UnitedHealth Group Optum API

openapi: 3.1.0
info:
  title: UnitedHealth Group Optum API
  description: >-
    The UnitedHealth Group interoperability APIs provide FHIR R4-compliant access to
    healthcare data including patient records, claims history, provider directories,
    and formulary information in compliance with CMS Interoperability and Patient Access
    final rule (CMS-9115-F). Operates under the Optum platform serving UnitedHealthcare,
    UHC Medicare & Retirement, UHC Community & State, and Optum health services.
    Enables third-party applications and partners to access member health data using
    HL7 FHIR R4 standards for interoperable health data exchange.
  version: 'R4'
  contact:
    name: UnitedHealth Group Interoperability
    url: https://www.uhc.com/legal/interoperability-apis
  license:
    name: UnitedHealth Group API Terms of Use
    url: https://www.uhc.com/legal/terms-of-use
externalDocs:
  description: UnitedHealth Group Interoperability APIs
  url: https://www.uhc.com/legal/interoperability-apis
servers:
  - url: https://api.uhc.com/fhir/R4
    description: UnitedHealth Group FHIR R4 Production
tags:
  - name: Patient Access
    description: FHIR R4 Patient Access API for member health data (CMS-9115-F)
  - name: Provider Directory
    description: FHIR R4 Provider Directory API implementing Da Vinci PDex Plan Net IG
  - name: Drug Formulary
    description: FHIR R4 Drug Formulary API for prescription drug coverage information
  - name: Clinical Data
    description: FHIR R4 clinical data including conditions, observations, and medications
security:
  - bearerAuth: []
paths:
  /Patient/{id}:
    get:
      operationId: getPatient
      summary: UnitedHealth Group Get Patient Demographics
      description: >-
        Retrieve FHIR R4 Patient resource for a UnitedHealthcare member including
        demographic information, member identifiers, contact details, and language
        preferences as required by the CMS Patient Access rule.
      tags:
        - Patient Access
      x-microcks-operation:
        dispatcher: URI_PARTS
        dispatcherRules: id
      parameters:
        - name: id
          in: path
          required: true
          description: FHIR Patient resource logical ID (maps to member ID)
          schema:
            type: string
      responses:
        '200':
          description: FHIR R4 Patient resource
          content:
            application/fhir+json:
              schema:
                $ref: '#/components/schemas/FHIRPatient'
        '401':
          description: Unauthorized - invalid or expired token
        '403':
          description: Forbidden - insufficient scope
        '404':
          description: Patient not found
        '429':
          description: Too many requests - rate limit exceeded
  /ExplanationOfBenefit:
    get:
      operationId: listExplanationOfBenefit
      summary: UnitedHealth Group List Claims as Explanation of Benefit
      description: >-
        Retrieve FHIR R4 ExplanationOfBenefit (EOB) resources for a member providing
        comprehensive claims data including services rendered, diagnosis codes, procedure
        codes, amounts billed and paid, and adjudication details. Supports CMS Patient
        Access rule compliance for claims data access.
      tags:
        - Patient Access
      x-microcks-operation:
        dispatcher: SCRIPT
        dispatcherRules: "return 'DEFAULT';"
      parameters:
        - name: patient
          in: query
          required: true
          description: Patient resource ID to retrieve ExplanationOfBenefits for
          schema:
            type: string
        - name: type
          in: query
          required: false
          description: Claim type filter (professional, institutional, pharmacy, oral)
          schema:
            type: string
            enum:
              - professional
              - institutional
              - pharmacy
              - oral
        - name: _lastUpdated
          in: query
          required: false
          description: Filter by last updated date/time in FHIR date format
          schema:
            type: string
        - name: service-date
          in: query
          required: false
          description: Filter by service date (FHIR date format)
          schema:
            type: string
            format: date
        - name: _count
          in: query
          required: false
          description: Maximum number of results per page
          schema:
            type: integer
            default: 20
            maximum: 100
        - name: _offset
          in: query
          required: false
          description: Pagination offset
          schema:
            type: integer
            default: 0
      responses:
        '200':
          description: FHIR Bundle of ExplanationOfBenefit resources
          content:
            application/fhir+json:
              schema:
                $ref: '#/components/schemas/FHIRBundle'
        '400':
          description: Bad request - invalid query parameter
        '401':
          description: Unauthorized
        '403':
          description: Forbidden
        '429':
          description: Too many requests
  /Coverage:
    get:
      operationId: listCoverage
      summary: UnitedHealth Group List Member Coverage
      description: >-
        Retrieve FHIR R4 Coverage resources for a member including current and historical
        insurance coverage details, plan names, benefit periods, group and member
        identifiers, and payer information across UnitedHealthcare commercial, Medicare,
        and Medicaid lines of business.
      tags:
        - Patient Access
      x-microcks-operation:
        dispatcher: SCRIPT
        dispatcherRules: "return 'DEFAULT';"
      parameters:
        - name: patient
          in: query
          required: true
          description: Patient resource ID
          schema:
            type: string
        - name: status
          in: query
          required: false
          description: Coverage status filter
          schema:
            type: string
            enum:
              - active
              - cancelled
              - draft
              - entered-in-error
      responses:
        '200':
          description: FHIR Bundle of Coverage resources
          content:
            application/fhir+json:
              schema:
                $ref: '#/components/schemas/FHIRBundle'
        '401':
          description: Unauthorized
        '403':
          description: Forbidden
        '429':
          description: Too many requests
  /Condition:
    get:
      operationId: listConditions
      summary: UnitedHealth Group List Member Conditions
      description: >-
        Retrieve FHIR R4 Condition resources for a member representing active and
        historical health conditions, diagnoses, and clinical problems as reflected
        in claims data and clinical records available through the Patient Access API.
      tags:
        - Clinical Data
      x-microcks-operation:
        dispatcher: SCRIPT
        dispatcherRules: "return 'DEFAULT';"
      parameters:
        - name: patient
          in: query
          required: true
          description: Patient resource ID
          schema:
            type: string
        - name: clinical-status
          in: query
          required: false
          description: Condition clinical status filter
          schema:
            type: string
            enum:
              - active
              - recurrence
              - relapse
              - inactive
              - remission
              - resolved
        - name: _count
          in: query
          required: false
          description: Maximum number of results
          schema:
            type: integer
            default: 20
      responses:
        '200':
          description: FHIR Bundle of Condition resources
          content:
            application/fhir+json:
              schema:
                $ref: '#/components/schemas/FHIRBundle'
        '401':
          description: Unauthorized
        '403':
          description: Forbidden
        '429':
          description: Too many requests
  /Practitioner:
    get:
      operationId: listPractitioners
      summary: UnitedHealth Group List Network Practitioners
      description: >-
        Search the UnitedHealthcare FHIR R4 Provider Directory for individual healthcare
        practitioners by name, NPI, specialty, or geographic location. Implements the
        Da Vinci PDex Plan Net Implementation Guide for provider directory services.
      tags:
        - Provider Directory
      x-microcks-operation:
        dispatcher: SCRIPT
        dispatcherRules: "return 'DEFAULT';"
      parameters:
        - name: name
          in: query
          required: false
          description: Provider name search
          schema:
            type: string
        - name: identifier
          in: query
          required: false
          description: NPI or other identifier
          schema:
            type: string
        - name: specialty
          in: query
          required: false
          description: Provider specialty taxonomy code
          schema:
            type: string
        - name: address-state
          in: query
          required: false
          description: State code for geographic filter
          schema:
            type: string
        - name: _count
          in: query
          required: false
          description: Maximum number of results
          schema:
            type: integer
            default: 20
            maximum: 100
      responses:
        '200':
          description: FHIR Bundle of Practitioner resources
          content:
            application/fhir+json:
              schema:
                $ref: '#/components/schemas/FHIRBundle'
        '401':
          description: Unauthorized
        '429':
          description: Too many requests
  /Organization:
    get:
      operationId: listOrganizations
      summary: UnitedHealth Group List Network Organizations
      description: >-
        Search the UnitedHealthcare FHIR R4 Provider Directory for healthcare
        organizations including hospitals, medical groups, and specialty facilities.
        Supports filtering by organization type, name, and location. Implements Da
        Vinci PDex Plan Net IG.
      tags:
        - Provider Directory
      x-microcks-operation:
        dispatcher: SCRIPT
        dispatcherRules: "return 'DEFAULT';"
      parameters:
        - name: name
          in: query
          required: false
          description: Organization name search
          schema:
            type: string
        - name: type
          in: query
          required: false
          description: Organization type code
          schema:
            type: string
        - name: address-state
          in: query
          required: false
          description: State code filter
          schema:
            type: string
        - name: _count
          in: query
          required: false
          description: Maximum number of results
          schema:
            type: integer
            default: 20
      responses:
        '200':
          description: FHIR Bundle of Organization resources
          content:
            application/fhir+json:
              schema:
                $ref: '#/components/schemas/FHIRBundle'
        '401':
          description: Unauthorized
        '429':
          description: Too many requests
  /MedicationKnowledge:
    get:
      operationId: listFormularyDrugs
      summary: UnitedHealth Group List Formulary Drug Coverage
      description: >-
        Retrieve drug formulary information from the UnitedHealthcare FHIR R4 Drug
        Formulary API including coverage tiers, formulary status, prior authorization
        requirements, quantity limits, and step therapy requirements for prescription
        drugs. Implements the Da Vinci Drug Formulary IG.
      tags:
        - Drug Formulary
      x-microcks-operation:
        dispatcher: SCRIPT
        dispatcherRules: "return 'DEFAULT';"
      parameters:
        - name: code
          in: query
          required: false
          description: RxNorm drug code
          schema:
            type: string
        - name: drug-name
          in: query
          required: false
          description: Drug name search string
          schema:
            type: string
        - name: tier
          in: query
          required: false
          description: Formulary tier number filter
          schema:
            type: string
        - name: _count
          in: query
          required: false
          description: Maximum number of results
          schema:
            type: integer
            default: 20
      responses:
        '200':
          description: FHIR Bundle of MedicationKnowledge resources
          content:
            application/fhir+json:
              schema:
                $ref: '#/components/schemas/FHIRBundle'
        '401':
          description: Unauthorized
        '429':
          description: Too many requests
components:
  securitySchemes:
    bearerAuth:
      type: http
      scheme: bearer
      description: OAuth 2.0 Bearer token obtained via authorization code flow
  schemas:
    FHIRBundle:
      type: object
      description: >-
        FHIR R4 Bundle resource containing a collection of FHIR resources returned
        from UnitedHealth Group interoperability API search operations
      properties:
        resourceType:
          type: string
          enum:
            - Bundle
          description: FHIR resource type identifier
        id:
          type: string
          description: Unique Bundle ID
        meta:
          type: object
          description: Bundle metadata
          properties:
            lastUpdated:
              type: string
              format: date-time
        type:
          type: string
          enum:
            - searchset
            - collection
          description: Bundle type
        total:
          type: integer
          description: Total number of matching resources
        link:
          type: array
          description: Pagination and navigation links
          items:
            type: object
            properties:
              relation:
                type: string
                enum:
                  - self
                  - next
                  - previous
                  - first
                  - last
              url:
                type: string
                format: uri
        entry:
          type: array
          description: Bundle entries containing FHIR resources
          items:
            type: object
            properties:
              fullUrl:
                type: string
                format: uri
              resource:
                type: object
                description: The embedded FHIR resource
              search:
                type: object
                properties:
                  mode:
                    type: string
                    enum:
                      - match
                      - include
                      - outcome
    FHIRPatient:
      type: object
      description: >-
        FHIR R4 Patient resource representing a UnitedHealth Group member with
        demographics, identifiers, and contact information
      properties:
        resourceType:
          type: string
          enum:
            - Patient
          description: FHIR resource type
        id:
          type: string
          description: Patient logical ID
        meta:
          type: object
          description: Resource metadata
          properties:
            lastUpdated:
              type: string
              format: date-time
            profile:
              type: array
              items:
                type: string
        identifier:
          type: array
          description: Patient identifiers including member ID and MBI
          items:
            type: object
            properties:
              system:
                type: string
                format: uri
              value:
                type: string
        name:
          type: array
          description: Patient name(s)
          items:
            type: object
            properties:
              use:
                type: string
                enum:
                  - official
                  - usual
                  - nickname
              family:
                type: string
              given:
                type: array
                items:
                  type: string
              prefix:
                type: array
                items:
                  type: string
        birthDate:
          type: string
          format: date
          description: Member date of birth
        gender:
          type: string
          enum:
            - male
            - female
            - other
            - unknown
          description: Administrative gender
        address:
          type: array
          description: Patient address(es)
          items:
            type: object
            properties:
              use:
                type: string
              line:
                type: array
                items:
                  type: string
              city:
                type: string
              state:
                type: string
              postalCode:
                type: string
        telecom:
          type: array
          description: Contact information (phone, email)
          items:
            type: object
            properties:
              system:
                type: string
                enum:
                  - phone
                  - email
                  - fax
              value:
                type: string
              use:
                type: string
        communication:
          type: array
          description: Language preferences
          items:
            type: object
            properties:
              language:
                type: object
              preferred:
                type: boolean