UnitedHealth Group Patient Access API

openapi: 3.2.0
info:
  title: UnitedHealth Group Optum Patient Access 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).
  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
servers:
- url: https://api.uhc.com/fhir/R4
  description: UnitedHealth Group FHIR R4 Production
security:
- bearerAuth: []
tags:
- name: Patient Access
  description: FHIR R4 Patient Access API for member health data (CMS-9115-F)
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
components:
  schemas:
    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
    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
  securitySchemes:
    bearerAuth:
      type: http
      scheme: bearer
      description: OAuth 2.0 Bearer token obtained via authorization code flow
externalDocs:
  description: UnitedHealth Group Interoperability APIs
  url: https://www.uhc.com/legal/interoperability-apis