml - name: UnitedHealthcare Interoperability API url: openapi/unitedhealthcare-interoperability-api-openapi.yml jsonSchema: - url: json-schema/provider-eligibility-request-schema.json - url: json-schema/provider-eligibility-response-schema.json - url: json-schema/provider-benefit-check-request-schema.json - url: json-schema/provider-benefit-check-response-schema.json - url: json-schema/provider-claim-pre-check-request-schema.json - url: json-schema/provider-claim-pre-check-response-schema.json - url: json-schema/provider-claim-inquiry-request-schema.json - url: json-schema/provider-claim-inquiry-response-schema.json - url: json-schema/provider-prior-auth-check-request-schema.json - url: json-schema/provider-prior-auth-check-response-schema.json - url: json-schema/provider-provider-demographics-schema.json - url: json-schema/interoperability-fhir-bundle-schema.json - url: json-schema/interoperability-fhir-patient-schema.json jsonStructure: - url: json-structure/provider-eligibility-response-structure.json - url: json-structure/provider-claim-inquiry-response-structure.json - url: json-structure/provider-provider-demographics-structure.json - url: json-structure/interoperability-fhir-bundle-structure.json - url: json-structure/interoperability-fhir-patient-structure.json jsonLd: - url: json-ld/unitedhealthcare-provider-api-context.jsonld - url: json-ld/unitedhealthcare-interoperability-api-context.jsonld examples: - url: examples/provider-eligibility-response-example.json - url: examples/provider-claim-inquiry-response-example.json - url: examples/provider-prior-auth-check-response-example.json - url: examples/interoperability-fhir-bundle-example.json - url: examples/interoperability-fhir-patient-example.json spectralRules: - url: rules/unitedhealthcare-spectral-rules.yml capabilities: shared: - url: capabilities/shared/provider-api.yaml - url: capabilities/shared/interoperability-api.yaml workflows: - url: capabilities/provider-operations.yaml - url: capabilities/patient-data-access.yaml vocabulary: - url: vocabulary/unitedhealthcare-vocabulary.yaml maintainers: - FN: Kin Lane email: kin@apievangelist.com