UnitedHealthcare

UnitedHealthcare Claims API

Claim pre-check, submission, and inquiry

Documentation GitHub OpenAPI

Operations 2

POST /claims/v1/pre-check UnitedHealthcare Real Claim Pre-Check #

POST /claims/v1/inquiry UnitedHealthcare Real Claim Inquiry #

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OpenAPI Specification

openapi: 3.2.0
info:
  title: UnitedHealthcare Provider Claims 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
servers:
- url: https://api.uhcprovider.com
  description: Production
security:
- bearerAuth: []
tags:
- name: Claims
  description: Claim pre-check, submission, and inquiry
paths:
  /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: "{\n  \"memberId\": \"123456789\",\n  \"npi\": \"1234567890\",\n  \"serviceDate\": \"2026-05-03\",\n  \"diagnosisCodes\": [\"J06.9\"],\n  \"procedureCodes\": [\"99213\"],\n  \"charges\": 150.00\n}\n"
      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: "{\n  \"claimNumber\": \"CLM-2026-001234\",\n  \"npi\": \"1234567890\",\n  \"memberId\": \"123456789\",\n  \"dateOfServiceFrom\": \"2026-01-01\",\n  \"dateOfServiceTo\": \"2026-05-03\"\n}\n"
      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
components:
  schemas:
    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
    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
  securitySchemes:
    bearerAuth:
      type: http
      scheme: bearer
      description: OAuth 2.0 Bearer token from UnitedHealthcare API Marketplace
externalDocs:
  description: UnitedHealthcare API Marketplace Documentation
  url: https://apimarketplace.uhcprovider.com/#/