Aetna
Aetna, a CVS Health company, offers health insurance, dental, vision, and other plans for individuals, families, employers, health care providers, and insurance agents and brokers. As a major U.S. health insurer, Aetna provides federally mandated FHIR R4 APIs for patient access, provider directory, and drug formulary data under CMS Interoperability and Patient Access Final Rule (CMS-9115-F). Provider connectivity is supported through the Availity portal for EDI transactions.
APIs
Aetna Patient Access FHIR API
FHIR R4 compliant Patient Access API providing members secure access to their health data including claims, clinical data, and coverage information. Required under CMS Interoper...
Aetna Provider Directory FHIR API
FHIR R4 compliant Provider Directory API providing standardized access to in-network provider and facility information. Enables third-party applications to search for providers,...
Aetna Drug Formulary FHIR API
FHIR R4 compliant Drug Formulary API providing standardized access to plan formulary data including covered drugs, tiers, cost-sharing requirements, and prior authorization requ...
Aetna Provider EDI API
Electronic Data Interchange connectivity for healthcare providers enabling electronic submission of claims, eligibility verification, claim status inquiries, and remittance advi...
Features
All patient-facing APIs implement HL7 FHIR Release 4 standard for interoperability.
Secure OAuth 2.0 authorization framework for patient-authorized third-party app access.
Full compliance with CMS-9115-F Interoperability and Patient Access Final Rule.
Complete HIPAA-compliant EDI transaction set for provider administrative workflows.
Supports member-directed payer-to-payer data exchange for continuity of care.
Implements HL7 DaVinci Project PDEX, PDex Drug Formulary, and Plan Net guides.
Use Cases
Members use SMART on FHIR apps to access their complete health records across providers.
Developers build directory search tools to help patients find in-network providers.
Applications use formulary API to compare medication costs across Aetna plans.
Healthcare providers submit claims electronically via EDI 837 transactions through Availity.
Providers verify member eligibility and benefits in real time using 270/271 EDI transactions.
Providers receive and process electronic remittance advice via EDI 835 transactions.
Integrations
Integrated pharmacy benefit management for prescription drug coverage and mail-order pharmacy.
Primary provider portal for EDI transactions, eligibility, claims, and authorization requests.
EHR integration enabling clinical workflows including prior authorization and care management.
FHIR-based integration enabling Aetna members to view health data in Apple Health app.
Interoperability network participation for cross-organization health data exchange.
Alignment with CMS Blue Button 2.0 FHIR API patterns for Medicare data access.