A single REST API covering clinical policies, prior auth status, formulary data, payer enrollment, and ACO performance — queryable in milliseconds and built for healthcare platforms.
RESTful endpoints designed for healthcare platforms. All requests authenticated via API key.
/v1/policies/searchSearch 20K+ clinical and reimbursement policies by drug, service, or diagnosis.
Input Parameters
api_keystringYour designated API key for authentication.search_termstringDrug name, service, CPT code, or diagnosis term.payer_idstringoptionalFilter results to a specific payer.Output Parameters
policy_namestringName of the policy.policy_idstringUnique identifier for the policy.payerstringPayer associated with the policy./v1/policies/{policy_id}/criteriaRetrieve structured medical necessity criteria for a specific policy and service.
Input Parameters
api_keystringYour designated API key for authentication.policy_idstringUnique identifier for the policy.servicestringName or CPT code of the clinical service.Output Parameters
summarystringPlain-language summary of the policy.clinical_criteriaJSON arrayStructured list of medical necessity criteria.diag_codesarrayDiagnosis codes relevant to the policy./v1/prior-auth/statusLook up prior authorization requirements for a clinical service or procedure by payer.
Input Parameters
api_keystringYour designated API key for authentication.payer_idstringPayer identifier (e.g., UHC, AETNA, BCBS).servicestringoptionalClinical service or procedure name.cpt_codestringoptionalCPT code for the procedure.Output Parameters
prior_auth_requiredbooleanWhether prior authorization is required.auth_typestringType of authorization (standard, expedited, etc.).criteria_summarystringSummary of criteria required for approval.effective_datestringDate the PA requirement became effective./v1/formulary/lookupQuery formulary status for a drug by NDC code across payer plan types.
Input Parameters
api_keystringYour designated API key for authentication.ndcstring11-digit NDC code for the drug.payer_idstringoptionalFilter to a specific payer.plan_typestringoptionalPlan type (commercial, Medicare Part D, Medicaid).Output Parameters
drug_namestringBrand and generic name of the drug.tierintegerFormulary tier (1–6).prior_authbooleanWhether prior authorization is required.step_therapybooleanWhether step therapy applies.copaystringEstimated patient copay or coinsurance.quantity_limitstringQuantity limit if applicable./v1/enrollment/payerAccess payer enrollment data including membership counts by plan type and geography.
Input Parameters
api_keystringYour designated API key for authentication.payer_idstringoptionalFilter to a specific payer.statestringoptionalTwo-letter state code to filter by geography.plan_typestringoptionalPlan type (MA, commercial, Medicaid, exchange).Output Parameters
payerstringPayer name.total_enrollmentintegerTotal enrolled members.plan_typestringPlan type.statestringState.yearintegerEnrollment year.yoy_change_pctfloatYear-over-year enrollment change (%)./v1/aco/performanceRetrieve MSSP ACO performance data including savings rate, quality score, and beneficiary counts.
Input Parameters
api_keystringYour designated API key for authentication.aco_idstringoptionalCMS ACO identifier.statestringoptionalFilter by ACO primary state.yearintegeroptionalPerformance year (e.g., 2023).Output Parameters
aco_namestringName of the ACO.beneficiariesintegerTotal assigned beneficiaries.savings_rate_pctfloatNet savings rate as a percentage of benchmark.quality_scorefloatComposite quality score (0–100).shared_savingsstringDollar amount of shared savings earned.trackstringMSSP participation track.Get API access and start embedding policies, prior auth, formulary, enrollment, and ACO data directly into your platform today.