UnitedHealthcare Provider API

openapi: 3.1.0
info:
  title: UnitedHealthcare Provider API
  description: >-
    The UnitedHealthcare Provider API provides real-time access to eligibility verification,
    claims management, prior authorization, and provider directory services for healthcare
    providers, payers, and health IT developers. Available through the UnitedHealthcare API
    Marketplace at apimarketplace.uhcprovider.com.
  version: '1.0'
  contact:
    name: UnitedHealthcare API Marketplace
    url: https://apimarketplace.uhcprovider.com
  license:
    name: UnitedHealthcare API Terms of Use
    url: https://apimarketplace.uhcprovider.com/legal
externalDocs:
  description: UnitedHealthcare API Marketplace Documentation
  url: https://apimarketplace.uhcprovider.com/#/
servers:
  - url: https://api.uhcprovider.com
    description: Production
tags:
  - name: Eligibility
    description: Real-time eligibility and benefit verification
  - name: Claims
    description: Claim pre-check, submission, and inquiry
  - name: Prior Authorization
    description: Prior authorization and referral actions
  - name: Providers
    description: Provider demographics and directory
security:
  - bearerAuth: []
paths:
  /eligibility/v1/real-time:
    post:
      operationId: checkEligibility
      summary: UnitedHealthcare Real-Time Eligibility Check
      description: >-
        Perform a real-time pre-service eligibility and benefit verification for a
        UnitedHealthcare member. Returns coverage details, deductibles, copays, and
        benefit limits for a specific service type and date of service.
      tags:
        - Eligibility
      x-microcks-operation:
        dispatcher: SCRIPT
        dispatcherRules: "return 'ACTIVE';"
      requestBody:
        required: true
        content:
          application/json:
            schema:
              $ref: '#/components/schemas/EligibilityRequest'
            x-microcks-default: |
              {
                "memberId": "123456789",
                "dateOfBirth": "1980-01-15",
                "serviceType": "30",
                "dateOfService": "2026-05-03",
                "npi": "1234567890"
              }
      responses:
        '200':
          description: Eligibility verification result
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/EligibilityResponse'
        '400':
          description: Bad request - invalid input
        '401':
          description: Unauthorized - invalid or missing token
        '404':
          description: Member not found
        '429':
          description: Too many requests
  /eligibility/v1/patient-benefit-check:
    post:
      operationId: checkPatientBenefit
      summary: UnitedHealthcare Real Patient Benefit Check
      description: >-
        Check specific patient benefit details for a given service including covered
        benefits, cost-sharing information, network status, and utilization management
        requirements.
      tags:
        - Eligibility
      x-microcks-operation:
        dispatcher: SCRIPT
        dispatcherRules: "return 'COVERED';"
      requestBody:
        required: true
        content:
          application/json:
            schema:
              $ref: '#/components/schemas/BenefitCheckRequest'
            x-microcks-default: |
              {
                "memberId": "123456789",
                "dateOfBirth": "1980-01-15",
                "serviceCode": "99213",
                "dateOfService": "2026-05-03",
                "npi": "1234567890",
                "providerTaxId": "12-3456789"
              }
      responses:
        '200':
          description: Benefit check result
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/BenefitCheckResponse'
        '400':
          description: Bad request
        '401':
          description: Unauthorized
        '404':
          description: Member not found
        '429':
          description: Too many requests
  /claims/v1/pre-check:
    post:
      operationId: claimPreCheck
      summary: UnitedHealthcare Real Claim Pre-Check
      description: >-
        Validate a claim before submission to identify potential issues including
        missing information, coverage gaps, authorization requirements, and billing
        edits. Reduces claim denials and accelerates payment.
      tags:
        - Claims
      x-microcks-operation:
        dispatcher: SCRIPT
        dispatcherRules: "return 'VALID';"
      requestBody:
        required: true
        content:
          application/json:
            schema:
              $ref: '#/components/schemas/ClaimPreCheckRequest'
            x-microcks-default: |
              {
                "memberId": "123456789",
                "npi": "1234567890",
                "serviceDate": "2026-05-03",
                "diagnosisCodes": ["J06.9"],
                "procedureCodes": ["99213"],
                "charges": 150.00
              }
      responses:
        '200':
          description: Claim pre-check result
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/ClaimPreCheckResponse'
        '400':
          description: Bad request
        '401':
          description: Unauthorized
        '422':
          description: Validation failed
        '429':
          description: Too many requests
  /claims/v1/inquiry:
    post:
      operationId: inquireClaim
      summary: UnitedHealthcare Real Claim Inquiry
      description: >-
        Retrieve the status and details of submitted claims including payment information,
        denial reasons, adjustment codes, and explanation of benefits data for a member
        or provider.
      tags:
        - Claims
      x-microcks-operation:
        dispatcher: SCRIPT
        dispatcherRules: "return 'PROCESSED';"
      requestBody:
        required: true
        content:
          application/json:
            schema:
              $ref: '#/components/schemas/ClaimInquiryRequest'
            x-microcks-default: |
              {
                "claimNumber": "CLM-2026-001234",
                "npi": "1234567890",
                "memberId": "123456789",
                "dateOfServiceFrom": "2026-01-01",
                "dateOfServiceTo": "2026-05-03"
              }
      responses:
        '200':
          description: Claim inquiry result
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/ClaimInquiryResponse'
        '400':
          description: Bad request
        '401':
          description: Unauthorized
        '404':
          description: Claim not found
        '429':
          description: Too many requests
  /prior-auth/v1/check:
    post:
      operationId: checkPriorAuth
      summary: UnitedHealthcare Real Prior Auth Check
      description: >-
        Check if a prior authorization or referral is required for a specific service
        and procedure, and determine the authorization status for a UnitedHealthcare member.
      tags:
        - Prior Authorization
      x-microcks-operation:
        dispatcher: SCRIPT
        dispatcherRules: "return 'NOT_REQUIRED';"
      requestBody:
        required: true
        content:
          application/json:
            schema:
              $ref: '#/components/schemas/PriorAuthCheckRequest'
            x-microcks-default: |
              {
                "memberId": "123456789",
                "npi": "1234567890",
                "serviceCode": "27447",
                "serviceType": "Surgery",
                "dateOfService": "2026-06-01"
              }
      responses:
        '200':
          description: Prior authorization requirement result
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/PriorAuthCheckResponse'
        '400':
          description: Bad request
        '401':
          description: Unauthorized
        '404':
          description: Member not found
        '429':
          description: Too many requests
  /providers/v1/demographics:
    get:
      operationId: getProviderDemographics
      summary: UnitedHealthcare Provider Demographics
      description: >-
        Retrieve demographic and credentialing information for healthcare providers
        in the UnitedHealthcare network, including contact details, specialties,
        network participation, and accepting new patients status.
      tags:
        - Providers
      x-microcks-operation:
        dispatcher: SCRIPT
        dispatcherRules: "return 'FOUND';"
      parameters:
        - name: npi
          in: query
          required: true
          description: National Provider Identifier (NPI) for the provider
          schema:
            type: string
            pattern: '^\d{10}$'
        - name: state
          in: query
          required: false
          description: Two-letter state code to filter results
          schema:
            type: string
            maxLength: 2
      responses:
        '200':
          description: Provider demographic information
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/ProviderDemographics'
        '400':
          description: Bad request
        '401':
          description: Unauthorized
        '404':
          description: Provider not found
        '429':
          description: Too many requests
components:
  securitySchemes:
    bearerAuth:
      type: http
      scheme: bearer
      description: OAuth 2.0 Bearer token from UnitedHealthcare API Marketplace
  schemas:
    EligibilityRequest:
      type: object
      description: Request parameters for real-time eligibility verification
      required:
        - memberId
        - dateOfBirth
        - serviceType
        - dateOfService
      properties:
        memberId:
          type: string
          description: UnitedHealthcare member ID
        dateOfBirth:
          type: string
          format: date
          description: Member date of birth (YYYY-MM-DD)
        serviceType:
          type: string
          description: Service type code (X12 270/271 service type codes)
        dateOfService:
          type: string
          format: date
          description: Requested date of service
        npi:
          type: string
          description: Rendering provider NPI
        groupNumber:
          type: string
          description: Insurance group number
    EligibilityResponse:
      type: object
      description: Real-time eligibility verification response
      properties:
        memberId:
          type: string
          description: UnitedHealthcare member ID
        memberName:
          type: string
          description: Member full name
        coverageStatus:
          type: string
          enum:
            - ACTIVE
            - INACTIVE
            - TERMED
          description: Current coverage status
        planName:
          type: string
          description: Insurance plan name
        groupNumber:
          type: string
          description: Group number
        effectiveDate:
          type: string
          format: date
          description: Coverage effective date
        terminationDate:
          type: string
          format: date
          description: Coverage termination date
        deductible:
          type: number
          format: float
          description: Annual deductible amount
        deductibleMet:
          type: number
          format: float
          description: Year-to-date deductible amount met
        outOfPocketMax:
          type: number
          format: float
          description: Annual out-of-pocket maximum
        outOfPocketMet:
          type: number
          format: float
          description: Year-to-date out-of-pocket amount met
        copay:
          type: number
          format: float
          description: Copay amount for the service type
        coinsurance:
          type: number
          format: float
          description: Coinsurance percentage (0-100)
        networkStatus:
          type: string
          enum:
            - IN_NETWORK
            - OUT_OF_NETWORK
            - UNKNOWN
          description: Provider network participation status
    BenefitCheckRequest:
      type: object
      description: Request for patient-specific benefit check
      required:
        - memberId
        - dateOfBirth
        - serviceCode
        - dateOfService
      properties:
        memberId:
          type: string
          description: UnitedHealthcare member ID
        dateOfBirth:
          type: string
          format: date
          description: Member date of birth
        serviceCode:
          type: string
          description: CPT/HCPCS service code
        dateOfService:
          type: string
          format: date
          description: Date of service
        npi:
          type: string
          description: Rendering provider NPI
        providerTaxId:
          type: string
          description: Provider tax ID
        placeOfService:
          type: string
          description: Place of service code
    BenefitCheckResponse:
      type: object
      description: Patient benefit check response
      properties:
        coveredBenefit:
          type: boolean
          description: Whether the service is a covered benefit
        authorizationRequired:
          type: boolean
          description: Whether prior authorization is required
        referralRequired:
          type: boolean
          description: Whether a referral is required
        estimatedPatientResponsibility:
          type: number
          format: float
          description: Estimated patient cost responsibility
        estimatedPlanPayment:
          type: number
          format: float
          description: Estimated plan payment amount
        costSharingDetails:
          type: object
          description: Detailed cost-sharing breakdown
          properties:
            copay:
              type: number
              format: float
            coinsurance:
              type: number
              format: float
            deductibleApplies:
              type: boolean
    ClaimPreCheckRequest:
      type: object
      description: Request for claim pre-submission validation
      required:
        - memberId
        - npi
        - serviceDate
        - diagnosisCodes
        - procedureCodes
      properties:
        memberId:
          type: string
          description: Member ID
        npi:
          type: string
          description: Billing provider NPI
        serviceDate:
          type: string
          format: date
          description: Date of service
        diagnosisCodes:
          type: array
          description: ICD-10 diagnosis codes
          items:
            type: string
        procedureCodes:
          type: array
          description: CPT/HCPCS procedure codes
          items:
            type: string
        charges:
          type: number
          format: float
          description: Total billed charges
        placeOfService:
          type: string
          description: Place of service code
    ClaimPreCheckResponse:
      type: object
      description: Claim pre-check validation result
      properties:
        validationStatus:
          type: string
          enum:
            - VALID
            - ERRORS
            - WARNINGS
          description: Overall validation status
        errors:
          type: array
          description: Validation errors that will cause denial
          items:
            type: object
            properties:
              code:
                type: string
              message:
                type: string
        warnings:
          type: array
          description: Validation warnings that may cause issues
          items:
            type: object
            properties:
              code:
                type: string
              message:
                type: string
        estimatedPayment:
          type: number
          format: float
          description: Estimated payment if claim is valid
    ClaimInquiryRequest:
      type: object
      description: Request for claim status inquiry
      properties:
        claimNumber:
          type: string
          description: UHC claim number
        npi:
          type: string
          description: Provider NPI
        memberId:
          type: string
          description: Member ID
        dateOfServiceFrom:
          type: string
          format: date
          description: Start date for service date range
        dateOfServiceTo:
          type: string
          format: date
          description: End date for service date range
    ClaimInquiryResponse:
      type: object
      description: Claim inquiry response
      properties:
        claimNumber:
          type: string
          description: UHC claim number
        claimStatus:
          type: string
          enum:
            - RECEIVED
            - IN_PROCESS
            - PROCESSED
            - DENIED
            - ADJUSTED
            - REVERSED
          description: Current claim status
        serviceDate:
          type: string
          format: date
          description: Date of service
        billedAmount:
          type: number
          format: float
          description: Total billed charges
        allowedAmount:
          type: number
          format: float
          description: Allowed amount
        paidAmount:
          type: number
          format: float
          description: Amount paid to provider
        patientResponsibility:
          type: number
          format: float
          description: Patient responsibility amount
        paymentDate:
          type: string
          format: date
          description: Date of payment
        checkNumber:
          type: string
          description: Payment check or EFT trace number
        denialReasonCode:
          type: string
          description: Reason code if claim was denied
        denialReasonDescription:
          type: string
          description: Description of denial reason
    PriorAuthCheckRequest:
      type: object
      description: Request to check prior authorization requirements
      required:
        - memberId
        - npi
        - serviceCode
      properties:
        memberId:
          type: string
          description: Member ID
        npi:
          type: string
          description: Provider NPI
        serviceCode:
          type: string
          description: CPT/HCPCS service code
        serviceType:
          type: string
          description: Service type description
        dateOfService:
          type: string
          format: date
          description: Planned date of service
        diagnosisCodes:
          type: array
          description: Supporting ICD-10 diagnosis codes
          items:
            type: string
        placeOfService:
          type: string
          description: Place of service code
    PriorAuthCheckResponse:
      type: object
      description: Prior authorization requirement response
      properties:
        authorizationRequired:
          type: boolean
          description: Whether prior authorization is required
        authorizationStatus:
          type: string
          enum:
            - NOT_REQUIRED
            - REQUIRED
            - APPROVED
            - PENDING
            - DENIED
          description: Authorization status
        authorizationNumber:
          type: string
          description: Authorization number if already approved
        validFromDate:
          type: string
          format: date
          description: Authorization valid from date
        validToDate:
          type: string
          format: date
          description: Authorization valid to date
        approvedUnits:
          type: integer
          description: Number of approved units/visits
        referralRequired:
          type: boolean
          description: Whether a referral is required
    ProviderDemographics:
      type: object
      description: Healthcare provider demographic and credentialing information
      properties:
        npi:
          type: string
          description: National Provider Identifier
        firstName:
          type: string
          description: Provider first name
        lastName:
          type: string
          description: Provider last name
        organizationName:
          type: string
          description: Organization name (for group practices)
        providerType:
          type: string
          enum:
            - INDIVIDUAL
            - ORGANIZATION
          description: Provider type
        specialty:
          type: string
          description: Primary specialty
        subspecialties:
          type: array
          description: List of subspecialties
          items:
            type: string
        networkStatus:
          type: string
          enum:
            - IN_NETWORK
            - OUT_OF_NETWORK
          description: Network participation status
        acceptingNewPatients:
          type: boolean
          description: Whether accepting new patients
        address:
          type: object
          description: Practice address
          properties:
            street1:
              type: string
            street2:
              type: string
            city:
              type: string
            state:
              type: string
            zip:
              type: string
        phone:
          type: string
          description: Office phone number
        languages:
          type: array
          description: Languages spoken
          items:
            type: string
        boardCertifications:
          type: array
          description: Board certifications
          items:
            type: string