UnitedHealthcare

UnitedHealthcare Eligibility API

Real-time eligibility and benefit verification

Documentation GitHub OpenAPI

Operations 2

POST /eligibility/v1/real-time UnitedHealthcare Real-Time Eligibility Check #

POST /eligibility/v1/patient-benefit-check UnitedHealthcare Real Patient Benefit Check #

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OpenAPI Specification

openapi: 3.2.0
info:
  title: UnitedHealthcare Provider Eligibility 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: Eligibility
  description: Real-time eligibility and benefit verification
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: "{\n  \"memberId\": \"123456789\",\n  \"dateOfBirth\": \"1980-01-15\",\n  \"serviceType\": \"30\",\n  \"dateOfService\": \"2026-05-03\",\n  \"npi\": \"1234567890\"\n}\n"
      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: "{\n  \"memberId\": \"123456789\",\n  \"dateOfBirth\": \"1980-01-15\",\n  \"serviceCode\": \"99213\",\n  \"dateOfService\": \"2026-05-03\",\n  \"npi\": \"1234567890\",\n  \"providerTaxId\": \"12-3456789\"\n}\n"
      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
components:
  schemas:
    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
    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
  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/#/