coverage-rights

List tracked U.S. health insurers with whether verified CMS-0057-F prior-authorization metrics are available for each.

{
  "type": "object",
  "properties": {},
  "$schema": "http://json-schema.org/draft-07/schema#"
}

Get an insurer's verified CY2025 prior-authorization metrics (denial rate, appeal overturn rate, decision times) from its own CMS-0057-F disclosure, plus contract/plan-level rows where collected. Includes source URLs and scope notes.

{
  "type": "object",
  "properties": {
    "slug": {
      "type": "string",
      "description": "Insurer slug from list_insurers, e.g. 'unitedhealthcare'"
    }
  },
  "required": [
    "slug"
  ],
  "additionalProperties": false,
  "$schema": "http://json-schema.org/draft-07/schema#"
}

Insurer prior-authorization denial rates (CY2025), ranked only within compatible reporting cohorts. Each row includes its cohort, rank within that cohort, exact source scope, calculation method, and source link. Never compare ranks across cohorts.

{
  "type": "object",
  "properties": {},
  "$schema": "http://json-schema.org/draft-07/schema#"
}

External-review outcomes for a treatment: how often insurer denials of this treatment/drug/procedure were overturned by independent reviewers (42,749 published CA IMR decisions, 2001–2026). Accepts a category slug (e.g. 'pharmacy') or specific treatment slug (e.g. 'zepbound', 'speech-therapy').

{
  "type": "object",
  "properties": {
    "slug": {
      "type": "string",
      "description": "Treatment slug, e.g. 'zepbound', 'pharmacy', 'speech-therapy'. Use search_outcomes to find slugs."
    }
  },
  "required": [
    "slug"
  ],
  "additionalProperties": false,
  "$schema": "http://json-schema.org/draft-07/schema#"
}

External-review outcomes for a medical condition: how often insurance denials involving this condition were overturned, plus the most-fought treatments for it.

{
  "type": "object",
  "properties": {
    "slug": {
      "type": "string",
      "description": "Condition slug, e.g. 'obesity', 'autism', 'hepatitis-c'"
    }
  },
  "required": [
    "slug"
  ],
  "additionalProperties": false,
  "$schema": "http://json-schema.org/draft-07/schema#"
}

Search treatments (categories + specific drugs/procedures) and conditions by name. Returns slugs for get_treatment_outcomes / get_condition_outcomes plus headline overturn rates.

{
  "type": "object",
  "properties": {
    "query": {
      "type": "string",
      "minLength": 2,
      "description": "Search text, e.g. 'wegovy', 'back pain', 'imaging'"
    },
    "limit": {
      "type": "integer",
      "minimum": 1,
      "maximum": 50,
      "description": "Max results per type (default 10)"
    }
  },
  "required": [
    "query"
  ],
  "additionalProperties": false,
  "$schema": "http://json-schema.org/draft-07/schema#"
}

Deterministically resolve the governing appeal route, missing facts, filing recipient, deadlines, current external-review status, and verified grounds. Distinguishes Original Medicare, Medicare Advantage medical benefits, Part D pharmacy benefits, employer funding/governance, ACA, Medicaid, FEHB, TRICARE, and unknown coverage; unsupported or ambiguous routes fail closed.

{
  "type": "object",
  "properties": {
    "program": {
      "type": "string",
      "enum": [
        "medicare-advantage",
        "original-medicare",
        "medicare-part-d",
        "erisa-employer-plans",
        "aca-marketplace",
        "medicaid",
        "fehb",
        "tricare",
        "other-unknown"
      ],
      "description": "Plan type"
    },
    "denial_reason": {
      "type": "string",
      "enum": [
        "medical-necessity",
        "experimental-investigational",
        "prior-authorization",
        "out-of-network",
        "not-covered-benefit",
        "coding-billing-error",
        "prescription-drug"
      ],
      "description": "Denial reason category. Use 'prescription-drug' for medication denials — formulary exclusion, step therapy, quantity limits, or drug prior authorization — which return the formulary-exception grounds and their short decision deadlines."
    },
    "state": {
      "type": "string",
      "minLength": 2,
      "maxLength": 2,
      "description": "Two-letter state code, e.g. 'ca'"
    },
    "insurer_slug": {
      "type": "string",
      "description": "Insurer slug for insurer-specific stats"
    },
    "employer_type": {
      "type": "string",
      "enum": [
        "private",
        "government",
        "church",
        "union",
        "unknown"
      ],
      "description": "Required to resolve job-based coverage"
    },
    "funding_status": {
      "type": "string",
      "enum": [
        "fully-insured",
        "self-funded",
        "unknown"
      ],
      "description": "Required to resolve job-based state versus federal governance"
    },
    "drug_channel": {
      "type": "string",
      "enum": [
        "not-a-drug",
        "medical-benefit",
        "pharmacy-benefit",
        "unknown"
      ],
      "description": "For a drug denial, whether the medical or pharmacy benefit applies"
    },
    "regulatory_marker": {
      "type": "string",
      "enum": [
        "state-regulated",
        "federal-or-self-funded",
        "unknown"
      ]
    },
    "regulatory_state_basis": {
      "type": "string",
      "enum": [
        "denial-letter",
        "insurance-card",
        "plan-document",
        "residence-only",
        "unknown"
      ]
    },
    "appeal_stage": {
      "type": "string",
      "enum": [
        "initial-denial",
        "internal-appeal-filed",
        "first-internal-denial",
        "final-internal-denial",
        "external-review-filed",
        "unknown"
      ]
    },
    "current_status": {
      "type": "string",
      "enum": [
        "awaiting-service",
        "receiving-service",
        "service-ended",
        "post-service-claim",
        "unknown"
      ]
    }
  },
  "required": [
    "program",
    "denial_reason"
  ],
  "additionalProperties": false,
  "$schema": "http://json-schema.org/draft-07/schema#"
}

Drug-specific denial patterns and appeal strategy for the medications plans fight hardest over: GLP-1s (Wegovy, Zepbound, Mounjaro, Ozempic, Saxenda) and IBD biologics (Humira, Skyrizi, Stelara, Entyvio, Remicade, Rinvoq). Returns FDA-approved indications stated conservatively, why plans deny that specific drug, what winning appeals argue, and the step-therapy exception framing — plus the published external-review record for the drug when the corpus has it. Accepts a brand or generic name.

{
  "type": "object",
  "properties": {
    "drug": {
      "type": "string",
      "minLength": 2,
      "maxLength": 80,
      "description": "Brand or generic drug name, e.g. 'Zepbound', 'ustekinumab'"
    }
  },
  "required": [
    "drug"
  ],
  "additionalProperties": false,
  "$schema": "http://json-schema.org/draft-07/schema#"
}

How a state's external review process works: filing deadline, regulator contact, and key facts. Verified detail currently covers 10 states (CA, TX, FL, NY, PA, IL, OH, GA, NC, MI); other states return the covered list.

{
  "type": "object",
  "properties": {
    "state": {
      "type": "string",
      "minLength": 2,
      "maxLength": 2,
      "description": "Two-letter state code, e.g. 'ca', 'ny', 'fl'"
    }
  },
  "required": [
    "state"
  ],
  "additionalProperties": false,
  "$schema": "http://json-schema.org/draft-07/schema#"
}