Aetna

aid: aetna
url: https://raw.githubusercontent.com/api-evangelist/aetna/refs/heads/main/apis.yml
modified: '2026-04-19'
name: Aetna
description: 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.
tags:
- Health Insurance
- Healthcare
- FHIR
- Patient Access
- Provider Directory
- Fortune 100
apis:
- aid: aetna-patient-access-fhir-api
  name: Aetna Patient Access FHIR API
  description: FHIR R4 compliant Patient Access API providing members secure access to their health data including claims,
    clinical data, and coverage information. Required under CMS Interoperability and Patient Access Final Rule (CMS-9115-F).
    Supports SMART on FHIR authorization and provides access to ExplanationOfBenefit, Coverage, Patient, and related FHIR
    resources.
  tags:
  - FHIR
  - Patient Access
  - Health Data
  - Claims
  - CMS Mandate
  properties:
  - type: Documentation
    url: https://www.aetna.com/individuals-families/member-rights-resources/member-data-access.html
  - type: Authentication
    url: https://www.aetna.com/individuals-families/member-rights-resources/member-data-access.html
  - url: graphql/aetna-graphql.md
    type: GraphQL
- aid: aetna-provider-directory-fhir-api
  name: Aetna Provider Directory FHIR API
  description: FHIR R4 compliant Provider Directory API providing standardized access to in-network provider and facility
    information. Enables third-party applications to search for providers, verify network participation, and access provider
    details. Required under CMS Interoperability and Patient Access Final Rule for payer-to-payer data exchange.
  tags:
  - FHIR
  - Provider Directory
  - Network
  - Healthcare Providers
  - CMS Mandate
  properties:
  - type: Documentation
    url: https://www.aetna.com/health-care-professionals/working-with-aetna/provider-directory.html
- aid: aetna-drug-formulary-fhir-api
  name: Aetna Drug Formulary FHIR API
  description: FHIR R4 compliant Drug Formulary API providing standardized access to plan formulary data including covered
    drugs, tiers, cost-sharing requirements, and prior authorization requirements. Implements the DaVinci PDEX Formulary Implementation
    Guide. Enables members and third-party applications to compare drug coverage across health plans.
  tags:
  - FHIR
  - Drug Formulary
  - Pharmacy
  - Medications
  - CMS Mandate
  properties:
  - type: Documentation
    url: https://www.aetna.com/individuals-families/member-rights-resources/member-data-access.html
- aid: aetna-provider-edi-api
  name: Aetna Provider EDI API
  description: Electronic Data Interchange connectivity for healthcare providers enabling electronic submission of claims,
    eligibility verification, claim status inquiries, and remittance advice. Accessible through the Availity provider portal
    supporting EDI 837 (claims), 270/271 (eligibility), 276/277 (claim status), and 835 (remittance) HIPAA transactions.
  tags:
  - EDI
  - Claims
  - Eligibility
  - Provider Portal
  - HIPAA
  properties:
  - type: Documentation
    url: https://www.aetna.com/health-care-professionals/claims-payment/claims-submission.html
  - type: Portal
    url: https://www.availity.com
common:
- type: GitHubOrganization
  url: https://github.com/aetnahealth
- type: LinkedIn
  url: https://www.linkedin.com/company/aetna
- type: Website
  url: https://www.aetna.com
- type: Portal
  url: https://www.aetna.com/health-care-professionals.html
- type: Login
  url: https://member.aetna.com
- type: Support
  url: https://www.aetna.com/individuals-families/contact-aetna.html
- type: PrivacyPolicy
  url: https://www.aetna.com/legal-notices/privacy.html
- type: TermsOfService
  url: https://www.aetna.com/legal-notices/terms-of-use.html
- type: Features
  data:
  - name: FHIR R4 Compliance
    description: All patient-facing APIs implement HL7 FHIR Release 4 standard for interoperability.
  - name: SMART on FHIR Authorization
    description: Secure OAuth 2.0 authorization framework for patient-authorized third-party app access.
  - name: CMS Interoperability Compliance
    description: Full compliance with CMS-9115-F Interoperability and Patient Access Final Rule.
  - name: EDI Transaction Support
    description: Complete HIPAA-compliant EDI transaction set for provider administrative workflows.
  - name: Payer-to-Payer Data Exchange
    description: Supports member-directed payer-to-payer data exchange for continuity of care.
  - name: DaVinci Implementation Guides
    description: Implements HL7 DaVinci Project PDEX, PDex Drug Formulary, and Plan Net guides.
- type: UseCases
  data:
  - name: Member Health Record Access
    description: Members use SMART on FHIR apps to access their complete health records across providers.
  - name: Provider Network Verification
    description: Developers build directory search tools to help patients find in-network providers.
  - name: Drug Cost Comparison
    description: Applications use formulary API to compare medication costs across Aetna plans.
  - name: Electronic Claims Submission
    description: Healthcare providers submit claims electronically via EDI 837 transactions through Availity.
  - name: Eligibility Verification
    description: Providers verify member eligibility and benefits in real time using 270/271 EDI transactions.
  - name: Remittance Processing
    description: Providers receive and process electronic remittance advice via EDI 835 transactions.
- type: Integrations
  data:
  - name: CVS Caremark
    description: Integrated pharmacy benefit management for prescription drug coverage and mail-order pharmacy.
  - name: Availity
    description: Primary provider portal for EDI transactions, eligibility, claims, and authorization requests.
  - name: Epic Payer Platform
    description: EHR integration enabling clinical workflows including prior authorization and care management.
  - name: Apple Health
    description: FHIR-based integration enabling Aetna members to view health data in Apple Health app.
  - name: CommonWell Health Alliance
    description: Interoperability network participation for cross-organization health data exchange.
  - name: CMS Blue Button 2.0
    description: Alignment with CMS Blue Button 2.0 FHIR API patterns for Medicare data access.