openapi: 3.1.0
info:
title: WellCare FHIR Patient Access API
description: >-
The WellCare FHIR Patient Access API enables members and authorized
third-party applications to securely access and exchange health data
including medical, pharmacy, dental, and vision claims and clinical
information. The API supports HL7 FHIR R4 standards and SMART on FHIR
authorization, providing access to up to 5 years of historical health
information. Required under CMS Interoperability and Patient Access final
rule (CMS-9115-F) for Medicaid and Medicare Advantage plans. Access is
managed through the Centene Partner Portal at partners.centene.com/apis.
version: '1.0'
contact:
url: https://www.wellcare.com/en/interoperability-and-patient-access
servers:
- url: https://partners.centene.com
tags:
- name: Patient
description: Patient demographic and identity resources.
- name: Coverage
description: Member insurance coverage and enrollment information.
- name: Explanation of Benefits
description: Claims and EOB data for medical, pharmacy, dental, and vision.
- name: Condition
description: Member diagnosed conditions and clinical data.
- name: Observation
description: Clinical observations, lab results, and vital signs.
- name: Medication Request
description: Prescribed medications and medication orders.
- name: Immunization
description: Immunization records and history.
- name: Procedure
description: Procedures performed on the member.
- name: Encounter
description: Member care encounters and visits.
paths:
/fhir/r4/Patient/{id}:
get:
operationId: getPatient
summary: Get Patient
description: >-
Retrieves a patient resource by FHIR Patient ID for an authenticated
member, returning demographic information including name, birthdate,
address, and contact details.
tags:
- Patient
parameters:
- name: id
in: path
description: The FHIR Patient resource ID.
required: true
schema:
type: string
security:
- smartOnFhir:
- patient/Patient.read
responses:
'200':
description: Patient resource returned successfully.
content:
application/fhir+json:
schema:
$ref: '#/components/schemas/Patient'
'401':
description: Unauthorized - invalid or missing access token.
'404':
description: Patient not found.
/fhir/r4/Coverage:
get:
operationId: listCoverage
summary: List Coverage
description: >-
Retrieves insurance coverage resources for a member, including
plan details, enrollment period, group information, and benefit
categories for medical, pharmacy, dental, and vision coverage.
tags:
- Coverage
parameters:
- name: patient
in: query
description: The FHIR Patient ID to retrieve coverage for.
required: true
schema:
type: string
- name: _count
in: query
description: Number of results per page.
schema:
type: integer
- name: _page
in: query
description: Page number for paginated results.
schema:
type: integer
security:
- smartOnFhir:
- patient/Coverage.read
responses:
'200':
description: Bundle of Coverage resources returned.
content:
application/fhir+json:
schema:
$ref: '#/components/schemas/Bundle'
'401':
description: Unauthorized.
/fhir/r4/ExplanationOfBenefit:
get:
operationId: listExplanationOfBenefit
summary: List Explanation of Benefit
description: >-
Retrieves Explanation of Benefit (EOB) resources representing adjudicated
medical, pharmacy, dental, and vision claims for a member. Supports up
to 5 years of historical claims data as required by CMS interoperability
rules.
tags:
- Explanation of Benefits
parameters:
- name: patient
in: query
description: The FHIR Patient ID to retrieve EOBs for.
required: true
schema:
type: string
- name: service-date
in: query
description: Filter by service date range (format YYYY-MM-DD or YYYY-MM-DD,YYYY-MM-DD).
schema:
type: string
- name: type
in: query
description: Filter by claim type (e.g., pharmacy, oral, vision, institutional, professional).
schema:
type: string
- name: _count
in: query
description: Number of results per page.
schema:
type: integer
security:
- smartOnFhir:
- patient/ExplanationOfBenefit.read
responses:
'200':
description: Bundle of ExplanationOfBenefit resources returned.
content:
application/fhir+json:
schema:
$ref: '#/components/schemas/Bundle'
'401':
description: Unauthorized.
/fhir/r4/Condition:
get:
operationId: listConditions
summary: List Conditions
description: >-
Retrieves Condition resources representing a member's diagnosed conditions,
including ICD-10 codes, clinical status, and onset dates from clinical data.
tags:
- Condition
parameters:
- name: patient
in: query
description: The FHIR Patient ID.
required: true
schema:
type: string
security:
- smartOnFhir:
- patient/Condition.read
responses:
'200':
description: Bundle of Condition resources returned.
content:
application/fhir+json:
schema:
$ref: '#/components/schemas/Bundle'
'401':
description: Unauthorized.
/fhir/r4/Observation:
get:
operationId: listObservations
summary: List Observations
description: >-
Retrieves Observation resources including laboratory results, vital
signs, and other clinical measurements for an authenticated member.
tags:
- Observation
parameters:
- name: patient
in: query
description: The FHIR Patient ID.
required: true
schema:
type: string
- name: category
in: query
description: Filter by observation category (e.g., laboratory, vital-signs).
schema:
type: string
security:
- smartOnFhir:
- patient/Observation.read
responses:
'200':
description: Bundle of Observation resources returned.
content:
application/fhir+json:
schema:
$ref: '#/components/schemas/Bundle'
'401':
description: Unauthorized.
/fhir/r4/MedicationRequest:
get:
operationId: listMedicationRequests
summary: List Medication Requests
description: >-
Retrieves MedicationRequest resources representing prescribed medications
and medication orders for an authenticated member.
tags:
- Medication Request
parameters:
- name: patient
in: query
description: The FHIR Patient ID.
required: true
schema:
type: string
- name: status
in: query
description: Filter by medication request status (active, completed, stopped).
schema:
type: string
security:
- smartOnFhir:
- patient/MedicationRequest.read
responses:
'200':
description: Bundle of MedicationRequest resources returned.
content:
application/fhir+json:
schema:
$ref: '#/components/schemas/Bundle'
'401':
description: Unauthorized.
/fhir/r4/Immunization:
get:
operationId: listImmunizations
summary: List Immunizations
description: >-
Retrieves Immunization resources representing a member's immunization
history including vaccine type, administration date, and lot number.
tags:
- Immunization
parameters:
- name: patient
in: query
description: The FHIR Patient ID.
required: true
schema:
type: string
security:
- smartOnFhir:
- patient/Immunization.read
responses:
'200':
description: Bundle of Immunization resources returned.
content:
application/fhir+json:
schema:
$ref: '#/components/schemas/Bundle'
'401':
description: Unauthorized.
/fhir/r4/Encounter:
get:
operationId: listEncounters
summary: List Encounters
description: >-
Retrieves Encounter resources representing care encounters, visits, and
admissions for an authenticated member, including encounter type, date,
provider, and location.
tags:
- Encounter
parameters:
- name: patient
in: query
description: The FHIR Patient ID.
required: true
schema:
type: string
- name: date
in: query
description: Filter by encounter date range.
schema:
type: string
security:
- smartOnFhir:
- patient/Encounter.read
responses:
'200':
description: Bundle of Encounter resources returned.
content:
application/fhir+json:
schema:
$ref: '#/components/schemas/Bundle'
'401':
description: Unauthorized.
components:
securitySchemes:
smartOnFhir:
type: oauth2
description: SMART on FHIR OAuth 2.0 authorization for patient-facing apps.
flows:
authorizationCode:
authorizationUrl: https://partners.centene.com/oauth2/authorize
tokenUrl: https://partners.centene.com/oauth2/token
scopes:
patient/Patient.read: Read patient demographic data
patient/Coverage.read: Read coverage and enrollment data
patient/ExplanationOfBenefit.read: Read claims and EOB data
patient/Condition.read: Read diagnosed conditions
patient/Observation.read: Read observations and lab results
patient/MedicationRequest.read: Read medication requests
patient/Immunization.read: Read immunization records
patient/Encounter.read: Read care encounters
schemas:
Bundle:
type: object
description: A FHIR Bundle resource containing a collection of resources.
properties:
resourceType:
type: string
example: Bundle
id:
type: string
type:
type: string
enum: [searchset, collection, transaction, history]
total:
type: integer
link:
type: array
items:
type: object
properties:
relation:
type: string
url:
type: string
entry:
type: array
items:
type: object
properties:
fullUrl:
type: string
resource:
type: object
Patient:
type: object
description: A FHIR Patient resource.
properties:
resourceType:
type: string
example: Patient
id:
type: string
name:
type: array
items:
type: object
properties:
family:
type: string
given:
type: array
items:
type: string
birthDate:
type: string
format: date
gender:
type: string
enum: [male, female, other, unknown]
address:
type: array
items:
type: object